Analysis of the UK recommendations on obesity based on a proposed implementation framework

Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity

Background

This meta-review investigated the context-related implementation determinants from seven domains (geographical, epidemiological, sociocultural, economic, ethics-related, political, and legal) that were systematically indicated as occurring during the implementation of obesity prevention policies targeting a healthy diet and a physically active lifestyle.

Methods

Data from nine databases and documentation of nine major stakeholders were searched for the purpose of this preregistered meta-review (#CRD42019133341). Context-related determinants were considered strongly supported if they were indicated in ≥60% of the reviews/stakeholder documents. The ROBIS tool and the Methodological Quality Checklist-SP were used to assess the quality-related risk of bias.

Results

Published reviews (k = 25) and stakeholder documents that reviewed the evidence of policy implementation (k = 17) were included. Across documents, the following six determinants from three context domains received strong support: economic resources at the macro (66.7% of analyzed documents) and meso/micro levels (71.4%); sociocultural context determinants at the meso/micro level, references to knowledge/beliefs/abilities of target groups (69.0%) and implementers (73.8%); political context determinants (interrelated policies supported in 71.4% of analyzed reviews/documents; policies within organizations, 69.0%).

Conclusions

These findings indicate that sociocultural, economic, and political contexts need to be accounted for when formulating plans for the implementation of a healthy diet and physical activity/sedentary behavior policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13340-4.

Frameworks for implementation of policies promoting healthy nutrition and physically active lifestyle: systematic review

Background

Policy frameworks focusing on policy implementation may vary in terms of their scope, included constructs, relationships between the constructs, and context factors. Although multiple policy implementation frameworks exist, the overarching synthesis characterizing differences between the frameworks is missing. This study investigated frameworks guiding implementation of policies aiming at healthy nutrition, physical activity promotion, and a reduction of sedentary behavior. In particular, we aimed at examining the scope of the frameworks and the content of included constructs (e.g., referring to implementation processes, determinants, or implementation evaluation), the level at which these constructs operate (e.g., the individual level, the organizational/community level), relationships between the constructs, and the inclusion of equity factors.

Methods

A systematic review (the PROSPERO registration no. CRD42019133251) was conducted using 9 databases and 8 stakeholder websites. The content of 38 policy implementation frameworks was coded and analyzed.

Results

Across the frameworks, 47.4% (18 in 38) addressed three aims: description of the process, determinants, and the evaluation of implementation. The majority of frameworks (65.8%; 25 in 38) accounted for constructs from three levels: individual, organizational/community, and the system level. System-level constructs were included less often (76.3%; 29 in 38) than individual-level or organizational/community-level constructs (86.8% [33 in 38 frameworks] and 94.7% [36 in 38 frameworks] respectively). The majority of frameworks (84.2%, 32 in 38) included at least some sections that were solely of descriptive character (a list of unassociated constructs); 50.0% (19 in 38) included sections of prescriptive character (general steps of implementation); 60.5% (23 in 38) accounted for explanatory sections (assuming bi- or uni-directorial associations). The complex system approach was accounted for only in 21.1% (8 in 38) of frameworks. More than half (55.3%; 21 in 38) of frameworks did not account for any equity constructs (e.g., socioeconomic status, culture).

Conclusions

The majority of policy implementation frameworks have two or three aims (combining processes, determinants and/or the evaluation of implementation), include multi-level constructs (although the system-level determinants are less frequently included than those from the individual- or organizational/community-level), combine sections of purely descriptive character with sections accounting for prescriptive and/or explanatory associations, and are likely to include a little or no equity constructs.

Registration

PROSPERO, #CRD42019133251.

Is Obesity Policy in England Fit for Purpose? Analysis of Government Strategies and Policies, 1992-2020

Policy Points This analysis finds that government obesity policies in England have largely been proposed in a way that does not readily lead to implementation; that governments rarely commission evaluations of previous government strategies or learn from policy failures; that governments have tended to adopt less interventionist policy approaches; and that policies largely make high demands on individual agency, meaning they rely on individuals to make behavior changes rather than shaping external influences and are thus less likely to be effective or equitable. These findings may help explain why after 30 years of proposed government obesity policies, obesity prevalence and health inequities still have not been successfully reduced. If policymakers address the issues identified in this analysis, population obesity could be tackled more successfully, which has added urgency given the COVID-19 pandemic.

CONTEXT

In England, the majority of adults, and more than a quarter of children aged 2 to 15 years live with obesity or excess weight. From 1992 to 2020, even though the government published 14 obesity strategies in England, the prevalence of obesity has not been reduced. We aimed to determine whether such government strategies and policies have been fit for purpose regarding their strategic focus, nature, basis in theory and evidence, and implementation viability.

METHOD

We undertook a mixed-methods study, involving a document review and analysis of government strategies either wholly or partially dedicated to tackling obesity in England. We developed a theory-based analytical framework, using content analysis and applied thematic analysis (ATA) to code all policies. Our interpretation drew on quantitative findings and thematic analysis.

FINDINGS

We identified and analyzed 14 government strategies published from 1992 to 2020 containing 689 wide-ranging policies. Policies were largely proposed in a way that would be unlikely to lead to implementation; the majority were not interventionist and made high demands on individual agency, meaning that they relied on individuals to make behavior changes rather than shaping external influences, and are thus less likely to be effective or to reduce health inequalities.

CONCLUSIONS

The government obesity strategies' failure to reduce the prevalence of obesity in England for almost 30 years may be due to weaknesses in the policies' design, leading to a lack of effectiveness, but they may also be due to failures of implementation and evaluation. These failures appear to have led to insufficient or no policy learning and governments proposing similar or identical policies repeatedly over many years. Governments should learn from their earlier policy failures. They should prioritize policies that make minimal demands on individuals and have the potential for population-wide reach so as to maximize their potential for equitable impacts. Policies should be proposed in ways that readily lead to implementation and evaluation.

Obesity prevention in the early years: A mapping study of national policies in England from a behavioural science perspective

Background

Evidence indicates that early life is critical for determining future obesity risk. A sharper policy focus on pregnancy and early childhood could help improve obesity prevention efforts. This study aimed to systematically identify and categorise policy levers used in England with potential to influence early life course (pregnancy, 0–5 years) and identify how these interface with energy balance behaviours. The objective is to identify gaps and where further policy actions could most effectively focus.

Methods

A behavioural science approach was taken using the Capability-Opportunity-Motivation-Behaviour (COM-B) model and Behaviour Change Wheel (BCW) framework. The key determinants of energy balance in the early years were identified from the Foresight Systems Map. Policy actions were scoped systematically from available literature, including any health or non-health policies which could impact on energy balance behaviours. Foresight variables and policy actions were considered in terms of COM-B and the BCW to determine approaches likely to be effective for obesity prevention and treatment. Existing policies were overlaid across the map of key risk factors to identify gaps in obesity prevention and treatment provision.

Results

A wide range of policy actions were identified (n = 115) to address obesity-relevant risk factors. These were most commonly educational or guidelines relating to environmental restructuring (i.e. changing the physical or social context). Scope for strengthening policies relating to the food system (e.g. the market price of food) and psychological factors contributing to obesity were identified. Policies acted via all aspects of the COM-B model, but there was scope for improving policies to increase capability through skills acquisition and both reflective and automatic motivation.

Conclusions

There is substantial policy activity to address early years obesity but much is focused on education. Scope exists to strengthen actions relating to upstream policies which act on food systems and those targeting psychological factors contributing to obesity risk.

Translation of obesity practice guidelines: measurement and evaluation

OBJECTIVE(S)

A public health nurse (PHN) in the Midwestern United States (U.S.) led a collaborative system-level intervention to translate the Institute of Clinical Systems Improvement (ICSI) Adult Obesity Guideline into interprofessional practice. This study (1) evaluated the extent of guideline translation across organizations and (2) assessed the Omaha System as a method for translating system-level interventions and measuring outcomes.

DESIGN AND SAMPLE

This retrospective, mixed methods study was conducted with a purposeful sample of one administrator (n = 10) and two to three clinicians (n = 29) from each organization (n = 10).

MEASURES

Omaha System Problem Rating Scale for Outcomes Knowledge, Behavior, and Status (KBS). KBS ratings gathered from semi-structured interviews and Omaha System documentation were analyzed using standard descriptive and inferential statistics and triangulated findings with participant quotes.

RESULTS

KBS ratings and participant quotes revealed intervention effectiveness in creating sustained system-level changes. Self-reported and observed KBS ratings demonstrated improvement across organizations. There was moderate to substantial agreement regarding benchmark attainment within organizations. On average, self-reported improvement exceeded observer improvement.

CONCLUSIONS

System-level PHN practice facilitator interventions successfully translated clinical obesity guidelines into interprofessional use in health care organizations. The Omaha System Problem Rating Scale for Outcomes reliably measured system-level outcomes.

Increased body mass index in ankylosing spondylitis is associated with greater burden of symptoms and poor perceptions of the benefits of exercise

OBJECTIVE

Increased body mass index (BMI) in patients with ankylosing spondylitis (AS) is associated with a greater burden of symptoms and poor perceptions of the benefits of exercise. In AS, the effect of obesity on disease characteristics and exercise perceptions is unknown. We evaluated the prevalence of obesity in AS, to assess the attitudes of patients toward exercise and to evaluate the effect of obesity on symptoms and disease activity.

METHODS

Demographic data and disease characteristics were collected from 46 patients with AS. Disease activity, symptomatology, and functional disability were examined using standard AS questionnaires. BMI was calculated. Comorbidity was analyzed using the Charlson Comorbidity Index. Patients' attitudes toward exercise were assessed using the Exercise Benefits and Barriers Scale (EBBS). We compared the disease characteristics, perceptions regarding exercise, and functional limitations in those who were overweight to those who had a normal BMI.

RESULTS

The mean BMI in the group was 27.4; 67.5% of subjects were overweight or obese. There was a statistically significant difference between those who were overweight and those with a normal BMI regarding their perceptions of exercise (EBBS 124.7 vs 136.6, respectively), functional limitation (Bath AS Functional Index 4.7 vs 2.5, Health Assessment Questionnaire 0.88 vs 0.26), and disease activity (Bath AS Disease Activity Index 4.8 vs 2.9). There was no difference between the groups in terms of their comorbid conditions or other demographic variables.

CONCLUSION

The majority of patients in this AS cohort were overweight. They had a greater burden of symptoms, worse perceptions regarding the benefits of exercise, and enhanced awareness of their barriers to exercising. This is of particular concern in a disease where exercise plays a crucial role.

Socioeconomic inequalities in childhood obesity in the United Kingdom: a systematic review of the literature

Childhood obesity is a major public health challenge worldwide. There is a growing literature documenting socioeconomic inequalities in childhood obesity risk. Here we draw inference from the literature about inequalities in childhood obesity risk in the UK. We summarize and appraise the extant peer-reviewed literature about socioeconomic inequalities in childhood obesity in the UK. Common area-level indices of socioeconomic position, including the Carstairs Deprivation Index, the Index of Multiple Deprivation and the Townsend Deprivation Index, as well as common household and individual-level metrics of childhood socioeconomic position, including head-of-household social class and maternal education, were generally inversely associated with childhood obesity in the UK. We summarize key methodological limitations to the extant literature and suggest avenues for future research.