How to influence the obesity landscape using health policies

Normalisation and equity of referral to the NHS Low Calorie Diet programme pilot; a qualitative evaluation of the experiences of health care staff

BACKGROUND

Health and wellbeing can be profoundly impacted by both obesity and type 2 diabetes, while the normalisation and equity of care for people living with these non-communicable diseases remain as challenges for local health systems. The National Health Service Low Calorie Diet programme in England, aims to support people to achieve type 2 diabetes remission, while also reducing health inequalities. We have explored the experiences of health care staff who have made a referral to the LCD programme, while identifying effective and equitable delivery of programme referrals, and their normalisation into routine care.

METHODS

Nineteen individual semi-structured interviews were completed health care staff in the first year of the Low Calorie Diet programme. Interviewees were purposively sampled from the ten localities who undertook the Low Calorie Diet programme pilot. Each interview explored a number of topics of interest including communication and training, referrals, equity, and demands on primary care, before being subjected to a thematic analysis.

RESULTS

From the data, five core themes were identified: Covid-19 and the demands on primary care, the expertise and knowledge of referrers, patient identification and the referral process, barriers to referrals and who gets referred to the NHS LCD programme. Our findings demonstrate the variation in the real world settings of a national diabetes programme. It highlights the challenge of COVID-19 for health care staff, whereby the increased workload of referrals occurred at a time when capacity was curtailed. We have also identified several barriers to referral and have shown that referrals had not yet been normalised into routine care at the point of data collection. We also raise issues of equity in the referral process, as not all eligible people are informed about the programme.

CONCLUSIONS

Referral generation had not yet been consistently normalised into routine care, yet our findings suggest that the LCD programme runs the risk of normalising an inequitable referral process. Inequalities remain a significant challenge, and the adoption of an equitable referral process, normalised at a service delivery level, has the capacity to contribute to the improvement of health inequalities.

How do local authority plans to tackle obesity reflect systems thinking?

AIMS

A whole systems approach to tackling obesity has been recommended by Public Health England for several years. This qualitative study aimed to investigate whether systems thinking is reflected in local authority plans and strategies to tackle obesity, using the leverage points for intervention in a complex system, as a framework.

METHOD

We sought to identify obesity strategies/plans for Southampton and 19 other local authority comparators (based on children's services and Office for National Statistics data). A healthy weight strategy was available for 10 local authorities and a qualitative document analysis was undertaken. The policy actions proposed in the plans were coded against the leverage points for intervention in a complex system and themes were developed to characterise interventions in each category.

RESULTS

A majority of actions included in the plans were categorised as 'Numbers, Constants and Parameters' which reflect downstream measures. However, there were examples of actions that could act on higher leverage points. In addition, some local authority plans included interventions that could act on 10 of the 12 leverage points suggesting incorporation of systems thinking.

CONCLUSIONS

Some local authority plans to tackle obesity do reflect systems thinking when viewed through the lens of the leverage points for intervention in a complex system. Interventions at higher leverage points should be prioritised by public health decision-makers, especially in a climate of competing agendas and limited resources.

Modelled Distributional Cost-Effectiveness Analysis of Childhood Obesity Interventions: A Demonstration

OBJECTIVE

To demonstrate how distributional cost-effectiveness analyses of childhood obesity interventions could be conducted and presented for decision makers.

METHODS

We conducted modelled distributional cost-effectiveness analyses of three obesity interventions in children: an infant sleep intervention (POI-Sleep), a combined infant sleep, food, activity and breastfeeding intervention (POI-Combo) and a clinician-led treatment for primary school-aged children with overweight and obesity (High Five for Kids). For each intervention, costs and socioeconomic position (SEP)-specific effect sizes were applied to an Australian child cohort (n = 4898). Using a purpose-built microsimulation model we simulated SEP-specific body mass index (BMI) trajectories, healthcare costs and quality-adjusted life years (QALYs) from age 4 to 17 years for control and intervention cohorts. We examined the distribution of each health outcome across SEP and determined the net health benefit and equity impact accounting for opportunity costs and uncertainty due to individual-level heterogeneity. Finally, we conducted scenario analyses to test the effect of assumptions about health system marginal productivity, the distribution of opportunity costs and SEP-specific effect sizes. The results of the primary analyses, uncertainty analyses and scenario analyses were presented on an efficiency-equity impact plane.

RESULTS

Accounting for uncertainty, POI-Sleep and High Five for Kids were found to be 'win-win' interventions, with a 67% and 100% probability, respectively, of generating a net health benefit and positive equity impact compared with control. POI-Combo was found to be a 'lose-lose' intervention, with a 91% probability of producing a net health loss and a negative equity impact compared with control. Scenario analyses indicated that SEP-specific effect sizes were highly influential on equity impact estimates for POI-Combo and High Five for Kids, while health system marginal productivity and opportunity cost distribution assumptions primarily influenced the net health benefit and equity impact of POI-Combo.

CONCLUSIONS

These analyses demonstrated that distributional cost-effectiveness analyses using a fit-for-purpose model are appropriate for differentiating and communicating the efficiency and equity impacts of childhood obesity interventions.

A Critical Analysis of Representations of Inequalities in Childhood Obesity in Australian Health Policy Documents

BACKGROUND

In Australia, childhood obesity follows a socioeconomic gradient whereby children with lower socioeconomic position are disproportionately burdened. To reduce these inequalities in childhood obesity requires a multi-component policy-driven response. Action to address health issues is underpinned by the ways in which they are represented as 'problems' in public policy. This study critically examines representations of inequalities in childhood obesity within Australian health policy documents published between 2000-2019.

METHODS

Australia's federal, state and territory government health department websites were searched for health policy documents including healthy weight, obesity, healthy eating, food and nutrition strategies; child and youth health strategies; and broader health and wellbeing, prevention and health promotion policies that proposed objectives or strategies for childhood obesity prevention. Thematic analysis of eligible documents was guided by a theoretical framework informed by problematization theory, ecological systems theory, and theoretical principles for equity in health policy.

RESULTS

Eighteen policy documents were eligible for inclusion. The dominant representation of inequalities in childhood obesity was one of individual responsibility. The social determinants of inequalities in childhood obesity were acknowledged, yet policy actions predominantly focused on individual determinants. Equity was positioned as a principle of policy documents but was seldom mentioned in policy actions.

CONCLUSION

Current representations of inequalities in childhood obesity in Australian health policy documents do not adequately address the underlying causes of health inequities. In order to reduce inequalities in childhood obesity future policies will need greater focus on health equity and the social determinants of health (SDoH).

Temperamental and Personality Traits as Factors Related to Changes in Health Behaviors and Quality of Life in Patients With Metabolic Syndrome in Poland

Lifestyle changes in diet and physical activity are necessary for managing metabolic syndrome. The aim of this longitudinal study was to examine temperamental and personality traits as moderators of lifestyle changes prompted by motivational intervention. The sample consisted of 50 patients aged 22–65years (M=45.26; SD=9.79) who fulfilled the diagnostic criteria for metabolic syndrome and were undergoing treatment at the Military Institute of Medicine in Warsaw. There were two measurements: an initial measurement and a second 15months after motivational counseling. Each patient completed the questionnaires: Formal Characteristics of Behavior – Temperament Inventory, NEO Five Factor Inventory, Inventory of Health Behavior, and Short Form Survey SF-36. Body Mass Index (BMI), Fat Mass, Fat-free Mass, Intracellular Water, and Basal Metabolic Rate (BMR) were also measured. Data were analyzed using dependent samples t-tests to detect the changes in consecutive measurements, the hierarchical regression analysis was used to investigate temperamental and personality traits as predictors of change, the cluster analysis was used to extract the subgroups of patients with distinct profiles of temperamental and personality traits, and the analysis of variance was used to analyze extracted profiles as potential moderators of change. Three subgroups were extracted using k-means clustering: patients with higher Neuroticism, Perseveration, and Emotional Reactivity; patients higher Extraversion, Briskness, Sensory Sensitivity, Endurance, Activity, and Conscientiousness; and patients with lower Perseveration. All patients improved significantly in terms of physical quality of life (QoL), health behaviors, BMI, BMR, and Fat-free Mass (p<0.05). Regression analysis found that higher Sensory Sensitivity, lower Perseveration, and higher Agreeableness fostered positive change (p<0.05). Patients with higher Neuroticism, Perseveration, and Emotional Reactivity also improved in terms of their Emotional Quality of Life and Health Practices, reaching parity with other patients, which was verified on the basis of statistically significant interaction (p<0.05). The temperamental and personality trait profiles moderated the changes in health practices and emotional QoL. Motivational counseling was effective for patients diagnosed with metabolic syndrome in general, but patients with higher Neuroticism, Perseveration, and Emotional Reactivity benefited even more, as they were in poorer psychological condition before the motivational intervention.

National nutrition policy in high-income countries: is health equity on the agenda?

OBJECTIVE

Equity-oriented policy actions are a key public health principle. In this study, how equity and socioeconomic inequalities are represented in policy problematizations of population nutrition were examined.

DATA SOURCES

We retrieved a purposive sample of government nutrition-policy documents (n = 18) from high-income nations.

DATA SYNTHESIS

Thematic analysis of policy documents was informed by a multitheoretical understanding of equitable policies and Bacchi's "What's the Problem Represented to be?' analysis framework. Despite common rhetorical concerns about the existence of health inequalities, these concerns were often overshadowed by greater emphasis on lifestyle "problems" and reductionist policy actions. The notion that policy actions should be for all and reach everyone were seldom backed by specific actions. Rhetorical acknowledgements of the upstream drivers of health inequalities were also rarely problematized, as were government responsibilities for health equity and the role of policy and governance in reducing socioeconomic inequalities in nutrition.

CONCLUSION

To positively influence health equity outcomes, national nutrition policy will need to transition toward the prioritization of actions that uphold social justice and comprehensively address the upstream determinants of health.

The role of colour and summary indicators in influencing front-of-pack food label effectiveness across seven countries

OBJECTIVE

Many countries are considering the implementation of front-of-pack nutrition labels as a strategy to address high and increasing levels of overweight and obesity. A growing body of work demonstrates the superiority of labels that use colour and/or provide a summary indicator of product healthiness to enhance comprehension. However, previous studies have been confounded in determining the relative effectiveness of these two attributes by comparing labels that also differ in other ways. The present study tested labels that varied only on use of colour and/or reliance on a summary indicator across an international sample to provide unique insights into the relative importance of these attributes.

DESIGN

Participants were randomised to see one of four variations of the Health Star Rating label that differed on the basis of use of colour and sole provision of a summary indicator.

SETTING

Australia, Canada, China, India, New Zealand, the UK and the USA.

PARTICIPANTS

Adults (n 7545) in seven countries were exposed to online choice tasks requiring them to select a preferred breakfast cereal and then nominate the healthiest cereal.

RESULTS

Overall, the coloured versions, and particularly the one with just a summary indicator, outperformed the monochrome version that included nutrient-specific information. However, there were some differences by country, with results from Canada and China indicating superior outcomes for monochrome labels and those providing nutrient-specific information.

CONCLUSIONS

The results highlight the importance of colour, but suggest that the introduction of front-of-pack nutrition labels should be preceded by country-specific formative testing to identify potential differences in outcomes.

Identifying implementation gaps and priorities for the Singapore government to improve food environment policies: perspectives from a local expert panel

OBJECTIVE

Singapore, an urbanised, developed nation, with a high reliance on food importation and a high prevalence of eating out is facing rising rates of obesity and diabetes. The objective of the current study was to characterise and evaluate the Singapore government's policies to improve the food environment and to identify and prioritise concrete actions.

DESIGN

The Healthy Food Environment Policy Index tool and process were used. An expert panel rated the Singapore government's implementation of forty-seven indicators compared with international best practice in 2018. Indicators were prioritised, and specific recommendations were proposed by panel.

SETTING

Singapore.

PARTICIPANTS

Twenty experts primarily from academia.

RESULTS

As compared with international benchmarks, the level of implementation of most indicators (thirty-three indicators, 70 %) by the Singapore government was evaluated as being at least moderate. Highly rated indicators included those related to provision of healthier meals at school, supporting the use of healthier ingredients by food vendors and governmental leadership. More policy indicators (6, 26 %) as compared with infrastructure support indicators (2, 8 %) received a 'very little or no implementation' rating. After rating, the experts prioritised eleven indicators and proposed thirty-one actions informed by several considerations including those of effectiveness, political acceptability, feasibility and unique characteristics of food retail in Singapore.

CONCLUSIONS

Supported by documented evidence, an independent expert panel identified areas of strengths and provided specific recommendations to meaningfully improve the Singapore food environment to facilitate healthier eating. Fundamental recommendations including improving nutrition profiling and strengthening monitoring systems have the potential to positively influence environments across policy domains.

Maboo wirriya, be healthy: Community-directed development of an evidence-based diabetes prevention program for young Aboriginal people in a remote Australian town

Supporting healthy lifestyle behaviours is a key aspect of preventing type 2 diabetes which disproportionately affects disadvantaged groups from a younger age. Formative participatory research was undertaken to design a program for young Aboriginal people in a remote town in North West Australia with a high level of health needs and relatively few prevention initiatives. Focus groups and advisory discussions with Aboriginal community members were used to determine the nature of the program. The need for a comprehensive program was consistently expressed and limited healthy lifestyle knowledge and difficulties with healthy eating influenced by food environments were noted to be important. With guidance from the Derby Aboriginal Health Service, findings were integrated with previous international research evidence to develop a program tailored to local Aboriginal people aged 15-25 years and refine it after piloting. This 8-session program, 'Maboo wirriya, be healthy' involved an education component consistent with the US Diabetes Prevention Program and practical activities including group exercise. Changes to program structure and documentation were made after piloting for future use. The community-directed approach used in this study is vital to ensure relevance of localised chronic disease prevention programs in a range of settings.

Proportion of Cancer Cases Attributable to Excess Body Weight by US State, 2011-2015

Importance

Excess body weight (EBW) is an established cause of cancer. Despite variations in the prevalence of EBW among US states, there is little information on the EBW-related cancer burden by state; this information would be useful for setting priorities for cancer-control initiatives.

Objective

To calculate the population attributable fraction (PAF) of incident cancer cases attributable to EBW among adults 30 years or older in 2011 to 2015 in all 50 states and the District of Columbia.

Design, Setting, and Participants

State-level, self-reported body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) data from the Behavioral Risk Factor Surveillance System were adjusted by sex, age, race/ethnicity, and education using objectively measured BMI values from the National Health and Nutrition Examination Survey. Age- and sex-specific cancer incidence data by state were obtained from the US Cancer Statistics database. All analyses were performed between February 15, 2018, and July 17, 2018.

Main Outcomes and Measures

Sex-, age-, and state-specific adjusted prevalence estimates for 4 high BMI categories and corresponding relative risks from large-scale pooled analyses or meta-analyses were used to compute the PAFs for each US state for esophageal adenocarcinoma, multiple myeloma, and cancers of the gastric cardia, colorectum, liver, gallbladder, pancreas, female breast, corpus uteri, ovary, kidney and renal pelvis, and thyroid.

Results

Each year, an estimated 37 670 cancer cases in men (4.7% of all cancer cases excluding nonmelanoma skin cancers) and 74 690 cancer cases in women (9.6%) 30 years or older in the United States were attributable to EBW from 2011 to 2015. In both men and women, there was at least a 1.5-fold difference in the proportions of cancers attributable to EBW between states with the highest and lowest PAFs. Among men, the PAF ranged from 3.9% (95% CI, 3.6%-4.3%) in Montana to 6.0% (95% CI, 5.6%-6.4%) in Texas. The PAF for women was approximately twice as high as for men, ranging from 7.1% (95% CI, 6.7%-7.6%) in Hawaii to 11.4% (95% CI, 10.7%-12.2%) in the District of Columbia. The largest PAFs were found mostly in southern and midwestern states, as well as Alaska and the District of Columbia.

Conclusions and Relevance

The proportion of cancers attributable to EBW varies among states, but EBW accounts for at least 1 in 17 of all incident cancers in each state. Broad implementation of known community- and individual-level interventions is needed to reduce access to and marketing of unhealthy foods (eg, through a tax on sugary drinks) and to promote and increase access to healthy foods and physical activity, as well as preventive care.

Toward Whole-of-System Action to Promote Physical Activity: A Cross-Sectoral Analysis of Physical Activity Policy in Australia

BACKGROUND

The value of a systems thinking approach to tackling population physical inactivity is increasingly recognized. This study used conceptual systems thinking to develop a cognitive map for physical activity (PA) influences and intervention points, which informed a standardized approach to the coding and notation of PA-related policies in Australia.

METHODS

Policies were identified through desktop searches and input from 33 nominated government representatives attending 2 national PA policy workshops. Documents were audited using predefined criteria spanning policy development, strategic approaches to PA, implementation processes, and evaluation. Data were analyzed using descriptive statistics.

RESULTS

The audit included 110 policies, mainly led by the health or planning/infrastructure sectors (n = 54, 49%). Most policies purporting to promote PA did so as a cobenefit of another objective that was not focused on PA (n = 63, 57%). An intention to monitor progress was indicated in most (n = 94, 85%); however, fewer than half (n = 52, 47%) contained evaluable goals/actions relevant to PA. Descriptions of resourcing/funding arrangements were generally absent or lacked specific commitment (n = 67, 61%).

CONCLUSIONS

This study describes current PA-relevant policy in Australia and identifies opportunities for improving coordination, implementation, and evaluation to strengthen a whole-of-system and cross-agency approach to increasing population PA.

The Population Cost-Effectiveness of Weight Watchers with General Practitioner Referral Compared with Standard Care

OBJECTIVE

This study aimed to assess population-level cost-effectiveness of the Weight Watchers (WW) program with doctor referral compared with standard care (SC) for Australian adults with overweight and obesity.

METHODS

The target population was Australian adults ≥ 20 years old with BMI ≥ 27 kg/m² , whose obesity status was subsequently modeled for 2015 to 2025. A microsimulation model (noncommunicable disease model [NCDMod]) was used to assess the incremental cost-effectiveness of WW compared with SC. A health system perspective was taken, and outcomes were measured by obesity cases averted in 2025, BMI units averted for 2015 to 2025, and quality-adjusted life years for 2015 to 2025. Univariate sensitivity testing was used to measure variations in the model parameters.

RESULTS

The WW intervention resulted in 60,445 averted cases of obesity in 2025 (2,311 more cases than for SC), extra intervention costs of A$219 million, and cost savings within the health system of A$17,248 million (A$82 million more than for SC) for 2015 to 2025 compared with doing nothing. The modeled WW had an incremental cost-effectiveness ratio of A$35,195 in savings per case of obesity averted in 2025. WW remained dominant over SC for the different scenarios in the sensitivity analysis.

CONCLUSIONS

The WW intervention represents good value for money. The WW intervention needs serious consideration in a national package of obesity health services.

Time-course and dynamics of obesity-related behavioral changes induced by energy-dense foods in mice

Obesity represents an important risk factor contributing to the global burden of disease. The current obesogenic environment with easy access to calorie-dense foods is fueling this obesity epidemic. However, how these foods contribute to the progression of feeding behavior changes that lead to overeating is not well understood and needs systematic assessment. Using novel automated methods for the high-throughput screening of behavior, we here examine mice meal pattern upon long-term exposure to a free-choice chocolate-mixture diet and a high-fat diet with face validity for a rapid development of obesity induced by unhealthy food regularly consumed in our societies. We identified rapid diet-specific behavioral changes after exposure to those high-caloric diets. Mice fed with high-fat chow, showed long-lasting meal pattern disturbances, which initiate with a stable loss of circadian feeding rhythmicity. Mice receiving a chocolate-mixture showed qualitatively similar changes, though less marked, consisting in a transient disruption of the feeding behavior and the circadian feeding rhytmicity. Strikingly, compulsive-like eating behavior is triggered immediately after exposure to both high-fat food and chocolate-mixture diet, well before any changes in body weight could be observed. We propose these changes as behavioral biomarkers of prodromal states of obesity that could allow early intervention.

The Global Epidemic of the Metabolic Syndrome

Metabolic syndrome, variously known also as syndrome X, insulin resistance, etc., is defined by WHO as a pathologic condition characterized by abdominal obesity, insulin resistance, hypertension, and hyperlipidemia. Though there is some variation in the definition by other health care organization, the differences are minor. With the successful conquest of communicable infectious diseases in most of the world, this new non-communicable disease (NCD) has become the major health hazard of modern world. Though it started in the Western world, with the spread of the Western lifestyle across the globe, it has become now a truly global problem. The prevalence of the metabolic syndrome is often more in the urban population of some developing countries than in its Western counterparts. The two basic forces spreading this malady are the increase in consumption of high calorie-low fiber fast food and the decrease in physical activity due to mechanized transportations and sedentary form of leisure time activities. The syndrome feeds into the spread of the diseases like type 2 diabetes, coronary diseases, stroke, and other disabilities. The total cost of the malady including the cost of health care and loss of potential economic activity is in trillions. The present trend is not sustainable unless a magic cure is found (unlikely) or concerted global/governmental/societal efforts are made to change the lifestyle that is promoting it. There are certainly some elements in the causation of the metabolic syndrome that cannot be changed but many are amenable for corrections and curtailments. For example, better urban planning to encourage active lifestyle, subsidizing consumption of whole grains and possible taxing high calorie snacks, restricting media advertisement of unhealthy food, etc. Revitalizing old fashion healthier lifestyle, promoting old-fashioned foods using healthy herbs rather than oil and sugar, and educating people about choosing healthy/wholesome food over junks are among the steps that can be considered.