Food for thought: pilot randomized controlled trial of lay health trainers supporting dietary change to reduce cardiovascular disease in deprived communities

Insights for dementia risk reduction among lower SES adults in OECD countries: scoping review of interventions targeting multiple common health risk factors

The number of people living with dementia is expected to rise to 153 million cases globally by 2050. This will come at a high economic and human cost to societies with disproportionate effects on socioeconomically disadvantaged groups who experience greater exposures to- and fewer protections from- the environmental, social and behavioural drivers of dementia risk. Almost half (45%) of dementia incidence could theoretically be prevented or delayed by addressing 14 modifiable risk factors. While several studies have demonstrated the feasibility of multidomain dementia risk reduction interventions in relatively older, educated and wealthy populations, we are not aware of any studies to date explicitly targeting younger adults (< 50 years) with lower socioeconomic status. To inform future strategies, we conducted a scoping review of intervention studies targeting multiple 'dementia-related' risk factors among adults with lower socioeconomic status in developed country contexts. We identified 1003 unique records; 34 met our criteria for inclusion - involving more than 17,500 participants from 13 countries. While none of the studies explicitly targeted dementia risk reduction, they reported on 30 relevant multidomain interventions targeting common risk factors associated with dementia including; diet (28), physical inactivity (27), obesity (22), diabetes (9), hypertension (8), smoking (6), alcohol use (6), depression (3) and social isolation (1). While most studies recorded positive effects on one or more health behaviours, there was a diversity in the design, approach and outcomes of interventions, with significant intervention effects being associated with the use of a wider range of behaviour change techniques. We suggest that designing interventions to reduce dementia risk and disparities requires a high degree of contextual specificity and propose a structured and participatory approach.

Barriers and facilitators to healthy eating in disadvantaged adults living in the UK: a scoping review

In the UK people living in disadvantaged communities are less likely than those with higher socio-economic status to have a healthy diet. To address this inequality, it is crucial scientists, practitioners and policy makers understand the factors that hinder and assist healthy food choice in these individuals. In this scoping review, we aimed to identify barriers and facilitators to healthy eating among disadvantaged individuals living in the UK. Additionally, we used the Theoretical Domains Framework (TDF) to synthesise results and provide a guide for the development of theory-informed behaviour change interventions. Five databases were searched, (CINAHL, Embase, MEDLINE, PsycINFO, and Web of Science) for articles assessing healthy dietary intake of disadvantaged adults living in the UK. A total of 50 papers (34 quantitative; 16 qualitative) were included in this review. Across all studies we identified 78 barriers and 49 facilitators found to either impede and/or encourage healthy eating. Both barriers and facilitators were more commonly classified under the Environmental, Context and Resources TDF domain, with 74% of studies assessing at least one factor pertaining to this domain. Results thus indicate that context related factors such as high cost and accessibility of healthy food, rather than personal factors, such as lack of efficiency in healthy lifestyle drive unhealthy eating in disadvantaged individuals in the UK. We discuss how such factors are largely overlooked in current interventions and propose that more effort should be directed towards implementing interventions that specifically target infrastructures rather than individuals.

Peer-led lifestyle interventions for the primary prevention of cardiovascular disease in community: a systematic review of randomised controlled trials

BACKGROUND

Peer-led lifestyle interventions have gained recognition as effective approaches for managing and preventing chronic diseases. However, there remains a critical knowledge gap regarding the impact and effectiveness of peer-led interventions specifically in the primary prevention of cardiovascular disease (CVD). Our systematic review aims to synthesise the available evidence and evaluate the impact of peer-led lifestyle interventions, providing invaluable insights that can guide the development of peer-led strategies for preventing CVD.

METHODS

Systematic database searches were conducted on Ovid Medline, Embase, Cochrane Centre for Controlled Trials, PubMed and Scopus to source peer-reviewed articles published between 2013 and 2023. Reference lists of the included publications were also manually searched.

RESULTS

Fourteen unique randomised controlled trials were identified, of which three were pilot studies. Most of the interventions were conducted among individuals at moderate to high risk of CVD and lasted for a year. There is a variety of components in intervention delivery, including group discussions and individual counselling. Peer leader training mostly covered intervention delivery, communication, and research-specific skills. Systolic blood pressure showed the most promising CVD-related improvement, while mixed results were found for several other dietary and lifestyle behavioural outcomes.

CONCLUSION

Peer-led lifestyle interventions have shown varying effectiveness in cardiovascular health outcomes. The competencies and roles of peer leaders were identified to guide future intervention development with a more comprehensive approach to the primary prevention of CVD.

Multiple deprivation and other risk factors for maternal obesity in Portsmouth, UK

BACKGROUND

Maternal obesity is known to be associated with a range of adverse outcomes, both for the mothers and their children. It may be more prevalent in areas with higher deprivation as measured by the Index of Multiple Deprivation (IMD), but this has not been demonstrated consistently. This study focused primarily on the relationship between maternal obesity and deprivation in a setting where areas of significant deprivation are surrounded by the overall affluent South East England.

METHODS

The study used the records of 3830 women who delivered under the care of a Portsmouth hospital from 1 April 2013 to 31 March 2014. Logistic regression was used to analyse the association between national IMD quintiles and maternal obesity, accounting for the potential confounders of age, ethnic origin, smoking status and parity.

RESULTS

Following adjustment, women in the most deprived IMD quintile were 1.60 (95% CI: 1.13, 2.26) times more likely to be obese compared to those in the least deprived quintile. Maternal obesity was also found to be associated with ethnicity and parity, but not with age or smoking status.

CONCLUSIONS

Maternal obesity increased with increasing deprivation. IMD may be a useful group-level indicator when planning interventions aimed at tackling maternal obesity.

Impact and acceptability of lay health trainer-led lifestyle interventions delivered in primary care: a mixed method study

Aim

To evaluate the impact and acceptability of offering one-to-one lifestyle interventions delivered by lay health trainers in the primary care setting.

Background

Chronic conditions represent major causes of ill-health, avoidable disability, pain and anxiety, and tend to be more prevalent in less affluent groups. This is due, in part, to the link between unhealthy lifestyles and lower socio-economic status, although factors such as poverty, worklessness and social exclusion play a larger role. Lay health trainers were introduced in England with the aim of providing personalised lifestyle advice, support and access to services for people living in disadvantaged areas. There is a body of literature on the effectiveness of lay or community health workers in the management of chronic conditions. However, little is known about their potential to promote lifestyle changes in newly diagnosed patients. An innovative health trainer service was piloted in the primary care setting, to work with people diagnosed with a chronic condition or identified as potentially benefitting from one-to-one support.

Methods

A mixed method study design was utilised. Semi-structured interviews and focus groups were conducted with practice staff (n=11) and patients (n=15) from one primary care practice in North East England, United Kingdom. Discussions were audio-recorded and analysed using a thematic content approach. Routinely collected pre-/post-intervention data (n=246 patients at baseline; sample sizes varied at end line) were analysed and appropriate descriptive and summary statistics produced.

Findings

The discussions highlighted a high level of satisfaction with the health trainer model in terms of supporting positive lifestyle changes. Locating the intervention within the practice removed access barriers, particularly for those with long-term conditions. Anecdotal evidence of health improvement was supported by the quantitative analyses, which revealed statistically significant improvements in body mass index, blood pressure, dietary habits, exercise levels, alcohol intake, self-rated health and self-efficacy amongst those who completed the intervention.

Outcomes of an integrated community-based nurse-led cardiovascular disease prevention programme

Background

National guidance for England recommends that cardiovascular disease (CVD) should be managed as a family of diseases in the community. Here, we describe the results of such an approach.

Methods

Patients with established CVD or who were at high multifactorial risk (HRI) underwent a 12-week community-based nurse-led prevention programme (MyAction) that included lifestyle and risk factor management, prescription of medication and weekly exercise and education sessions.

Results

Over a 6-year period, 3232 patients attended an initial assessment; 63% were male, and 48% belonged to black and minority ethnic groups. 56% attended an end-of-programme assessment, and 33% attended a one year assessment. By the end of the programme, there was a significant reduction in smoking prevalence but only in HRI (−3.7%, p<0.001). Mediterranean diet score increased in both CVD (+1.2, p<0.001) and HRI (+1.5; p<0.001), as did fitness levels (CVD +0.8 estimated Mets maximum, p<0.001, HRI +0.9 estimated Mets maximum, p<0.001) and the proportions achieving their physical activity targets (CVD +40%, p<0.001, HRI +37%, p<0.001). There were significant increases in proportions achieving their blood pressure (CVD +15.4%, p<0.001, HRI +25%, p<0.001 and low-density lipoprotein cholesterol targets (CVD +6%, p=0.004, HRI +23%, p<0.001). Statins and antihypertensive medications significantly increased in HRI. Significant improvements in depression scores and quality-of-life measures were also seen. The majority of improvements were maintained at 1 year.

Conclusion

These results demonstrate that an integrated vascular prevention programme is feasible in practice and reduces cardiovascular risk in patients with established CVD and in those at high multifactorial risk.

Defining Feasibility and Pilot Studies in Preparation for Randomised Controlled Trials: Development of a Conceptual Framework

We describe a framework for defining pilot and feasibility studies focusing on studies conducted in preparation for a randomised controlled trial. To develop the framework, we undertook a Delphi survey; ran an open meeting at a trial methodology conference; conducted a review of definitions outside the health research context; consulted experts at an international consensus meeting; and reviewed 27 empirical pilot or feasibility studies. We initially adopted mutually exclusive definitions of pilot and feasibility studies. However, some Delphi survey respondents and the majority of open meeting attendees disagreed with the idea of mutually exclusive definitions. Their viewpoint was supported by definitions outside the health research context, the use of the terms 'pilot' and 'feasibility' in the literature, and participants at the international consensus meeting. In our framework, pilot studies are a subset of feasibility studies, rather than the two being mutually exclusive. A feasibility study asks whether something can be done, should we proceed with it, and if so, how. A pilot study asks the same questions but also has a specific design feature: in a pilot study a future study, or part of a future study, is conducted on a smaller scale. We suggest that to facilitate their identification, these studies should be clearly identified using the terms 'feasibility' or 'pilot' as appropriate. This should include feasibility studies that are largely qualitative; we found these difficult to identify in electronic searches because researchers rarely used the term 'feasibility' in the title or abstract of such studies. Investigators should also report appropriate objectives and methods related to feasibility; and give clear confirmation that their study is in preparation for a future randomised controlled trial designed to assess the effect of an intervention.

The Feasibility of Health Trainer Improved Patient Self-Management in Patients with Low Health Literacy and Poorly Controlled Diabetes: A Pilot Randomised Controlled Trial

Type 2 diabetes mellitus is most prevalent in deprived communities and patients with low health literacy have worse glycaemic control and higher rates of diabetic complications. However, recruitment from this patient population into intervention trials is highly challenging. We conducted a study to explore the feasibility of recruitment and to assess the effect of a lay health trainer intervention, in patients with low health literacy and poorly controlled diabetes from a socioeconomically disadvantaged population, compared with usual care. Methods. A pilot RCT comparing the LHT intervention with usual care. Patients with HbA1c > 7.5 (58 mmol/mol) were recruited. Baseline and 7-month outcome data were entered directly onto a laptop to reduce patient burden. Results. 76 patients were recruited; 60.5% had low health literacy and 75% were from the most deprived areas of England. Participants in the LHT arm had significantly improved mental health (p = 0.049) and illness perception (p = 0.040). The intervention was associated with lower resource use, better patient self-care management, and better QALY profile at 7-month follow-up. Conclusion. This study describes successful recruitment strategies for hard-to-reach populations. Further research is warranted for this cost-effective, relatively low-cost intervention for a population currently suffering a disproportionate burden of diabetes, to demonstrate its sustained impact on treatment effects, health, and health inequalities.