Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

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.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

Interventions for preventing obesity in children

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

WITHDRAWN: Interventions for treating obesity in children

BACKGROUND

Child and adolescent obesity is increasingly prevalent, and can be associated with significant short- and long-term health consequences.

OBJECTIVES

To assess the efficacy of lifestyle, drug and surgical interventions for treating obesity in childhood.

SEARCH METHODS

We searched CENTRAL on The Cochrane Library Issue 2 2008, MEDLINE, EMBASE, CINAHL, PsycINFO, ISI Web of Science, DARE and NHS EED. Searches were undertaken from 1985 to May 2008. References were checked. No language restrictions were applied.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of lifestyle (i.e. dietary, physical activity and/or behavioural therapy), drug and surgical interventions for treating obesity in children (mean age under 18 years) with or without the support of family members, with a minimum of six months follow up (three months for actual drug therapy). Interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data following the Cochrane Handbook. Where necessary authors were contacted for additional information.

MAIN RESULTS

We included 64 RCTs (5230 participants). Lifestyle interventions focused on physical activity and sedentary behaviour in 12 studies, diet in 6 studies, and 36 concentrated on behaviorally orientated treatment programs. Three types of drug interventions (metformin, orlistat and sibutramine) were found in 10 studies. No surgical intervention was eligible for inclusion. The studies included varied greatly in intervention design, outcome measurements and methodological quality.Meta-analyses indicated a reduction in overweight at 6 and 12 months follow up in: i) lifestyle interventions involving children; and ii) lifestyle interventions in adolescents with or without the addition of orlistat or sibutramine. A range of adverse effects was noted in drug RCTs.

AUTHORS' CONCLUSIONS

While there is limited quality data to recommend one treatment program to be favoured over another, this review shows that combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. In obese adolescents, consideration should be given to the use of either orlistat or sibutramine, as an adjunct to lifestyle interventions, although this approach needs to be carefully weighed up against the potential for adverse effects. Furthermore, high quality research that considers psychosocial determinants for behaviour change, strategies to improve clinician-family interaction, and cost-effective programs for primary and community care is required.

Feasibility of working with a wholesale supplier to co-design and test acceptability of an intervention to promote smaller portions: an uncontrolled before-and-after study in British Fish & Chip shops

OBJECTIVES

To explore the feasibility of working with a wholesale supplier to co-design and deliver, and to assess the acceptability of, an intervention to promote smaller portions in Fish & Chip shops.

DESIGN

Uncontrolled before-and-after study.

SETTING

Fish & Chip shops in northern England, 2016.

PARTICIPANTS

Owners (n=11), a manager and customers (n=46) of Fish & Chip shops; and intervention deliverers (n=3).

INTERVENTION

Supplier-led, three-hour engagement event with shop owners and managers, highlighting the problem of excessive portion sizes and potential ways to reduce portion sizes; provision of box packaging to serve smaller portions; promotional posters and business incentives.

DATA COLLECTION

In-store observations and sales data collected at baseline and postintervention. Exit survey with customers. Semistructured interviews with owners/managers and intervention deliverers postintervention.

RESULTS

Twelve Fish & Chip shops were recruited. Observational data were collected from eight shops: at baseline, six shops did not promote the availability of smaller portion meals; at follow-up, all eight did and five displayed the promotional poster. Seven out of 12 shops provided sales data and all reported increased sales of smaller portion meals postintervention. Of 46 customers surveyed: 28% were unaware of the availability of smaller portion meals; 20% had bought smaller portion meals; and 46% of those who had not bought these meals were interested to try them in the future. Interviews revealed: owners/managers found the intervention acceptable but wanted a clearer definition of a smaller portion meal; the supplier valued the experience of intervention co-production and saw the intervention as being compatible with their responsibility to drive innovation.

CONCLUSIONS

The co-design of the intervention with a supplier was feasible. The partnership facilitated the delivery of an intervention that was acceptable to owners and customers. Sales of smaller meal packaging suggest that promotion of such meals is viable and may be sustainable.

Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Researchers have suggested that 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)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this.

OBJECTIVES

To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies 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 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies 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 0.5g/d LCn3 to > 5 g/d (16 RCTs gave at least 3g/d LCn3).Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.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, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs) and ALA may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence with greater effects in trials at low summary risk of bias), and probably reduces risk of arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, except LCn3 reduced triglycerides by ˜15% in a dose-dependant way (high-quality evidence).

AUTHORS' CONCLUSIONS

This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event and arrhythmia risk.

Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Researchers have suggested that 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)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this.

OBJECTIVES

To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies 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 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet.Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.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, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and it may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence), and probably reduces risk of CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs), and arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, although LCn3 slightly reduced triglycerides and increased HDL. ALA probably reduces HDL (high- or moderate-quality evidence).

AUTHORS' CONCLUSIONS

This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event risk, CHD mortality and arrhythmia.

The challenges of interventions to promote healthier food in independent takeaways in England: qualitative study of intervention deliverers' views

BACKGROUND

Much of the food available from takeaways, pubs and restaurants particularly that sold by independent outlets, is unhealthy and its consumption is increasing. These food outlets are therefore important potential targets for interventions to improve diet and thus prevent diet related chronic diseases. Local authorities in England have been charged with delivering interventions to increase the provision of healthy food choices in independent outlets, but prior research shows that few such interventions have been rigorously developed or evaluated. We aimed to learn from the experiences of professionals delivering interventions in independent food outlets in England to identify the operational challenges and their suggestions for best practice.

METHODS

We used one-to-one semi-structured qualitative interviews to explore the views and experiences of professionals who were either employees of, or contracted by, a local authority to deliver interventions to increase the provision of healthier food choices in independent food outlets. Purposive sampling was used to recruit a sample which included men and women, from a range of professional roles, across different areas of England. Interviews were informed by a topic guide, and proceeded until no new themes emerged. Interviews were recorded, transcribed verbatim and analysed using the Framework method.

RESULTS

We conducted 11 individual interviews. Participants focussed on independent takeaways and their unhealthy food offerings, and highlighted the advantages and disadvantages of intervention delivery methods, their evaluation and impact. The main barriers to implementation of interventions in independent takeaways were identified as limited funding and the difficulties of engaging the food outlet owner/manager. Engagement was thought to be facilitated by delivering intensive, interactive and tailored interventions, clear and specific information, and incentives, whilst accounting for practical, primarily financial, constraints of food businesses. Alternative intervention approaches, targeting suppliers or customers, were suggested.

CONCLUSIONS

Participants emphasised independent takeaways as particularly challenging, but worthwhile intervention targets. Participants perceived that interventions need to take account of the potentially challenging operating environment, particularly the primacy of the profit motive. Upstream interventions, engaging suppliers, as well as those that drive consumer demand, may be worth exploring. Rigorous, evidence-informed development and evaluation of such interventions is needed.

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in children and adults with overweight or obesity

BACKGROUND

The prevalence of overweight and obesity is increasing globally, an increase which has major implications for both population health and costs to health services. This is an update of a Cochrane Review.

OBJECTIVES

To assess the effects of strategies to change the behaviour of health professionals or the organisation of care compared to standard care, to promote weight reduction in children and adults with overweight or obesity.

SEARCH METHODS

We searched the following databases for primary studies up to September 2016: CENTRAL, MEDLINE, Embase, CINAHL, DARE and PsycINFO. We searched the reference lists of included studies and two trial registries.

SELECTION CRITERIA

We considered randomised trials that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in children and adults with overweight or obesity.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane when conducting this review. We report the results for the professional interventions and the organisational interventions in seven 'Summary of findings' tables.

MAIN RESULTS

We identified 12 studies for inclusion in this review, seven of which evaluated interventions targeting healthcare professional and five targeting the organisation of care. Eight studies recruited adults with overweight or obesity and four recruited children with obesity. Eight studies had an overall high risk of bias, and four had a low risk of bias. In total, 139 practices provided care to 89,754 people, with a median follow-up of 12 months. Professional interventions Educational interventions aimed at general practitioners (GPs), may slightly reduce the weight of participants (mean difference (MD) -1.24 kg, 95% confidence interval (CI) -2.84 to 0.37; 3 studies, N = 1017 adults; low-certainty evidence).Tailoring interventions to improve GPs' compliance with obesity guidelines probably leads to little or no difference in weight loss (MD 0.05 (kg), 95% CI -0.32 to 0.41; 1 study, N = 49,807 adults; moderate-certainty evidence).It is uncertain if providing doctors with reminders results in a greater weight reduction than standard care (men: MD -11.20 kg, 95% CI -20.66 kg to -1.74 kg, and women: MD -1.30 kg, 95% CI [-7.34, 4.74] kg; 1 study, N = 90 adults; very low-certainty evidence).Providing clinicians with a clinical decision support (CDS) tool to assist with obesity management at the point of care leads to little or no difference in the body mass index (BMI) z-score of children (MD -0.08, 95% CI -0.15 to -0.01 in 378 children; moderate-certainty evidence), CDS tools may lead to little or no difference in weight loss in adults: MD -0.095 kg (-0.21 lbs), P = 0.47; 1 study, N = 35,665; low-certainty evidence. Organisational interventions Adults with overweight or obesity may lose more weight if the care was provided by a dietitian (by -5.60 kg, 95% CI -4.83 kg to -6.37 kg) or by a doctor-dietitian team (by -6.70 kg, 95% CI -7.52 kg to -5.88 kg; 1 study, N = 270 adults; low-certainty evidence). Shared care leads to little or no difference in the BMI z-score of children with obesity (adjusted MD -0.05, 95% CI -0.14 to 0.03; 1 study, N = 105 children; low-certainty evidence).Organisational restructuring of the delivery of primary care (i.e. introducing the chronic care model) may result in a slightly lower increase in the BMI of children who received care at intervention clinics (BMI change: adjusted MD -0.21, 95% CI -0.50 to 0.07; 1 study, unadjusted MD -0.18, 95% CI -0.20 to -0.16; N=473 participants; moderate-certainty evidence).Mail and phone interventions probably lead to little or no difference in weight loss in adults (mean weight change (kg) using mail: -0.36, 95% CI -1.18 to 0.46; phone: -0.44, 95% CI -1.26 to 0.38; 1 study, N = 1801 adults; moderate-certainty evidence). Care delivered by a nurse at a primary care clinic may lead to little or no difference in the BMI z-score in children (MD -0.02, 95% CI -0.16 to 0.12; 1 study, N = 52 children; very low-certainty evidence).Two studies reported data on cost effectiveness: one study favoured mail and standard care over telephone consultations, and the other study achieved weight loss at a modest cost in both intervention groups (doctor and doctor-dietitian). One study of shared care reported similar adverse effects in both groups.

AUTHORS' CONCLUSIONS

We found little convincing evidence for a clinically-important effect on participants' weight or BMI of any of the evaluated interventions. While pooled results from three studies indicate that educational interventions targeting healthcare professionals may lead to a slight weight reduction in adults, the certainty of these results is low. Two trials evaluating CDS tools (unpooled results) for improved weight management suggest little or no effect on weight or BMI change in adults or children with overweight or obesity. Evidence for all the other interventions evaluated came mostly from single studies. The certainty of the included evidence varied from moderate to very low for the main outcomes (weight and BMI). All of the evaluated interventions would need further investigation to ascertain their strengths and limitations as effective strategies to change the behaviour of healthcare professionals or the organisation of care. As only two studies reported on cost, we know little about cost effectiveness across the evaluated interventions.

Initial protocol for a national evaluation of an area-based intervention programme (A Better Start) on early-life outcomes: a longitudinal cohort study with comparison (control) cohort samples

INTRODUCTION

Pregnancy and the first few years of a child's life are important windows of opportunity in which to equalise life chances. A Better Start (ABS) is an area-based intervention being delivered in five areas of socioeconomic disadvantage across England. This protocol describes an evaluation of the impact and cost-effectiveness of ABS.

METHODS AND ANALYSIS

The evaluation of ABS comprises a mixed-methods design including impact, cost-effectiveness and process components. It involves a cohort study in the 5 ABS areas and 15 matched comparison sites (n=2885), beginning in pregnancy in 2017 and ending in 2024 when the child is age 7, with a separate cross-sectional baseline survey in 2016/2017. Process data will include a profiling of the structure and services being provided in the five ABS sites at baseline and yearly thereafter, and data regarding the participating families and the services that they receive. Eligible participants will include pregnant women living within the designated sites, with recruitment beginning at 16 weeks of pregnancy. Data collection will involve interviewer-administered and self-completion surveys at eight time points. Primary outcomes include nutrition, socioemotional development, speech, language and learning. Data analysis will include the use of propensity score techniques to construct matched programme and comparison groups, and a range of statistical techniques to calculate the difference in differences between the intervention and comparison groups. The economic evaluation will involve a within-cohort study economic evaluation to compare individual-level costs and outcomes, and a decision analytic cost-effectiveness model to estimate the expected incremental cost per unit change in primary outcomes for ABS in comparison to usual care.

ETHICS AND DISSEMINATION

Ethical approval to conduct the study has been obtained. The learning and dissemination workstream involves working within and across the sites to generate learning via communities of practice and a range of learning and dissemination events.

The impact of interventions to promote healthier ready-to-eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review

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.

A description of interventions promoting healthier ready-to-eat meals (to eat in, to take away, or to be delivered) sold by specific food outlets in England: a systematic mapping and evidence synthesis

BACKGROUND

Ready-to-eat meals (to eat in, to take away or to be delivered) sold by food outlets are often more energy dense and nutrient poor compared with meals prepared at home, making them a reasonable target for public health intervention. The aim of the research presented in this paper was to systematically identify and describe interventions to promote healthier ready-to-eat meals (to eat in, to take away, or to be delivered) sold by specific food outlets in England.

METHODS

A systematic search and sift of the literature, followed by evidence mapping of relevant interventions, was conducted. Food outlets were included if they were located in England, were openly accessible to the public and, as their main business, sold ready-to-eat meals. Academic databases and grey literature were searched. Also, local authorities in England, topic experts, and key health professionals and workers were contacted. Two tiers of evidence synthesis took place: type, content and delivery of each intervention were summarised (Tier 1) and for those interventions that had been evaluated, a narrative synthesis was conducted (Tier 2).

RESULTS

A total of 75 interventions were identified, the most popular being awards. Businesses were more likely to engage with cost neutral interventions which offered imperceptible changes to price, palatability and portion size. Few interventions involved working upstream with suppliers of food, the generation of customer demand, the exploration of competition effects, and/or reducing portion sizes. Evaluations of interventions were generally limited in scope and of low methodological quality, and many were simple assessments of acceptability.

CONCLUSIONS

Many interventions promoting healthier ready-to-eat meals (to eat in, to take away, or to be delivered) sold by specific food outlets in England are taking place; award-type interventions are the most common. Proprietors of food outlets in England that, as their main business, sell ready-to-eat meals, can be engaged in implementing interventions to promote healthier ready-to-eat-food. These proprietors are generally positive about such interventions, particularly when they are cost neutral and use a health by stealth approach.

Parental response to a letter reporting child overweight measured as part of a routine national programme in England: results from interviews with parents

BACKGROUND

Rising rates of childhood obesity have become a pressing issue in public health, threatening both the mental and physical well-being of children. Attempts to address this problem are multifaceted, and in England include the National Child Measurement Programme (NCMP) which assesses weight status in English primary school children in reception class (aged 4-5) and in year 6 (aged 10-11), with results being sent out to parents. However the effectiveness and impact of this routine parental feedback has yet to be fully understood. This paper reports one component of a mixed methods study undertaken in North East England, examining the impact of the feedback letters on parents' understanding and feelings about their child's weight status and whether or not this seemed likely to lead to behaviour change.

METHODS

One-to-one semi-structured interviews (n = 16) were conducted with a sample of parents/guardians after they had received their child's weight results letter. Eight parents/guardians were sub-sampled from the group whose child had been indicated to be overweight or obese and eight were from the group whose child had been indicated to be of ideal weight status. Interviews were conducted until data saturation was reached for both groups.

RESULTS

The reactions of parents/guardians whose children were identified as being overweight followed a sequence of behaviours ranging from shock, disgust with the programme, through denial and self-blame to acceptance, worry and intention to seek help. On the other hand, the reaction of parents/guardians whose children were identified as being ideal weight ranged from relief, pleasure and happiness through affirmation and self-congratulation to 'othering'.

CONCLUSIONS

Whilst overweight and obesity is often portrayed as a medical condition, parents/guardians see it as deeply rooted in their social lives and not in health terms. Parents believe that the causes of overeating and lack of exercise relate closely to the obesogenic environment, particularly the complex social and cultural milieu and time pressures within which this sample of people live. Associating this problem in feedback letters with dangerous diseases like cancer, and advising parents to visit GPs to resolve child weight issues was perceived as inappropriate by the parents, and caused controversy and anger. Given the likelihood that the NCMP will continue as a monitoring device, it is evident that the management of the process needs to be reviewed, with particular attention being paid to the feedback process. Local health authorities will need to manage parental expectations and ensure linkage with appropriately commissioned remedial weight management interventions.

Perceptions of nursery staff and parent views of healthy eating promotion in preschool settings: an exploratory qualitative study

BACKGROUND

In the UK just over a fifth of all children start school overweight or obese and overweight 2-5 year olds are at least 4 times more likely to become overweight adults. This can lead to serious future health problems. The WHO have recently highlighted the preschool years as a critical time for obesity prevention, and have recommended preschools as an ideal setting for intervention. However, existing evidence suggests that the preschool environment, including the knowledge, beliefs and practices of preschool staff and parents of young children attending nurseries can be a barrier to the successful implementation of healthy eating interventions in this setting.

METHODS

This study examined the perceptions of preschool centre staff and parents' of preschool children of healthy eating promotion within preschool settings. The participants were preschool staff working in private and local authority preschool centres in the North East of England, and parents of preschool children aged 3-4 years. Preschool staff participated in semi-structured interviews (n = 16 female, 1 male). Parents completed a mapping activity interview (n = 14 mothers, 1 father). Thematic analysis was applied to interpret the findings.

RESULTS

Complex communication issues surrounding preschool centre dietary 'rules' were apparent. The staff were keen to promote healthy eating to families and felt that parents needed 'education' and 'help'. The staff emphasised that school policies prohibited providing children with sugary or fatty snacks such as crisps, cakes, sweets and 'fizzy' drinks, however, some preschool centres appeared to have difficulty enforcing such guidelines. Parents were open to the idea of healthy eating promotion in preschool settings but were wary of being 'told what to do' and being thought of as 'bad parents'.

CONCLUSIONS

There is a need to further explore nursery staff members' personal perceptions of health and how food policies which promote healthier food in preschool settings can be embedded and implemented. Family friendly healthy eating strategies and activities which utilise nudge theory should be developed and delivered in a manner that is sensitive to parents' concerns. Preschool settings may offer an opportunity for delivery of such activities.

Reduced or modified dietary fat for preventing cardiovascular disease

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.

Community pharmacy interventions for public health priorities: a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions

Background

The Department of Health has identified interventions to manage alcohol misuse, smoking and overweight, delivered by community pharmacists, as public health priorities.

Objectives

To 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 sources

Ten 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 methods

The 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.

Results

The 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.

Limitations

The 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.

Conclusions

Community 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 registration

This study is registered as PROSPERO CRD42013005943.

Funding

The National Institute for Health Research Public Health Research programme.

Community pharmacy-delivered interventions for public health priorities: a systematic review of interventions for alcohol reduction, smoking cessation and weight management, including meta-analysis for smoking cessation

OBJECTIVES

To systematically review the effectiveness of community pharmacy-delivered interventions for alcohol reduction, smoking cessation and weight management.

DESIGN

Systematic review and meta-analyses. 10 electronic databases were searched from inception to May 2014.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

STUDY DESIGN

randomised and non-randomised controlled trials; controlled before/after studies, interrupted times series.

INTERVENTION

any relevant intervention set in a community pharmacy, delivered by the pharmacy team. No restrictions on duration, country, age, or language.

RESULTS

19 studies were included: 2 alcohol reduction, 12 smoking cessation and 5 weight management. Study quality rating: 6 'strong', 4 'moderate' and 9 'weak'. 8 studies were conducted in the UK, 4 in the USA, 2 in Australia, 1 each in 5 other countries. Evidence from 2 alcohol-reduction interventions was limited. Behavioural support and/or nicotine replacement therapy are effective and cost-effective for smoking cessation: pooled OR was 2.56 (95% CI 1.45 to 4.53) for active intervention vs usual care. Pharmacy-based interventions produced similar weight loss compared with active interventions in other primary care settings; however, weight loss was not sustained longer term in a range of primary care and commercial settings compared with control. Pharmacy-based weight management interventions have similar provider costs to those delivered in other primary care settings, which are greater than those delivered by commercial organisations. Very few studies explored if and how sociodemographic or socioeconomic variables moderated intervention effects. Insufficient information was available to examine relationships between effectiveness and behaviour change strategies, implementation factors, or organisation and delivery of interventions.

CONCLUSIONS

Community pharmacy-delivered interventions are effective for smoking cessation, and demonstrate that the pharmacy is a feasible option for weight management interventions. Given the potential reach, effectiveness and associated costs of these interventions, commissioners should consider using community pharmacies to help deliver public health services.

WITHDRAWN: Dietary advice for the prevention of type 2 diabetes mellitus in adults

Review status was set to withdrawn. The review is out of date and does not meet current Cochrane standards. It will be superseded by a new expanding Cochrane review on 'Diet, physical activity or both for the prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk'.

The editorial group responsible for this previously published document have withdrawn it from publication.

Clustered randomised controlled trial of two education interventions designed to increase physical activity and well-being of secondary school students: the MOVE Project

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.

Effects of total fat intake on body weight

BACKGROUND

In order to prevent overweight and obesity in the general population we need to understand the relationship between the proportion of energy from fat and resulting weight and body fatness in the general population.

OBJECTIVES

To assess the effects of proportion of energy intake from fat on measures of weight and body fatness (including obesity, waist circumference and body mass index) in people not aiming to lose weight, using all appropriate randomised controlled trials (RCTs) and cohort studies in adults, children and young people

SEARCH METHODS

We searched CENTRAL to March 2014 and MEDLINE, EMBASE and CINAHL to November 2014. We did not limit the search by language. We also checked the references of relevant reviews.

SELECTION CRITERIA

Trials fulfilled the following criteria: 1) randomised intervention trial, 2) included children (aged ≥ 24 months), young people or adults, 3) randomised to a lower fat versus usual or moderate fat diet, without the intention to reduce weight in any participants, 4) not multifactorial and 5) assessed a measure of weight or body fatness after at least six months. We also included cohort studies in children, young people and adults that assessed the proportion of energy from fat at baseline and assessed the relationship with body weight or fatness after at least one year. We duplicated inclusion decisions and resolved disagreement by discussion or referral to a third party.

DATA COLLECTION AND ANALYSIS

We extracted data on the population, intervention, control and outcome measures in duplicate. We extracted measures of weight and body fatness independently in duplicate at all available time points. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity and funnel plot analyses.

MAIN RESULTS

We included 32 RCTs (approximately 54,000 participants) and 30 sets of analyses of 25 cohorts. There is consistent evidence from RCTs in adults of a small weight-reducing effect of eating a smaller proportion of energy from fat; this was seen in almost all included studies and was highly resistant to sensitivity analyses. The effect of eating less fat (compared with usual diet) is a mean weight reduction of 1.5 kg (95% confidence interval (CI) -2.0 to -1.1 kg), but greater weight loss results from greater fat reductions. The size of the effect on weight does not alter over time and is mirrored by reductions in body mass index (BMI) (-0.5 kg/m(2), 95% CI -0.7 to -0.3) and waist circumference (-0.3 cm, 95% CI -0.6 to -0.02). Included cohort studies in children and adults most often do not suggest any relationship between total fat intake and later measures of weight, body fatness or change in body fatness. However, there was a suggestion that lower fat intake was associated with smaller increases in weight in middle-aged but not elderly adults, and in change in BMI in the highest validity child cohort.

AUTHORS' CONCLUSIONS

Trials where participants were randomised to a lower fat intake versus usual or moderate fat intake, but with no intention to reduce weight, showed a consistent, stable but small effect of low fat intake on body fatness: slightly lower weight, BMI and waist circumference compared with controls. Greater fat reduction and lower baseline fat intake were both associated with greater reductions in weight. This effect of reducing total fat was not consistently reflected in cohort studies assessing the relationship between total fat intake and later measures of body fatness or change in body fatness in studies of children, young people or adults.

Preschoolers in the Playground: a pilot cluster randomised controlled trial of a physical activity intervention for children aged 18 months to 4 years

Background

The 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).

Objectives

This 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.

Design

The 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).

Setting

Bradford, West Yorkshire, UK.

Participants

Children aged from 18 months to 4 years.

Intervention

The 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 measures

Recruitment 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.

Results

In 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.

Conclusion

A 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 registration

Current Controlled Trials ISRCTN54165860.

Funding

This 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.

A qualitative study exploring pregnant women's weight-related attitudes and beliefs in UK: the BLOOM study

BACKGROUND

There is little information on the individual cognitive, perceptual and psychosocial factors that influence the lifestyle behaviours of pregnant women. This study explored pregnant women's weight-related attitudes and beliefs during pregnancy.

METHODS

Nineteen pregnant women with different pre-pregnancy BMIs and in their third trimester were purposefully sampled for face-to-face interviews. Topics covered included lifestyles, sources of information, feelings about their bodies, and level of control over themselves and their bodies. Systematic thematic content analysis was used to identify recurrent themes.

RESULTS

Women perceived their bodies as fragmented into 'my pregnancy' (the bump) and 'me' (rest of my body). This fragmentation was the key driver of their weight-related attitudes and beliefs and influenced their dietary and physical activity behaviours. Consuming healthy foods was necessary for 'my pregnancy' to provide the ideal gestational environment. Simultaneously, pregnancy was perceived as a time to relax previously set rigid rules around diet and physical activity, allowing women to consume unhealthy foods and lead sedentary lifestyles. Women faced emotional conflicts between limiting weight gain for 'me', and being perceived as acting morally by gaining enough weight for 'baby'. Although 'bump' related weight gain was acceptable, weight gain in other parts of their body was viewed negatively and implied lack of self-control. Conflict was often alleviated, and weight-related behaviours validated, by seeking practical and reputable information for weight management. Women felt that their midwives provided detailed information on what they should not do during pregnancy, but were rarely given information about what they should do in relation to diet and physical activity for weight management. Consequently, women often used information from a variety of sources which they filtered using 'common sense'.

CONCLUSIONS

This study has identified that a central concept to pregnant women's diet and physical activity beliefs during pregnancy is the fragmentation of self into 'me' and 'my pregnancy'. This fragmentation influenced beliefs about diet and physical activity, and control and acceptability of gestation weight gain on different parts of the body. Future interventions and antenatal care should take this fragmentation into consideration when providing pregnant women with advice, information and support relating to their diet and physical activity behaviours.

How effective are interventions at reducing socioeconomic inequalities in obesity among children and adults? Two systematic reviews

Background

Tackling obesity is one of the major contemporary public health policy challenges and is vital in terms of addressing health inequalities.

Objectives

To 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 sources

Nine 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 methods

Preferred 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).

Results

Of 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.

Limitations

The 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.

Conclusions

The 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 registration

The studies are registered as PROSPERO CRD42011001740 and CRD42013003612.

Funding

The National Institute for Health Research Public Health Research programme.

Weighing up the evidence: a systematic review of the effectiveness of workplace interventions to tackle socio-economic inequalities in obesity

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.

Community pharmacy interventions for public health priorities: protocol for a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions

BACKGROUND

Community pharmacists can deliver health care advice at an opportunistic level, related to prescription or non-prescription medicines and as part of focused services designed to reduce specific risks to health. Obesity, smoking and excessive alcohol intake are three of the most significant modifiable risk factors for morbidity and mortality in the UK, and interventions led by community pharmacists, aimed at these three risk factors, have been identified by the government as public health priorities. In 2008, the Department of Health for England stated that 'a sound evidence base that demonstrates how pharmacy delivers effective, high quality and value for money services is needed'; this systematic review aims to respond to this requirement.

METHODS/DESIGN

We will search the databases MEDLINE, Embase, CINAHL, PsycINFO, Social Sciences Citation Index, ASSIA, IBSS, Sociological Abstracts, Scopus and NHS Economic Evaluation Database for studies that have evaluated interventions based on community pharmacies that aim to target weight management, smoking cessation and alcohol misuse. We will include all randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series (ITS) and repeated measures studies. Data from included studies will be extracted by two independent reviewers and will include study details methods, results, intervention implementation/costs and methodological quality. Meta-analysis will be conducted if appropriate; if not, the synthesis will be restricted to a narrative overview of individual studies looking at the same question.

DISCUSSION

The review aims to summarise the evidence base on the effectiveness of community pharmacy interventions on health and health behaviours in relation to weight management, smoking cessation and alcohol misuse. It will also explore if, and how, socio-economic status, gender, ethnicity and age moderate the effect of the interventions and will describe how the interventions included in the review have been organised, implemented and delivered, since context is an important factor governing the success of public health interventions. The findings from this review will have an impact on the commissioning of public health services aiming to promote healthy weight, smoking cessation and prevent excessive alcohol consumption.

SYSTEMATIC REVIEW REGISTRATION

The review has been registered with PROSPERO (registration no. CRD42013005943). Available at: http://www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42013005943.

A systematic review of the effectiveness of individual, community and societal level interventions at reducing socioeconomic inequalities in obesity amongst children

BACKGROUND

Tackling childhood obesity is one of the major contemporary public health policy challenges and vital in terms of addressing socioeconomic health inequalities.We aimed to systematically review studies of the effectiveness of interventions (individual, community and societal) operating via different approaches (targeted or universal) in reducing socio-economic inequalities in obesity-related outcomes amongst children.

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 from interventions that aimed to prevent obesity, treat obesity, or improve obesity-related behaviours (diet and/or physical activity) amongst children (aged 0-18 years) in any setting and country, so long as they provided relevant information and analysis on both socioeconomic status and obesity-related outcomes. Data extraction and quality appraisal were conducted using established mechanisms and narrative synthesis was conducted.

RESULTS

We located 23 studies that provided the 'best available' (strongest methodologically) international evidence. At the individual level (n = 4), there was indicative evidence that screen time reduction and mentoring health promotion interventions could be effective in reducing inequalities in obesity. For the community level interventions (n = 17), evidence was inconclusive - with some studies suggesting that school-based health promotion activities and community-based group-based programmes were effective in reducing obesity - others not. Societal level evaluations were few (n = 1). However, there was no evidence to suggest that any of these intervention types increase inequalities and several studies found that interventions could at least prevent the widening of inequalities in obesity. The majority of studies were from America and were of 6-12 year old children.

CONCLUSIONS

The review has found only limited evidence although some individual and community based interventions may be effective in reducing socio-economic inequalities in obesity-related outcomes amongst children but further research is required, particularly of more complex, societal level interventions and amongst adolescents.

A systematic review of the effectiveness of individual, community and societal-level interventions at reducing socio-economic inequalities in obesity among adults

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.

The effectiveness of interventions targeting specific out-of-home food outlets: protocol for a systematic review

BACKGROUND

Eating out of the home has been associated with higher intakes of energy and fat and lower micronutrient intakes, as well as the development of obesity. Out-of-home food outlets (OHFOs) and the foods obtained from these outlets are an ideal target for interventions to improve diet and tackle obesity. This systematic review will explore the evidence for the effectiveness of promoting healthy behaviour through interventions that modify food practices in specific OHFOs.

METHODS/DESIGN

We will search the databases MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA and the NHS Economic Evaluation Database for studies that have evaluated interventions conducted in an OHFO that aim to promote healthier menu offerings. OHFOs which are not openly accessible to the general public and supermarkets will be excluded. Included study designs will be randomised controlled trials, non-randomised controlled trials, controlled before-after studies, interrupted time series studies and evaluations of single interventions where outcome measures were assessed at least once pre and post-intervention (repeated measures studies).

DISCUSSION

This systematic review aims to synthesise the available evidence with regard to interventions that aim to change specific OHFOs in order to promote healthier menu offerings. The findings of this review will provide information on the types of interventions that have been evaluated and the context in which they are set, and provide insights into what interventions, and intervention functions, are most effective in different OHFO settings, along with any important innovation, implementation and cost implications.The review has been registered with PROSPERO (registration no. CRD42013006931).

"Pre-schoolers in the playground" an outdoor physical activity intervention for children aged 18 months to 4 years old: study protocol for a pilot cluster randomised controlled trial

BACKGROUND

The pre-school years are considered critical for establishing healthy lifestyle behaviours such as physical activity. Levels of physical activity track through childhood into adulthood, thus establishing habitual physical activity early in life is 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 pre-school, playground-based interventions, and evaluations of these have found mixed results. A recent report published by the UK Chief Medical Officer (CMO) highlighted that new interventions to promote movement in the early years (0-5 years old) are needed. The aim of this study is to undertake a pilot cluster randomised controlled trial (RCT) of an outdoor playground-based physical activity intervention for parents and their children aged 18 months to 4 years old ("Pre-schoolers in the Playground"; PiP) and to assess the feasibility of conducting a full scale cluster RCT. The PiP intervention is grounded in behavioural theory (Social Cognitive Theory), and is in accordance with the CMO guidance for physical activity in the early years. It is informed by existing literature and data collected from focus groups with parents.

METHODS/DESIGN

One hundred and fifty pre-school children affiliated to 10 primary schools will be recruited. Schools will be randomised to either the PiP intervention arm or the control arm (usual practice). Children in the intervention arm will be invited to attend three 30 minute outdoor play sessions per week for 30 weeks (3 school terms) at the school. Feasibility will be assessed by examining recruitment rates, attendance, attrition, acceptability of the trial and of the PiP intervention to parents, fidelity of intervention implementation, capability and capacity for schools to deliver the intervention. Health outcomes and the feasibility of outcome measurement tools will be assessed. These include physical activity via triaxial, accelerometry (Actigraph GT3X+), anthropometry (height, body mass, BMI, waist and upper arm circumference), health related quality of life for child (PedsQL) and parent (EQ5D), parent wellbeing (ComQol-A5), injuries and health service use. A health economic evaluation will also be undertaken.

DISCUSSION

It is anticipated that results of this pilot trial will be published in spring 2015.

TRIAL REGISTRATION

Current controlled trials: ISRCTN54165860.

Technology-based dietary assessment: development of the Synchronised Nutrition and Activity Program (SNAP)

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.

Tackling inequalities in obesity: a protocol for a systematic review of the effectiveness of public health interventions at reducing socioeconomic inequalities in obesity among adults

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.

TRIAL REGISTRATION

PROSPERO registration number: CRD42013003612.

Characterizing the EPODE logic model: unravelling the past and informing the future

EPODE ('Ensemble Prévenons l'Obésité De Enfants' or 'Together let's Prevent Childhood Obesity') is a large-scale, centrally coordinated, capacity-building approach for communities to implement effective and sustainable strategies to prevent childhood obesity. Since 2004, EPODE has been implemented in over 500 communities in six countries. Although based on emergent practice and scientific knowledge, EPODE, as many community programs, lacks a logic model depicting key elements of the approach. The objective of this study is to gain insight in the dynamics and key elements of EPODE and to represent these in a schematic logic model. EPODE's process manuals and documents were collected and interviews were held with professionals involved in the planning and delivery of EPODE. Retrieved data were coded, themed and placed in a four-level logic model. With input from international experts, this model was scaled down to a concise logic model covering four critical components: political commitment, public and private partnerships, social marketing and evaluation. The EPODE logic model presented here can be used as a reference for future and follow-up research; to support future implementation of EPODE in communities; as a tool in the engagement of stakeholders; and to guide the construction of a locally tailored evaluation plan.

Existing maternal obesity guidelines may increase inequalities between ethnic groups: a national epidemiological study of 502,474 births in England

BACKGROUND

Asians are at increased risk of morbidity at a lower body mass index (BMI) than European Whites, particularly relating to metabolic risk. UK maternal obesity guidelines use general population BMI criteria to define obesity, which do not represent the risk of morbidity among Asian populations. This study compares incidence of first trimester obesity using Asian-specific and general population BMI criteria.

METHOD

A retrospective epidemiological study of 502,474 births between 1995 and 2007, from 34 maternity units across England. Data analyses included a comparison of trends over time between ethnic groups using Asian-specific and general population BMI criteria. Logistic regression estimated odds ratios for first trimester obesity among ethnic groups following adjustment for population demographics.

RESULTS

Black and South Asian women have a higher incidence of first trimester obesity compared with White women. This is most pronounced for Pakistani women following adjustment for population structure (OR 2.19, 95% C.I. 2.08, 2.31). There is a twofold increase in the proportion of South Asian women classified as obese when using the Asian-specific BMI criteria rather than general population BMI criteria. The incidence of obesity among Black women is increasing at the most rapid rate over time (p=0.01).

CONCLUSION

The twofold increase in maternal obesity among South Asians when using Asian-specific BMI criteria highlights inequalities among pregnant women. A large proportion of South Asian women are potentially being wrongly assigned to low risk care using current UK guidelines to classify obesity and determine care requirements. Further research is required to identify if there is any improvement in pregnancy outcomes if Asian-specific BMI criteria are utilised in the clinical management of maternal obesity to ensure the best quality of care is provided for women irrespective of ethnicity.

Effect of reducing total fat intake on body weight: systematic review and meta-analysis of randomised controlled trials and cohort studies

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.

Reduced or modified dietary fat for preventing cardiovascular disease

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.

OBJECTIVES

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.

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) randomised 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, I(2) 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.

Evidence-based recommendations for the development of obesity prevention programs targeted at preschool children

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.

Critical narrative review to identify educational strategies promoting physical activity in preschool

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.

Identifying effective behavioural models and behaviour change strategies underpinning preschool- and school-based obesity prevention interventions aimed at 4-6-year-olds: a systematic review

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.

A narrative review of psychological and educational strategies applied to young children's eating behaviours aimed at reducing obesity risk

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.

Tackling inequalities in obesity: a protocol for a systematic review of the effectiveness of public health interventions at reducing socioeconomic inequalities in obesity amongst children

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.

Interventions for preventing obesity in children

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies that governments, communities and families can implement to prevent obesity, and promote health, has been accumulating but remains unclear.

OBJECTIVES

This review primarily aims to update the previous Cochrane review of childhood obesity prevention research and determine the effectiveness of evaluated interventions intended to prevent obesity in children, assessed by change in Body Mass Index (BMI). Secondary aims were to examine the characteristics of the programs and strategies to answer the questions "What works for whom, why and for what cost?"

SEARCH METHODS

The searches were re-run in CENTRAL, MEDLINE, EMBASE, PsychINFO and CINAHL in March 2010 and searched relevant websites. Non-English language papers were included and experts were contacted.

SELECTION CRITERIA

The review includes data from childhood obesity prevention studies that used a controlled study design (with or without randomisation). Studies were included if they evaluated interventions, policies or programs in place for twelve weeks or more. If studies were randomised at a cluster level, 6 clusters were required.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies.  Data was extracted on intervention implementation, cost, equity and outcomes. Outcome measures were grouped according to whether they measured adiposity, physical activity (PA)-related behaviours or diet-related behaviours.  Adverse outcomes were recorded. A meta-analysis was conducted using available BMI or standardised BMI (zBMI) score data with subgroup analysis by age group (0-5, 6-12, 13-18 years, corresponding to stages of developmental and childhood settings).

MAIN RESULTS

This review includes 55 studies (an additional 36 studies found for this update). The majority of studies targeted children aged 6-12 years.  The meta-analysis included 37 studies of 27,946 children and demonstrated that programmes were effective at reducing adiposity, although not all individual interventions were effective, and there was a high level of observed heterogeneity (I(2)=82%).  Overall, children in the intervention group had a standardised mean difference in adiposity (measured as BMI or zBMI) of -0.15kg/m(2) (95% confidence interval (CI): -0.21 to -0.09).  Intervention effects by age subgroups were -0.26kg/m(2) (95% CI:-0.53 to 0.00) (0-5 years), -0.15kg/m(2) (95% CI -0.23 to -0.08) (6-12 years), and -0.09kg/m(2) (95% CI -0.20 to 0.03) (13-18 years). Heterogeneity was apparent in all three age groups and could not explained by randomisation status or the type, duration or setting of the intervention.  Only eight studies reported on adverse effects and no evidence of adverse outcomes such as unhealthy dieting practices, increased prevalence of underweight or body image sensitivities was found.  Interventions did not appear to increase health inequalities although this was examined in fewer studies.

AUTHORS' CONCLUSIONS

We found strong evidence to support beneficial effects of child obesity prevention programmes on BMI, particularly for programmes targeted to children aged six to 12 years. However, given the unexplained heterogeneity and the likelihood of small study bias, these findings must be interpreted cautiously. A broad range of programme components were used in these studies and whilst it is not possible to distinguish which of these components contributed most to the beneficial effects observed, our synthesis indicates the following to be promising policies and strategies:·         school curriculum that includes healthy eating, physical activity and body image·         increased sessions for physical activity and the development of fundamental movement skills throughout the school week·         improvements in nutritional quality of the food supply in schools·         environments and cultural practices that support children eating healthier foods and being active throughout each day·         support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development, capacity building activities)·         parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activitiesHowever, study and evaluation designs need to be strengthened, and reporting extended to capture process and implementation factors, outcomes in relation to measures of equity, longer term outcomes, potential harms and costs.Childhood obesity prevention research must now move towards identifying how effective intervention components can be embedded within health, education and care systems and achieve long term sustainable impacts.  

Modelling the relationship between obesity and mental health in children and adolescents: findings from the Health Survey for England 2007

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.

Reduced or modified dietary fat for preventing cardiovascular disease

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.

OBJECTIVES

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.

SEARCH STRATEGY

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) randomised 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, I(2) 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.