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The recent Covid-19 pandemic highlighted stark social inequalities, notably around access to food, nutrition and to green or blue space (i.e. outdoor spaces with vegetation and water). Consequently, obesity is socio-economically patterned by this inequality; and while the environmental drivers of obesity are widely acknowledged, there is currently little upstream intervention. We know that living with obesity contributes to increasing health inequalities, and places healthcare systems under huge strain. Our environment could broadly be described obesogenic, in the sense of supporting unhealthful eating patterns and sedentary behaviour. Evidence points to the existence of nearly 700 UK obesity policies, all of which have had little success. Obesity prevention and treatment has focused on educational and behavioural interventions targeted at individual consumers. A more sustainable approach would be to try and change the environments that promote less healthy eating and high energy intake as well as sedentary behaviour. Approaches which modify the environment have the potential to assist in the prevention of this complex condition. This review paper focuses on the role of wider food environments or foodscapes. While there is an imperfect evidence base relating to the role of the foodscape in terms of the obesity crisis, policy, practice, civic society and industry must work together and take action now, in areas where current evidence suggests change is required. Despite the current cost-of-living crisis, shaping the foodscape to better support healthful eating decisions has the potential to be a key aspect of a successful obesity prevention intervention.

Background. In 2020, Drug Related Deaths (DRD) in the United Kingdom (UK) reached the highest rate in over 25 years, with opioid related deaths doubling in the years from 2012 to 2015. Treatment systems are increasingly required to be innovative to engage the most vulnerable at risk from DRD. Heroin Assisted Treatment (HAT) is an alternative treatment modality for people for whom more traditional forms of Opioid Substitution Therapy (OST), such as methadone and buprenorphine, have failed. Middlesbrough, a town in the North-East England, is home to the first service in the UK to implement HAT outside of a clinical trial setting. Methods. Qualitative in-depth interviews with 17 health care providers (HCP) involved in the delivery or implementation of HAT were undertaken remotely. Interviews were audio recorded and thematically analysed. Results. HCP navigated multiple layers of constraint during HAT implementation and delivery. We explore this in relation to three themes: 1) Negotiating risk and safety within treatment. 2) More than a prescription: care beyond diamorphine 3) Internal and external delivery barriers and impact on treatment acceptability, identity and longevity. Negotiating and managing risks of poly substance use was a complex task. Benefits regarding access to holistic care, improved therapeutic and social relationships were recognised by HCP. The rigorous delivery schedule was the biggest barrier to engagement. Outside the treatment room, socio-structural barriers and short-term commissioning cycles posed additional challenges. Conclusion. Delivering HAT from the perspective of HCP is an effective method of engaging a population of marginalised people who use drugs (PWUD) with treatment services, and offers benefits over and above the provision of diamorphine.

Background: The National Planning Policy Framework advocates the promotion of ‘healthy communities’. Controlling availability and accessibility of hot food takeaways is a strategy which the planning system may use to promote healthier environments. Under certain circumstances, for example, local authorities can reject applications for new hot food takeaways. However, these decisions are often subject to appeal. The National Planning Inspectorate decide appeals – by upholding or dismissing cases. The aim of this research is to explore and examine the National Planning Inspectorate’s decision-making. Methods: The appeals database finder was searched to identify hot food takeaway appeal cases. Thematic analysis of appeals data was carried out. Narrative synthesis provided an overview of the appeals process and explored factors that were seen to impact on the National Planning Inspectorate’s decision-making processes. Results: The database search identified 52 appeals cases. Results suggest there is little research in this area and the appeals process is opaque. There appears to be minimal evidence to support associations between the food environment and health and a lack of policy guidance to inform local planning decisions. Furthermore, this research has identified non-evidence-based factors that influence the National Planning Inspectorate’s decisions. Conclusion: Results from this research will provide public health officers, policy planners and development control planners with applied public health research knowledge from which they can draw upon to make sound decisions in evaluating evidence to ensure they are successfully equipped to deal with and defend hot food takeaway appeal cases.

BACKGROUND Dietary management of type 2 diabetes is considered as a key remission and management strategy. This review explored clinicians' perceived barriers and enablers to the dietary management of adults with type 2 diabetes in primary care. METHODS MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA were searched from 1980 to 16 June 2020. RESULTS Of 2021 records, 14 studies met the inclusion criteria, describing the 14 domains of the refined Theoretical Domains Framework. The data synthesised to the domains of environmental context and resources, intentions and beliefs about capabilities were considered most trustworthy, closely followed by knowledge, behavioural regulation and beliefs about consequences. Two-thirds of studies cited time for staff training or patient education as major constraints to type 2 diabetes management. Clinicians also identified lack of patient engagement and poor dietary adherence as issues. Despite this, clinician confidence about giving dietary advice to patients was high. With further exploration, knowledge gaps were apparent and feelings of despondency as a result of poor outcomes were visible. CONCLUSIONS This review revealed four clinician behaviours: (2) the perception of the dietitian; (2) the definition of a clinician qualified to give dietary advice; (3) clinician belief in dietary management as a treatment; and (4) clinician belief in a patient's capability to change dietary behaviour. These behaviours, if challenged and changed, have the potential to improve dietary management and outcomes for people with type 2 diabetes in primary care.

Summary Sedentary behaviour tracks from early to middle childhood, suggesting the need to intervene early. The aim of this systematic review was to identify determinants of change in accelerometer‐assessed sedentary behaviour in young children, with a view to informing interventions. Ten electronic databases were searched. Longitudinal and intervention studies were included if they (a) targeted sedentary behaviour in young children (less than of equal to 6 years), (b) assessed change in accelerometer‐assessed sedentary behaviour, and (c) reported on at least one determinant of change in sedentary behaviour. Intervention components were coded according to clusters of behaviour change technique (BCT) (ie, grouping similar BCTs components). Data synthesis was guided by the socioecological model. Sixteen studies (four longitudinal; 12 intervention) met the inclusion criteria. Two (out of five identified determinants) were associated with an increase in sedentary behaviour in longitudinal studies: the after childcare/school period and transition from childcare to school. Three (out of 21 identified determinants) were associated with a decrease in sedentary behaviour in intervention studies: “goals and planning” (ie, “behavioural contract”), “repetition and substitution” (ie, “graded tasks”), and “reward and treat” (ie, “incentives”). The environmental and interpersonal determinants identified in this review may help to inform behavioural strategies, timing, and settings for future interventions.

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

BACKGROUND: Omega‐3 polyunsaturated fatty acids from oily fish (long‐chain omega‐3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha‐linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega‐3‐rich foods, and sometimes supplementation, but recent trials have not confirmed this. OBJECTIVES: To assess the effects of increased intake of fish‐ and plant‐based omega‐3 fats for all‐cause mortality, cardiovascular events, adiposity and lipids. SEARCH METHODS: We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random‐effects meta‐analysis for ALA and LCn3 interventions, and assessed dose‐response relationships through meta‐regression. MAIN RESULTS: We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high‐income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3‐ or ALA‐rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta‐analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all‐cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high‐certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate‐certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high‐certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate‐certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low‐certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334, RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low‐certainty evidence) and coronary heart disease events (NNTB 167, RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low‐certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre‐planned subgrouping or meta‐regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all‐cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate‐certainty evidence),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate‐certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate‐certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low‐certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events (NNTB 500, RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low‐certainty evidence), and probably slightly reduces risk of arrhythmia (NNTB 91, RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate‐certainty evidence). Effects on stroke are unclear. Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose‐dependent way (high‐certainty evidence). AUTHORS' CONCLUSIONS: This is the most extensive systematic assessment of effects of omega‐3 fats on cardiovascular health to date. Moderate‐ and low‐certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia.

This study presents a worked example of a stepped process to reliably estimate the habitual physical activity and sedentary time of a sample of young children. A total of 299 children (2.9 ± 0.6 years) were recruited. Outcome variables were daily minutes of total physical activity, sedentary time, moderate to vigorous physical activity and proportional values of each variable. In total, 282 (94%) provided 3 h of accelerometer data on ≥1 day and were included in a 6-step process: Step-1: determine minimum wear-time; Step-2: process 7-day-data; Step-3: determine the inclusion of a weekend day; Step-4: examine day-to-day variability; Step-5: calculate single day intraclass correlation (ICC) (2,1); Step-6: calculate number of days required to reach reliability. Following the process the results were, Step-1: 6 h was estimated as minimum wear-time of a standard day. Step-2: 98 (32%) children had ≥6 h wear on 7 days. Step-3: no differences were found between weekdays and weekend days (P ≥ 0.05). Step-4: no differences were found between day-to-day variability (P ≥ 0.05). Step-5: single day ICC's (2,1) ranged from 0.48 (total physical activity and sedentary time) to 0.53 (proportion of moderate to vigorous physical activity). Step-6: to reach reliability (ICC = 0.7), 3 days were required for all outcomes. In conclusion following a 7 day wear protocol, ≥6 h on any 3 days was found to have acceptable reliability. The stepped-process offers researchers a method to derive sample-specific wear-time criterion.

Process evaluation (PE) is used for the in-depth evaluation of the implementation process of health promotion programmes. The aim of the current paper was to present the PE design and tools used in the ToyBox-intervention. The PE design was based on a three-step approach, including the identification of ToyBox-specific PE elements (step 1), the development of PE tools and harmonization of procedures (step 2), and the implementation of PE using standardized protocol and tools across the intervention countries (step 3). Specifically, to evaluate the implementation of the intervention, teachers' monthly logbooks were recorded (dose delivered, fidelity, dose received); post-intervention questionnaires were completed by parents/caregivers and teachers (dose received); participation and attrition rates were recorded (recruitment, reach); and audit questionnaires and retrospective information on weather conditions were collected (physical and social environment within which the intervention was implemented). Regarding the teachers' training sessions, the researchers who performed the trainings completed evaluation forms and documented teachers' attendance after each training (dose delivered, fidelity, dose received) and teachers completed evaluation forms after each training (dose received). The PE performed in the ToyBox-intervention may contribute in the evaluation of its effectiveness, guide the revision of the intervention material and provide insights for future health promotion programmes and public health policy.

The ToyBox-study aims to develop and test an innovative and evidence-based obesity prevention programme for preschoolers in six European countries: Belgium, Bulgaria, Germany, Greece, Poland and Sp ...

Purpose– The purpose of this paper is to review the evidence base for effective public health interventions which aim to improve the diet of children aged zero to three years.Design/methodology/approach– General review.Findings– Key approaches and components of effective interventions include: repeated tasting, parental modelling, use of rewards, moderate restriction of “unhealthy” foods alongside an increase in portion sizes of fruits and vegetables, culturally appropriate messages, culturally acceptable health care provider, sufficient intensity of intervention, and an intervention which targets parental self-efficacy and modelling. Interventions which provide home visits (rather than require visits to a GP surgery or local community centre) financial incentives and/or mobile phone reminders may increase retention, particularly for some individuals. Recruiting mothers into programmes whilst they are pregnant may improve recruitment and retention rates.Originality/value– Allows for key public health interventions, approaches and components to be explored and identified. This will ensure that there is guidance to inform the development of new interventions for this age group and more importantly recommend that those components which are most successful be incorporated in policy and practice.

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

Background: Accurate, reliable and feasible methods of dietary intake and physical activity assessment are required to improve our understanding of the associations between energy balance-related behaviours and health. Methods: The Synchronised Nutrition and Activity Program (SNAP™) was developed to enhance recall in children by integrating new and established methods of dietary intake and physical activity recall. A list of commonly consumed foods (n = 40), drinks (n = 9) and physical activities (n = 29) was used in SNAP™. All foods and drinks were analysed by count (i.e. the number of times a particular food was selected), as a proxy indicator of dietary behaviours. All reported physical activities were assigned an intensity code [in metabolic equivalents (METs)] to determine minutes of moderate–vigorous activity (MVPA; ≥3 METs). Results: Most participants completed a whole day's recall (both dietary intake and physical activities) in less than 25 min. SNAP™ was compared against 24-h multiple pass questionnaire and accelerometry in 121 children (aged 7–15 years old). For dietary variables, the accuracy of SNAP™ (mean difference) was within ±1 count for the majority of food groups. The proportion of the sample with a between-method agreement within ±1 count ranged from 0.40 to 0.99. For MVPA, there was no substantial fixed or proportional bias, with a mean difference between methods (SNAP™ – accelerometry) of −9 min of MVPA. Qualitatively, participants have indicated that they find SNAP™ easy and fun to use. Conclusions: SNAP™ was developed to be a simple, quick and engaging method of assessing energy balance-related behaviours at a group or population level and succeeded because it can collect a whole day's recall (dietary intake and physical activities) in less than 25 min to a reasonable and acceptable degree of accuracy.

Background Understanding the determinants of children’s health behaviours is important to develop successful behaviour-change interventions. Objective We aimed to synthesise the evidence around determinants (‘preceding predictors’) of change in physical activity (PA) in young children (0–6 years of age). Methods As part of a suite of reviews, prospective quantitative studies investigating change in physical activity in children aged 0–6 years were identified from eight databases (to October 2015): MEDLINE, Embase, CINAHL, PsycINFO, Web of Knowledge, British Nursing Index, Applied Social Sciences Index and Abstracts, and Sociological Abstracts. Determinants and direction of association were extracted, described and synthesised according to the socio-ecological model (individual, interpersonal, organisational, community, policy). Results Forty-four determinants, predominantly in the interpersonal and organisational domains, were reported across 44 papers (six prospective cohort, 38 interventional); 14 determinants were assessed in four or more papers. Parental monitoring showed a consistent positive association with change in PA; provider training was positively associated with change in children’s moderate-to-vigorous PA only. Five (sex, parental goal setting, social support, motor skill training and increased time for PA) showed no clear association. A further seven (child knowledge, parental knowledge, parental motivation, parenting skills, parental self-efficacy, curriculum materials and portable equipment) were consistently not associated with change in children’s PA. Maternal role-modelling was positively associated with change in PA in all three studies in which it was examined. Conclusions A range of studied determinants of change in young children’s PA were identified, but only parental monitoring was found to be consistently positively associated. More evidence dealing with community and policy domains from low-/middle-income countries and about lesser-explored modifiable family- and childcare-related determinants is required. International Prospective Register for Systematic Reviews (PROSPERO) Registration Number CRD42012002881. Electronic supplementary material The online version of this article (doi:10.1007/s40279-016-0656-0) contains supplementary material, which is available to authorized users.

BACKGROUND: Reduction and modification of dietary fats have differing effects on cardiovascular risk factors (such as serum cholesterol), but their effects on important health outcomes are less clear. OBJECTIVE: To assess the effect of reduction and/or modification of dietary fats on mortality, cardiovascular mortality, cardiovascular morbidity and individual outcomes including myocardial infarction, stroke and cancer diagnoses in randomised clinical trials of at least 6 months duration. METHODS: Search methods: For this review update, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase, were searched through to June 2010. References of Included studies and reviews were also checked. Selection criteria: Trials fulfilled the following criteria: 1) randomized with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) adult humans with or without cardiovascular disease, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available. Data collection and analysis: Participant numbers experiencing health outcomes in each arm were extracted independently in duplicate and random effects meta-analyses, meta-regression, sub-grouping, sensitivity analyses and funnel plots were performed. MAIN RESULTS: This updated review suggested that reducing saturated fat by reducing and/or modifying dietary fat reduced the risk of cardiovascular events by 14% (RR 0.86, 95% CI 0.77 to 0.96, 24 comparisons, 65,508 participants of whom 7% had a cardiovascular event, I2 50%). Subgrouping suggested that this reduction in cardiovascular events was seen in studies of fat modification (not reduction - which related directly to the degree of effect on serum total and LDL cholesterol and triglycerides), of at least two years duration and in studies of men (not of women). There were no clear effects of dietary fat changes on total mortality (RR 0.98, 95% CI 0.93 to 1.04, 71,790 participants) or cardiovascular mortality (RR 0.94, 95% CI 0.85 to 1.04, 65,978 participants). This did not alter with sub-grouping or sensitivity analysis. Few studies compared reduced with modified fat diets, so direct comparison was not possible. AUTHORS' CONCLUSIONS: The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates. The ideal type of unsaturated fat is unclear.

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

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

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

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

The Synchronised Nutrition and Activity Program for Adults (SNAPA™) was developed to address the need for accurate, reliable, feasible, inexpensive and low-burden methods for assessing specific dietary and physical activity behaviours in adults. Short-term test–retest reliability of SNAPA™ was assessed in forty-four adults (age 41·4 (sd17·3) years) who completed SNAPA™ twice in 1 day. Concurrent validity against direct dietary observation and combined heart rate and accelerometry was assessed in seventy-seven adults (age 34·4(sd11·1) years). Test–retest reliability revealed no substantial systematic shifts in mean values of the outcome variables: percentage of food energy from fat (% fat), number of portions of fruit and vegetables (FV) and minutes of moderate-to-vigorous physical activity (MVPA). For lunchtime dietary intake, the mean match rate between food items reported using SNAPA™ and those observed was 81·7 %, with a phantom rate of 5·6 %. Pearson's correlations between SNAPA™ and the reference methods ranged from 0·27 to 0·56 for % fat, FV portions and minutes of MVPA. For % fat and FV intake, there was no fixed or proportional bias, and mean differences between the methods (SNAPA™ − reference) were 5·1 % and 0 portions, respectively. For minutes of MVPA, a fixed bias of − 28 min was revealed when compared with all minutes of MVPA measured by combined heart rate and accelerometry, whereas a proportional bias (slope 1·47) was revealed when compared with minutes carried out in bouts ≥ 10 min. SNAPA™ is a promising tool for measuring specific energy balance behaviours, though further work is required to improve accuracy for physical activity behaviours.

Self-report recall questionnaires used to measure physical activity and dietary intake in children can be labour intensive and monotonous and tend to focus on either dietary intake or physical activity. The web-based software, Synchronised Nutrition and Activity ProgramTM(SNAPTM), was developed to produce a novel, simple, quick and engaging method of assessing energy balance-related behaviours at a population level, combining principles from new and existing 24 h recall methodologies, set within a user-friendly interface. Dietary intake was measured using counts for twenty-one food groups and physical activity levels were measured in min of moderate to vigorous physical activity (MVPA). A combination of the mean difference between methods, type II regression and non-parametric limits of agreement techniques were used to examine the accuracy and precision of SNAPTM. Method comparison analyses demonstrated a good agreement for both dietary intake and physical activity behaviours. For dietary variables, accuracy of SNAPTM(mean difference) was within ± 1 count for the majority of food groups. The proportion of the sample with between-method agreement within ± 1 count ranged from 0·40 to 0·99. For min of MVPA, there was no substantial fixed or proportional bias, and a mean difference between methods (SNAPTM– accelerometry) of − 9 min. SNAPTMprovides a quick, accurate, low-burden, cost-effective and engaging method of assessing energy balance behaviours at a population level. Tools such as SNAPTM, which exploit the popularity, privacy and engagement of the computer interface, and linkages with other datasets, could make a substantial contribution to future public health monitoring and research.

BackgroundThe Department of Health has identified interventions to manage alcohol misuse, smoking and overweight, delivered by community pharmacists, as public health priorities.ObjectivesTo systematically review the effectiveness of community pharmacy interventions to manage alcohol misuse, smoking cessation and weight loss; to explore if and how age, sex, ethnicity and socioeconomic status moderate effectiveness; and to describe how the interventions have been organised, implemented and delivered.Data sourcesTen electronic databases were searched: Applied Social Sciences Index and Abstracts; Cumulative Index to Nursing and Allied Health Literature; EMBASE; International Bibliography of the Social Sciences; MEDLINE; NHS Economic Evaluation Database; PsycINFO; Social Science Citation Index; Scopus; and the Sociological Abstracts from inception to May 2014. There was no restriction on language or country. Supplementary searches included website, grey literature, study registers, bibliographies and contacting experts.Review methodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Any type of intervention of any duration based in any country and in people of any age was included. The review included interventions set in a community pharmacy and delivered by the pharmacist or the wider pharmacy team. Randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies were included. Data extraction and quality assessment were conducted independently for each study by two reviewers. Meta-analysis and narrative synthesis were also conducted.ResultsThe searches identified over 14,000 records, of which 24 studies were included. There were two alcohol, 12 smoking cessation, five weight loss and five multicomponent interventions that included pharmacotherapy and lifestyle changes in participants with diabetes mellitus, dyslipidaemia or hypertension. Nine of the studies were UK based; seven of the studies were rated ‘strong’ for quality. All studies were of adults. Pharmacy-based smoking cessation interventions including behavioural support and/or nicotine replacement therapy are effective and cost-effective in helping adults to stop smoking, particularly when compared with usual care. The pooled odds ratio of the intervention effects for smoking cessation was 1.85 (95% confidence interval 1.25 to 2.75). It is currently unknown which specific types of smoking cessation interventions are the most effective. There was insufficient evidence for the effectiveness of community pharmacy-based brief alcohol interventions. Evidence suggests that pharmacy-based weight-loss interventions are as effective as similar interventions in other primary care settings, but not as effective or cost-effective as commercially provided weight management services based in community settings. None of the five multicomponent studies demonstrated an improvement compared with control for anthropometric outcomes in participants with comorbidities, but they did show improvement in measures associated with the comorbidities. Very few studies explored if and how sociodemographic or socioeconomic variables moderated the effect of interventions. In two studies based in areas of high deprivation, where participants chose the intervention, the sociodemographic characteristics of participants differed between intervention settings. There were also differences in recruitment, attendance and retention of participants by type of setting. The evidence suggests that a distinct group of people might access pharmacies compared with other settings for alcohol management, smoking cessation and weight loss. There is insufficient evidence to examine the relationship between behaviour change strategies and effectiveness; or evidence of consistent implementation factors or training components that underpin effective interventions.LimitationsThe information reported in the publications of included studies did not allow us to assess in detail if and how age, sex, ethnicity and socioeconomic status moderate effectiveness, or to describe how the interventions had been organised, implemented and delivered.ConclusionsCommunity pharmacy interventions are effective for smoking cessation. Evaluations of interventions to manage alcohol misuse and obesity, set within the community pharmacy, are needed. The effect of community pharmacy interventions on health inequalities is unclear. Future research in this area is warranted, and trials should include the assessment of age, sex, ethnicity, socioeconomic status and contextual factors, and present analysis of how these factors moderate effectiveness.Study registrationThis study is registered as PROSPERO CRD42013005943.FundingThe National Institute for Health Research Public Health Research programme.

Few evidence-based physical activity interventions for pre-school children are available. This two-armed pilot cluster randomised controlled trial aimed to evaluate the feasibility of conducting a full-scale trial and of delivering an outdoor physical activity intervention for pre-school children. School was the unit of randomisation, and follow-up occurred at 10 and 52 weeks. Trial feasibility was assessed by recruitment, retention and completion rates of primary (daily moderate-to-vigorous physical activity (MVPA)) and secondary (anthropometric, quality of life, self-efficacy) outcomes. Potential effectiveness was assessed for the primary outcome using a linear regression model comparing MVPA between trial arms adjusting for clustering by school. Feasibility of delivering the intervention was assessed by intervention fidelity and attendance. Semi-structured interviews with parents, intervention facilitators, and head teachers explored acceptability and capability to deliver the intervention as well as acceptability of the study design. Recruitment rates were 37 % of schools (n = 10 schools) and 48 % of pre-school children (n = 164 children). Retention of children to the trial at 52 weeks was 83.5 %. Thirty-nine percent of children had valid primary outcome accelerometer data at baseline and 52 weeks. Response rates for secondary outcome measures ranged from 52 to 88 % at 10 weeks and 59 to 80 % at 52 weeks. The mean difference in daily MVPA between trial arms at 52 weeks was 0.4, 95 % CI 16.3 to 17.0; p = 0.96. Fidelity of intervention implementation was 81 %. Intervention attendance was higher (82 %) during the summer initiation phase compared to autumn/spring initiation (50 %). Parents, facilitators and head teachers found the intervention acceptable and beneficial. Recruitment and retention rates suggest a trial in this outdoor setting with this population was feasible but is weather sensitive. However, strategies to increase accelerometer wear-time would need to be implemented for reliable primary outcome data to be obtained. There was high implementation fidelity by facilitators, and the intervention was seen as acceptable and deliverable. However, attendance was low and preliminary data showed no evidence of intervention effectiveness. A revised intervention, building on the successful elements of this pilot alongside adapting implementation strategies to improve attendance, should therefore be considered. Trial registry name and number: Current Controlled Trials, ISRCTN54165860 . Date of registration: 4 September 2012.

Objective To assess the effectiveness of 2 interventions in improving the physical activity and well-being of secondary school children. Design A clustered randomised controlled trial; classes, 1 per school, were assigned to 1 of 3 intervention arms or a control group based on a 2×2 factorial design. The interventions were peer-mentoring and participative learning. Year 7 children (aged 11–12) in the peer-mentoring intervention were paired with year 9 children for 6 weekly mentoring meetings. Year 7 children in the participative learning arm took part in 6 weekly geography lessons using personalised physical activity and Global Positioning System (GPS) data. Year 7 children in the combined intervention received both interventions, with the year 9 children only participating in the mentoring sessions. Participants 1494 year 7 students from 60 schools in the North of England took part in the trial. Of these, 43 students opted out of taking part in the evaluation measurements, 2 moved teaching group and 58 changed school. Valid accelerometry outcome data were collected for 892 students from 53 schools; and well-being outcome data were available for 927 students from 52 schools. Main outcome measures The primary outcomes were mean minutes of accelerometer-measured moderate-to-vigorous intensity physical activity per day, and well-being as evaluated by the KIDSCREEN-27 questionnaire. These data were collected 6 weeks after the intervention; a 12-month follow-up is planned. Results No significant effects (main or interaction) were observed for the outcomes. However, small positive differences were found for both outcomes for the participative learning intervention. Conclusions These findings suggest that the 2 school-based interventions did not modify levels of physical activity or well-being within the period monitored. Change in physical activity may require more comprehensive individual behavioural intervention, and/or more system-based efforts to address wider environmental influences such as family, peers, physical environment, transport and educational policy. Trial registration number ISRCTN82956355.

Background: In preschoolers, high levels of sedentary behaviour are associated with several adverse health outcomes. The purpose of this study is to report the effects of the ToyBox-intervention (a European 24-week cluster randomised controlled trial) on sedentary behaviour in preschoolers. Methods: In Belgium, 859 preschoolers from 27 kindergartens (15 intervention and 12 control) wore an accelerometer to objectively measure their sedentary time and 1715 parents/caregivers completed a questionnaire to assess sedentary activities in which preschoolers participate at home. Main outcomes were objectively measured sedentary time, time spent watching TV, using the computer and time spent in quiet play. Multilevel repeated measures analyses were conducted to take clustering into account. Intention to treat analysis was used to handle missing data. Results: A sample of 859 (29.5% of all contacted children) preschoolers (4.4 ± 0.6 years, 54.4% boys) provided valid accelerometer data at either baseline or follow-up and parents of 1715 (58.9% of all contacted children) preschoolers (4.4 ± 0.5 years, 52.5% boys) completed a questionnaire at either baseline or follow-up. No intervention effects were found on objectively and subjectively measured total sedentary time in the total sample. However, some effects on objectively and subjectively measured sedentary time were found in specific subgroups. Preschoolers from the intervention group from high SES kindergartens and preschoolers with high levels of sedentary time at baseline decreased their sedentary time, while preschoolers from the control group increased their sedentary time. Girls in the intervention group decreased their TV viewing time during weekend days (-5.83 min/day), while girls' &TV viewing in the control group increased (+4.15 min/day). In low SES kindergartens, a smaller increase for computer time during weekend days was found in preschoolers in intervention kindergartens (+6.06 min/day) than in control kindergartens (+12.49 min/day). Conclusion: While some small positive effects were found in some sub-groups, the ToyBox-intervention had no effect on objectively and subjectively measured sedentary time in the total sample. A longer period to implement the intervention and a more active involvement of parents/caregivers might enhance intervention effects. The ToyBox-study is registered with the clinical trials registry clinicaltrials.gov, ID: NCT02116296., Toy Box

BackgroundThe preschool years are considered critical for establishing healthy lifestyle behaviours such as physical activity. Levels of physical activity track through childhood into adulthood and establishing habitual physical activity early in life is therefore vital. Time spent outdoors is associated with greater physical activity and playground interventions have been shown to increase physical activity in school-aged children. There are few preschool, playground-based interventions and these have given inconclusive results. A report published by the UK’s Chief Medical Officer (CMO) highlighted the need for new interventions to promote movement in the early years (0–5 years).ObjectivesThis study aimed to undertake a pilot cluster randomised controlled trial (RCT) of an outdoor playground-based physical activity intervention for parents and their children aged from 18 months to 4 years (Preschoolers in the Playground or PiP) and to assess the feasibility of conducting a full-scale cluster RCT.DesignThe study was a two-armed pilot cluster RCT with economic and qualitative evaluations. Participants were randomised on a 1 : 1 basis to the PiP intervention (n = 83) or usual practice (control;n = 81).SettingBradford, West Yorkshire, UK.ParticipantsChildren aged from 18 months to 4 years.InterventionThe PiP intervention is grounded in behavioural theory (social cognitive theory) and is in accordance with CMO guidance for physical activity in the early years. It is informed by existing literature and data collected from focus groups with parents. The intervention was delivered in primary school playgrounds. Six 30-minute PiP sessions per week were available for 30 weeks; families were encouraged to come to three a week. The 10-week initiation phase was facilitated by a member of school staff and the maintenance phase was unsupervised.Main outcome measuresRecruitment and retention of schools and families to the trial were the main outcome measures. The acceptability of trial procedures and the intervention, the feasibility of collecting health outcome data and the fidelity of the implementation of the intervention were also evaluated. A preliminary assessment of cost-effectiveness and a sample size calculation for a full trial were conducted.ResultsIn total, 37% of schools and 48% of parents approached agreed to take part. Levels of retention were good at 10 and 52 weeks’ follow-up (82.3% and 83.5% respectively). Both the trial procedures and the intervention were acceptable. However, attendance was low during the autumn and winter/spring initiation phases but somewhat better in the summer initiation phase. Attendance was poor throughout all maintenance phases. The accelerometry protocol for measuring physical activity requires modification. The fidelity of intervention implementation was good (81% adherence). The intervention was borderline cost-effective. A sample size of 600 children from 38 schools is required for a full trial.ConclusionA full RCT of the PiP intervention is feasible. The PiP intervention requires some modification, for example running the intervention during the summer term only, but was found to be acceptable to schools and families.Trial registrationCurrent Controlled Trials ISRCTN54165860.FundingThis project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 3, No. 5. See the NIHR Journals Library website for further project information.

This study investigated the food offered to children under 5 years of age in UK day care, the influence of the childcare providers on a child's diet and their attitudes towards this role. A postal survey of a randomised quota sample of childcare providers enquired after the range of food on offer and explored attitudes towards the role of food in health and the role of promoting health. Themes emerging from these data were explored by in-depth interviews with a sample of 18 childcare providers and 7 Local Authority Early Years Service staff. We received 194 (56%) responses to 345 copies of the questionnaire. Half (46%) of nurseries and 23% of childminders provided a fruit or vegetable with the main meal 5 days a week. Only 14% of nurseries and 21% of childminders provided a dairy food (i.e. calcium-rich) at the main meal every day. Almost all the childcare providers saw themselves as responsible for promoting healthy diet, but it was rare for them to have had any formal training in nutrition, while current dietary guidance was perceived as too vague to be useful. The study also highlighted tensions on the issue of food provision between those delivering childcare and parents; further research should explore the parents' perspectives. Nursery staff and childminders should have access to carefully designed advice on nutritionally appropriate food and drink services for under-fives.

BackgroundTackling obesity is one of the major contemporary public health policy challenges and is vital in terms of addressing health inequalities.ObjectivesTo systematically review the effectiveness of interventions (individual, community and societal) in reducing socioeconomic inequalities in obesity among (1) children aged 0–18 years (including prenatal) and (2) adults aged ≥18 years, in any setting, in any country, and (3) to establish how such interventions are organised, implemented and delivered.Data sourcesNine electronic databases including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and NHS Economic Evaluation Database were searched from database start date to 10 October 2011 (child review) and to 11 October 2012 (adult review). We did not exclude papers on the basis of language, country or publication date. We supplemented these searches with website and grey literature searches.Review methodsPreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Experimental studies and observational studies with a duration of at least 12 weeks were included. The reviews considered strategies that might reduce existing inequalities in the prevalence of obesity [i.e. effective targeted interventions or universal interventions that work more effectively in low socioeconomic status (SES) groups] as well as those interventions that might prevent the development of inequalities in obesity (i.e. universal interventions that work equally along the SES gradient). Interventions that involved drugs or surgery and laboratory-based studies were excluded from the reviews. The initial screening of titles and abstracts was conducted by one reviewer with a random 10% of the sample checked by a second reviewer. Data extraction was conducted by one reviewer and independently checked by a second reviewer. The methodological quality of the included studies was appraised independently by two reviewers. Meta-analysis and narrative synthesis were conducted focusing on the ‘best-available’ evidence for each intervention type (defined in terms of study design and quality).ResultsOf 56,967 papers of inequalities in obesity in children, 76 studies (85 papers) were included, and of 70,730 papers of inequalities in obesity in adults, 103 studies (103 papers) were included. These studies suggested that interventions that aim to prevent, reduce or manage obesity do not increase inequalities. For children, there was most evidence of effectiveness for targeted school-delivered, environmental and empowerment interventions. For adults, there was most evidence of effectiveness for primary care-delivered tailored weight loss and community-based weight loss interventions, at least in the short term among low-income women. There were few studies of appropriate design that could be included on societal-level interventions, a clear limitation of the evidence base found.LimitationsThe reviews located few evaluations of societal-level interventions and this was probably because they included only experimental study designs. The quality assessment tool, although described as a tool for public health interventions, seemed to favour those that followed a more clinical model. The implementation tool was practical but enabled only a brief summary of implementation factors to be made. Most of the studies synthesised in the reviews were from outside the UK and related to women.ConclusionsThe reviews have found some evidence of interventions with the potential to reduce SES inequalities in obesity and that obesity management interventions do not increase health inequalities. More experimental studies of the effectiveness and cost-effectiveness of interventions (particularly at the societal level) to reduce inequalities in obesity, particularly among adolescents and adult men in the UK, are needed.Study registrationThe studies are registered as PROSPERO CRD42011001740 and CRD42013003612.FundingThe National Institute for Health Research Public Health Research programme.

Introduction Weight gain is determined by the cumulative effect of low levels of physical activity, high levels of sedentary behaviour, and unhealthy dietary behaviours, also referred to as energy balance-related behaviours. The aim of the current study was to compare levels of energy balance-related behaviours in 3.5–5.5 year-old children from six European countries (Belgium, Bulgaria, Germany, Greece, Poland, and Spain) within the ToyBox-study ( http://www.toybox-study.eu ) [1] , [2] . Methods A sample of 4045 preschoolers (4.77 ± 0.43 years; 52.2% boys) had valid physical activity data (steps per day), parents/caregivers of 8117 preschoolers (4.78 ± 0.46 years; 53.0% boys) completed a parental questionnaire with questions on sedentary behaviours (TV/DVD viewing, PC/video games, and quiet play), and parents of 7244 preschoolers (4.77 ± 0.44 years; 52.0% boys) completed a food frequency questionnaire with questions on water consumption, sugar-sweetened beverage consumption and unhealthy snacking. Results Across six European countries, significant differences in preschoolers’ energy balance-related behaviours were found. The highest levels of physical activity were found in Spain (12,669 steps/day on weekdays), while the lowest levels were found in Bulgaria and Greece (9777 and 9656 steps/day on weekdays, respectively). German preschoolers spent the least amount of time in television viewing (43.3 min/day on weekdays), while Greek preschoolers spent the most time in television viewing (88.5 min/day on weekdays). A considerable amount of time was spent in quiet play in all countries, with the highest levels in Poland (104.9 min/day on weekdays), and the lowest levels in Spain (60.4 min/day on weekdays). Belgian, German, and Polish preschoolers had the lowest intakes of water and the highest intakes of sugar-sweetened beverages. The intake of unhealthy snacks was the highest in Belgian preschoolers (73.1 g/day) and the lowest in Greek preschoolers (53.3 g/day). Conclusions Future interventions should target European preschoolers’ energy balance-related behaviours simultaneously, but should apply country-specific adaptations.

BACKGROUND: Addressing socio-economic inequalities in obesity is a public health priority and the workplace is seen as a potential health promotion site. However, there is a lack of evidence on what works. This article systematically reviews studies of the effects of workplace interventions on socio-economic inequalities in obesity. METHODS: Following PRISMA guidelines, we searched for published or unpublished experimental and observational evaluation studies. Nine electronic databases were searched as well as websites and bibliographies. Included studies were data extracted, quality assessed and narratively synthesized. RESULTS: Eighteen studies were included of which 14 examined behavioural interventions and 4 mixed or environmental ones. While most studies (n = 12) found no effects on inequalities in obesity--and a minority found increases (n = 3), there was also some evidence of potentially effective workplace interventions (n = 3) especially in terms of physical activity interventions targeted at lower occupational groups. CONCLUSION: There is experimental evidence that workplace delivered physical activity interventions have the potential to reduce inequalities in obesity by targeting lower occupational groups. However, overall, the evidence base is small, largely from the USA, and of a low quality. More high-quality, experimental study designs are required.

Background:Evidence suggests that many contemporary urban environments do not support healthy lifestyle choices and are implicated in the obesity pandemic. Middlesbrough, in the northeast of England is one such environment and a prime target for investigation.Methods:To measure physical activity (PA) levels in a sample of 28 adolescents (aged 11 to 14 years) and describe the environmental context of their activity and explore where they are most and least active over a 7-day period, accelerometry and Global Positioning System (GPS) technology were used. Twenty-five of these participants also took part in focus groups about their experiences and perceptions of PA engagement.Results:Findings indicated that all participants were relatively inactive throughout the observed period although bouts of moderate-vigorous physical activity (MVPA) were identified in 4 contexts: school, home, street, and rural/urban green spaces, with MVPA levels highest in the school setting. Providing access to local facilities and services (such as leisure centers) is not in itself sufficient to engage adolescents in MVPA.Conclusion:Factors influencing engagement in MVPA were identified within and across contexts, including ‘time’ as both a facilitator and barrier, perceptions of ‘gendered’ PA, and the social influences of peer groups and family members.

Background Socioeconomic inequalities in obesity and associated risk factors for obesity are widening throughout developed countries worldwide. Tackling obesity is high on the public health agenda both in the United Kingdom and internationally. However, what works in terms of interventions that are able to reduce inequalities in obesity is lacking. Methods/Design The review will examine public health interventions at the individual, community and societal level that might reduce inequalities in obesity among adults aged 18 years and over, in any setting and in any country. The following electronic databases will be searched: MEDLINE, EMBASE, CINAHL, PsycINFO, Social Science Citation Index, ASSIA, IBSS, Sociological Abstracts, and the NHS Economic Evaluation Database. Database searches will be supplemented with website and gray literature searches. No studies will be excluded based on language, country or publication date. Randomized and non-randomized controlled trials, prospective and retrospective cohort studies (with/without control groups) and prospective repeat cross-sectional studies (with/without control groups) that have a primary outcome that is a proxy for body fatness and have examined differential effects with regard to socioeconomic status (education, income, occupation, social class, deprivation, poverty) or where the intervention has been targeted specifically at disadvantaged groups or deprived areas will be included. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Meta-analysis and narrative synthesis will be conducted. The main analysis will examine the effects of 1) individual, 2) community and 3) societal level public health interventions on socioeconomic inequalities in adult obesity. Interventions will be characterized by their level of action and their approach to tackling inequalities. Contextual information on how such public health interventions are organized, implemented and delivered will also be examined. Discussion The review will provide evidence, and reveal any gaps in the evidence base, of public health strategies which reduce and prevent inequalities in the prevalence of obesity in adults and provide information on the organization, implementation and delivery of such interventions. Systematic review registration PROSPERO registration number:CRD42013003612

Objective To investigate the relation between total fat intake and body weight in adults and children. Design Systematic review and meta-analysis of randomised controlled trials and cohort studies. Data sources Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials to June 2010. Inclusion criteria Randomised controlled trials and cohort studies of adults or children that compared lower versus usual total fat intake and assessed the effects on measures of body fatness (body weight, body mass index, or waist circumference) after at least six months (randomised controlled trials) or one year (in cohorts). Randomised controlled trials with any intention to reduce weight in participants or confounded by additional medical or lifestyle interventions were excluded. Data extraction Data were extracted and validity was assessed independently and in duplicate. Random effects meta-analyses, subgroups, sensitivity analyses, and metaregression were done. Results 33 randomised controlled trials (73 589 participants) and 10 cohort studies were included, all from developed countries. Meta-analysis of data from the trials suggested that diets lower in total fat were associated with lower relative body weight (by 1.6 kg, 95% confidence interval −2.0 to −1.2 kg, I 2 =75%, 57 735 participants). Lower weight gain in the low fat arm compared with the control arm was consistent across trials, but the size of the effect varied. Metaregression suggested that greater reduction in total fat intake and lower baseline fat intake were associated with greater relative weight loss, explaining most of the heterogeneity. The significant effect of a low fat diet on weight was not lost in sensitivity analyses (including removing trials that expended greater time and attention on low fat groups). Lower total fat intake also led to lower body mass index (−0.51 kg/m 2 , 95% confidence interval −0.76 to −0.26, nine trials, I 2 =77%) and waist circumference (by 0.3 cm, 95% confidence interval −0.58 to −0.02, 15 671 women, one trial). There was no suggestion of negative effects on other cardiovascular risk factors (lipid levels or blood pressure). GRADE assessment suggested high quality evidence for the relation between total fat intake and body weight in adults. Only one randomised controlled trial and three cohort studies were found in children and young people, but these confirmed a positive relation between total fat intake and weight gain. Conclusions There is high quality, consistent evidence that reduction of total fat intake has been achieved in large numbers of both healthy and at risk trial participants over many years. Lower total fat intake leads to small but statistically significant and clinically meaningful, sustained reductions in body weight in adults in studies with baseline fat intakes of 28-43% of energy intake and durations from six months to over eight years. Evidence supports a similar effect in children and young people.

Background There is growing evidence of the impact of overweight and obesity on short- and long-term functioning, health and well-being. Internationally, childhood obesity rates continue to rise in some countries (for example, Mexico, India, China and Canada), although there is emerging evidence of a slowing of this increase or a plateauing in some age groups. In most European countries, the United States and Australia, however, socioeconomic inequalities in relation to obesity and risk factors for obesity are widening. Addressing inequalities in obesity, therefore, has a very high profile on the public health and health services agendas. However, there is a lack of accessible policy-ready evidence on what works in terms of interventions to reduce inequalities in obesity. Methods and design This article describes the protocol for a National Health Service Trust (NHS) National Institute for Health Research-funded systematic review of public health interventions at the individual, community and societal levels which might reduce socioeconomic inequalities in relation to obesity amongst children ages 0 to 18 years. The studies will be selected only if (1) they included a primary outcome that is a proxy for body fatness and (2) examined differential effects with regard to socioeconomic status (education, income, occupation, social class, deprivation and poverty) or the intervention was targeted specifically at disadvantaged groups (for example, children of the unemployed, lone parents, low income and so on) or at people who live in deprived areas. A rigorous and inclusive international literature search will be conducted for randomised and nonrandomised controlled trials, prospective and retrospective cohort studies (with and/or without control groups) and prospective repeat cross-sectional studies (with and/or without control groups). The following electronic databases will be searched: MEDLINE, Embase, CINAHL, PsycINFO, Social Science Citation Index, ASSIA, IBSS, Sociological Abstracts and the NHS Economic Evaluation Database. Database searches will be supplemented with website and grey literature searches. No studies will be excluded on the basis of language, country of origin or publication date. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Meta-analysis and narrative synthesis will be conducted. The main analysis will examine the effects of (1) individual, (2) community and (3) societal level public health interventions on socioeconomic inequalities in childhood obesity. Interventions will be characterised by their level of action and their approach to tackling inequalities. Contextual information on how such public health interventions are organised, implemented and delivered will also be examined. Discussion In this review, we consider public health strategies which reduce and prevent inequalities in the prevalence of childhood obesity, highlight any gaps in the evidence base and seek to establish how such public health interventions are organised, implemented and delivered. PROSPERO registration number: CRD42011001740

A number of studies have reported significant associations between obesity and poor psychological wellbeing in children but findings have been inconsistent. Methods: This study utilised data from 3,898 children aged 5-16 years obtained from the Health Survey for England 2007. Information was available on Body Mass Index (BMI), parental ratings of child emotional and behavioural health (Strengths and Difficulties Questionnaire), self-reported physical activity levels and sociodemographic variables. A multilevel modelling approach was used to allow for the clustering of children within households. Results: Curvilinear relationships between both internalising (emotional) and externalising (behavioural) symptoms and adjusted BMI were observed. After adjusting for potential confounders the relationships between obesity and psychological adjustment (reported externalising and internalising symptoms) remained statistically significant. Being overweight, rather than obese, had no impact on overall reported mental health. 17% of children with obesity were above the suggested screening threshold for emotional problems, compared to 9% of non-obese children. Allowing for clustering and potential confounding variables children classified as obese had an odds ratio (OR) of 2.13 (95% CI 1.39 to 3.26) for being above the screening threshold for an emotional disorder compared to non-obese young people. No cross-level interactions between household income and the relationships between obesity and internalising or externalising symptoms were observed. Conclusions: In this large, representative, UK-based community sample a curvilinear association with emotional wellbeing was observed for adjusted BMI suggesting the possibility of a threshold effect. Further research could focus on exploring causal relationships and developing targeted interventions.

Dr Duika L Burges Watson and Dr Helen J Moore from Durham University look at how community gardening could be a positive option for individuals who wish to confront a weight issue. But is it likely to be facilitated by 'Big Society' or 'nudge'? The Foresight report in the UK identified and quantified growing concerns about obesity.1 It has also been credited with shifting the discourse away from the stigmatizing focus on individual responsibility to the consideration of environmental determinants.2 The 'obesogenic' environment literature has shown that in areas that are deprived of access to healthy food choices as well as green space and transport links, there is a strong association with higher rates of obesity.3 A growing body of evidence reveals the impact of environmental factors on weight gain, for example, demonstrating the concentration of energy-dense 'fast' foods in areas of deprivation and links to obesity.4 It is generally accepted that community gardening and food growing may increase physical activity and benefit diet, particularly as such projects may enhance community access to fresh vegetables and fruit. However, the extent to which this is the case and the particular value of community gardening for obesity, is less well established. Moreover, while a focus on environment may reduce the stigmatizing effects of individually focused obesity policy, critiques of the 'obesogenic' literature caution against the ways in which such approaches create a dystopian view of the future, make people fearful and limit their positive life (and ergo gardening) experience in the present.2 There is a paucity of research specifically focusing on the impact of community gardening on obesity. In part this may reflect the far broader benefits that are both social and health related. European research suggests that people who live proximate to areas of greenery are three times more likely to engage in physical activity and 40% less likely to be overweight.5 A review and briefing document issued by the UK Faculty of Public Health succinctly sets out the 'mounting evidence' that green space has a positive impact on physical activity and mental health, as well as benefits for therapeutic and rehabilitation purposes.6 Studies have been carried out that demonstrate that participants/users of community gardens and allotment spaces particularly value the activity because of the psychological and social benefits that it brings; any health-related improvements generated from the activity are generally viewed as a secondary bonus and not the motivating factor to participate. Research in Australia, Canada, the USA and the UK has investigated the ways that gardening (community and allotment) contributes to the enhancement of health and well-being for urbanites. Gardening appears to have many health benefits (perceived or measured) that can positively improve the physical and psychological health of participants. Gardening itself appears to increase selfesteem, increase physical activity levels and also improve diet.7-10 Studies have also shown that participants of community garden and allotment spaces believe that other advantages of these schemes include generating a sense of community and a sense of achievement; provision of access to garden space where none existed before, increased levels of community attachment.11-14 However, as Arneson et al. note, in a recent review of research on community gardens and farmers' markets in the US, while such ventures have been extensively promoted and are well established, there has been little evaluation of their impact on nutritional intake.15 One survey of 766 adults in Flint, MI compared the fruit and vegetable intake of people who were and who were not engaged in community gardens. The survey included self-reported weight status with 68% claiming to be overweight. Overall, findings suggested that community gardeners were 3.5 times more likely to consume fruit and vegetables five times a day. …

Background Obesity treatment is by large ineffective long term, and more emphasis on the prevention of excessive weight gain in childhood and adolescence is warranted. To inform energy balance related behaviour (EBRB) change interventions, insight in the potential personal, family and school environmental correlates of these behaviours is needed. Studies on such multilevel correlates of EBRB among schoolchildren in Europe are lacking. The ENERGY survey aims to (1) provide up-to-date prevalence rates of measured overweight, obesity, self-reported engagement in EBRBs, and objective accelerometer-based assessment of physical activity and sedentary behaviour and blood-sample biomarkers of metabolic function in countries in different regions of Europe, (2) to identify personal, family and school environmental correlates of these EBRBs. This paper describes the design, methodology and protocol of the survey. Method/Design A school-based cross-sectional survey was carried out in 2010 in seven different European countries; Belgium, Greece, Hungary, the Netherlands, Norway, Slovenia, and Spain. The survey included measurements of anthropometrics, child, parent and school-staff questionnaires, and school observations to measure and assess outcomes (i.e. height, weight, and waist circumference), EBRBs and potential personal, family and school environmental correlates of these behaviours including the social-cultural, physical, political, and economic environmental factors. In addition, a selection of countries conducted accelerometer measurements to objectively assess physical activity and sedentary behaviour, and collected blood samples to assess several biomarkers of metabolic function. Discussion The ENERGY survey is a comprehensive cross-sectional study measuring anthropometrics and biomarkers as well as assessing a range of EBRBs and their potential correlates at the personal, family and school level, among 10-12 year old children in seven European countries. This study will result in a unique dataset, enabling cross country comparisons in overweight, obesity, risk behaviours for these conditions as well as the correlates of engagement in these risk behaviours.

Background There is an urgent need for more carefully developed public health measures in order to curb the obesity epidemic among youth. The overall aim of the "EuropeaN Energy balance Research to prevent excessive weight Gain among Youth" (ENERGY)-project is the development and formative evaluation of a theory-informed and evidence-based multi-component school-based and family-involved intervention program ready to be implemented and evaluated for effectiveness across Europe. This program aims at promoting the adoption or continuation of health behaviors that contribute to a healthy energy balance among school-aged children. Earlier studies have indicated that school and family environments are key determinants of energy-balance behaviors in schoolchildren. Schools are an important setting for health promotion in this age group, but school-based interventions mostly fail to target and involve the family environment. Methods Led by a multidisciplinary team of researchers from eleven European countries and supported by a team of Australian experts, the ENERGY-project is informed by the Environmental Research Framework for Weight gain Prevention, and comprises a comprehensive epidemiological analysis including 1) systematic reviews of the literature, 2) secondary analyses of existing data, 3) focus group research, and 4) a cross European school-based survey. Results and discussion The theoretical framework and the epidemiological analysis will subsequently inform stepwise intervention development targeting the most relevant energy balance-related behaviors and their personal, family-environmental and school-environmental determinants applying the Intervention Mapping protocol. The intervention scheme will undergo formative and pilot evaluation in five countries. The results of ENERGY will be disseminated among key stakeholders including researchers, policy makers and the general population. Conclusions The ENERGY-project is an international, multidisciplinary effort to develop and test an evidence-based and theory-informed intervention program for obesity prevention among school-aged children.