Pilot study of a ketogenic diet in bipolar disorder

BACKGROUND

Recent evidence from case reports suggests that a ketogenic diet may be effective for bipolar disorder. However, no clinical trials have been conducted to date.

AIMS

To assess the recruitment and feasibility of a ketogenic diet intervention in bipolar disorder.

METHOD

Euthymic individuals with bipolar disorder were recruited to a 6-8 week trial of a modified ketogenic diet, and a range of clinical, economic and functional outcome measures were assessed. Study registration number: ISRCTN61613198.

RESULTS

Of 27 recruited participants, 26 commenced and 20 completed the modified ketogenic diet for 6-8 weeks. The outcomes data-set was 95% complete for daily ketone measures, 95% complete for daily glucose measures and 95% complete for daily ecological momentary assessment of symptoms during the intervention period. Mean daily blood ketone readings were 1.3 mmol/L (s.d. = 0.77, median = 1.1) during the intervention period, and 91% of all readings indicated ketosis, suggesting a high degree of adherence to the diet. Over 91% of daily blood glucose readings were within normal range, with 9% indicating mild hypoglycaemia. Eleven minor adverse events were recorded, including fatigue, constipation, drowsiness and hunger. One serious adverse event was reported (euglycemic ketoacidosis in a participant taking SGLT2-inhibitor medication).

CONCLUSIONS

The recruitment and retention of euthymic individuals with bipolar disorder to a 6-8 week ketogenic diet intervention was feasible, with high completion rates for outcome measures. The majority of participants reached and maintained ketosis, and adverse events were generally mild and modifiable. A future randomised controlled trial is now warranted.

The understanding, application and influence of complexity in national physical activity policy-making

Background

Complexity theory and systems-thinking are increasingly popular in physical activity (PA) research and policy discourse. The impact of this perspective shift, across many sectors, may be underwhelming. We explore why, by focusing on how these concepts are understood and applied by PA policy-makers. This is of particular interest given the challenges of multisectoral interest and poorly defined stakeholder boundaries that are associated with PA promotion. In this study, we critique key elements of complexity theory and consider how it is understood and put into practice in PA policy-making.

Methods

We adopted a complex realist position. Ten semi-structured interviews were conducted with national-level policy-makers from United Kingdom government settings (five civil servants, three politicians, two policy advisors). An inductive thematic analysis was conducted, and managed with NVivo 10 software.

Results

Three overarching themes were constructed to reflect policy-makers’ uncertainty about complexity and the application of such perspectives to this policy space, their sense that PA was an unexceptionable yet unclaimed policy issue, and their desire for influence and change. Participants discussed complexity in contrasting ways. Its meaning was context-dependent and dynamic, which generated uncertainty about applying the concept. Participants also perceived an increasingly diverse but ill-defined PA policy system that spans the domains of expertise and responsibility. Collaborative practices may contribute to a previously unobserved sense of detachment from the systems’ complexity. Nevertheless, participants suggested potentially effective ways to stimulate system change, which require passionate and enterprising leadership, and included varied evidence use, a focus on localised implementation and different ways to connect people.

Conclusions

This research highlighted the importance of extending complexity theory and systems-thinking. While emphasizing the prevalence of these ideas across the PA sector, there is uncertainty as to their meaning and implications. This may prevent their use in ways that enhance PA policies and programmes. Participants conceptualised PA as a tool, which was imposed on the system. While this may support participative decision-making and localised implementation, further research is needed to understand how local systems foster leadership, the practical application of complexity and systems-thinking, and how to support system-wide change in the development and implementation of PA policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00864-9.

Challenges, opportunities and solutions for local physical activity stakeholders: an implementation case study from a cross-sectoral physical activity network in Northeast England

Background

Increasingly, national policy initiatives and programmes have been developed to increase physical activity (PA). However, challenges in implementing and translating these policies into effective local-level programmes have persisted, and change in population PA levels has been small. This may be due to insufficient attention given to the implementation context, and the limited interactions between local policy-makers, practitioners and researchers. In this paper we use a case study of a cross-sectoral network in Northeast England, to identify the local-level challenges and opportunities for implementing PA policies and programmes, particularly the updated 2019 UK PA guidelines.

Methods

Five focus groups (n = 59) were conducted with practice partners, local policy-makers and researchers during an initial workshop in April 2018. Through facilitated discussion, participants considered regional priorities for research and practice, along with barriers to implementing this agenda and how these may be overcome. During a second workshop in December 2018, overarching findings from workshop one were fedback to a similar group of stakeholders, along with national policy-makers, to stimulate feedback from delegates on experiences that may support the implementation of the UK PA guidelines locally, focusing on specific considerations for research, evidence and knowledge exchange.

Results

In workshop one, three overarching themes were developed to capture local challenges and needs: (i) understanding complexity and context; (ii) addressing the knowledge and skills gap; and (iii) mismatched timescales and practices. In workshop two, participants’ implementation plans encompassed: (i) exploring a systems approach to implementation; (ii) adapting policy to context; and (iii) local prioritising.

Conclusions

Our findings suggest that academics, practitioners and policy-makers understand the complexities of implementing PA strategies, and the challenges of knowledge exchange. The updated UK PA guidelines policy presented an opportunity for multiple agencies to consider context-specific implementation and address enduring tensions between stakeholders. An organically derived implementation plan that prioritises PA, maps links to relevant local policies and supports a context-appropriate communication strategy, within local policy, practice and research networks, will help address these. We present 10 guiding principles to support transferable knowledge exchange activities within networks to facilitate implementation of national PA policy in local contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09847-3.

Inequities and inequalities in outdoor walking groups: a scoping review

Background

Outdoor walking groups are widely-used programmes aimed at improving physical activity and health outcomes. Despite being promoted as accessible and inclusive, emerging work highlights participation biases based on gender, age and socioeconomic status, for example. To explicate the impact of outdoor walking groups on physical activity inequities, we conducted a scoping review of published outdoor walking group literatures. Specifically, we critically examined: (a) equity integration strategies; (b) intervention reach; (c) effectiveness; and (d) potential social determinants of engagement relating to the World Health Organization’s conceptual framework.

Methods

Arksey and O’Malley’s scoping review protocol was used to develop a comprehensive search strategy and identify relevant academic and grey literatures, which were screened using pre-defined inclusion and exclusion criteria. Data were organised by Cochrane PROGRESS-Plus equity characteristics and a narrative summary was presented for each thematic area.

Findings

Sixty-two publications were included. Key findings were: (a) some evidence of targeted intervention trials. Large-scale national programmes were tailored to regional activity and health needs, which may contribute toward addressing inequities. However, participant demographics seldom informed reported analyses; (b) participation was more likely among white, more socioeconomically advantaged, middle-to-older aged, female and able-bodied adults; (c) positive physical and psychological outcomes were unlikely to extend along social gradients; and (d) interventions primarily addressed intermediary determinants (e.g. psychosocial barriers; material resource). Social capital (e.g. friend-making) was identified as potentially important for addressing physical activity inequalities.

Conclusions

The published literature on outdoor walking groups leaves unanswered questions regarding participation inequalities, with implications for future physical activity promotion. Currently, participation in outdoor walking groups is typically more prevalent among advantaged subpopulations. We make recommendations for research and practice to address these issues, as well as aid the translation of existing knowledge into practice. We advocate increased focus on the social determinants of engagement. A more consistent approach to collecting and analysing participant socio-demographic data is required. Our findings also support recommendations that appropriate tailoring of universal programmes to community needs and embedding strategies to increase social cohesion are important in developing equitable programmes.