Health Improvement Review- Evidence Sub Group

Health Improvement Review Report on Evidence Mapping for Obesity Priority Area

Report structure: 1. Purpose 2. Methodology 3. Results – identification of potentially effective interventions 4. Conclusions - Implementation of potentially effective interventions in Wales

Purpose: This report has been prepared to support the Review of Health Improvement Programmes. A series of priority areas have been identified for the review derived from policy and strategy documents. The Review has a number of identified outputs, one of which is a high level summary of each priority area which highlights, based on current evidence of effectiveness, which interventions have the greatest potential to improve health in each priority area and the extent to which these are currently being delivered in Wales. The purpose of this report is to present this information for the priority area of Obesity.

Methodology The Review is being conducted within a limited timeframe, as a result an extensive review of the literature across all of the priority areas and initiatives is not feasible. The review team has adopted the following approach:  Evidence from systematic reviews or reviews of reviews  Guidelines derived from an assessment of the available evidence  Reviews from sources which have a clearly defined methodology and quality assurance process that is nationally or internationally recognised.

The Library and knowledge management service of Public Health Wales has undertaken an initial search of the following sources using agreed search terms:  NICE Guidelines  Cochrane Database of Systematic Reviews (Cochrane Reviews Only)  Campbell Collaboration Reviews  EPPI Centre Reviews  The Community Guide Recommendations

Version 1 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group Where limited material was identified, or specific information gaps, or where the reviews or recommendations are more than 5 years old, a further search has been undertaken of DARE and Health Evidence Canada for reviews conducted within the last five years, which are rated as moderate to good quality.

Reviews have been screened for inclusion based on agreed criteria e.g. health promotion interventions, interventions which involve clinical preventative services were excluded and those which focus on primary or secondary prevention.

Key information has been extracted and summarised in the ‘mapping evidence table’ (Table 1). An assessment has been made about the strength and direction of the evidence from the review based on the grading system developed and attached as Appendix 1. A subjective assessment has also been made by the reviewer of the extent of adoption or implementation of the intervention in Wales (Appendix 2). The grading of the evidence and the implementation assessment were reviewed by the team for consistency.

There are a number of limitations to this approach which it is important to consider when interpreting this report:  this is not an extensive review of the evidence in each area, a large amount of material will not have been considered  the sources used mean that the interventions used are more likely to reflect established or well-tested approaches and less likely to reflect innovative technologies and approaches  the assessment of implementation is subjective and based on the knowledge of the review team  the evidence grades are designed to give an indication of the strength of the evidence and enable current understanding of the efficacy of different interventions to be compared, the quality of the studies included within the reviews is drawn from the assessment by the reviewers

Version 1 2 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group 3. Results Table 1: Evidence Mapping Table Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales 1 NICE, 2006 Prevalence of Public health recommendations: Evidence statements: These interventions A. This . overweight and are mainly intervention Public health obesity NHS organisations Awareness raising implemented at a is supported actions: Weight 1.Managers and health professionals in all There is limited evidence local level and do by good prevention & maintenance primary care settings should ensure that (2+, 2- ) that a multi- not have co- evidence of management of Weight loss. preventing and managing obesity is a priority component intervention ordinated national its obesity: advice, at both strategic and delivery levels. including a public health programmes or effectiveness retail/catering Dedicated resources should be allocated for media campaign can have a monitoring and is schemes, action. beneficial effect on weight recommende environment, management particularly d for use in commercial weight 2. In their role as employers, NHS amongst those of higher the UK loss programmes organisations should set an example in social status. The developing public health policies to effectiveness of promotional prevent and manage obesity by campaigns focusing on National Institute following existing guidance. education alone is unclear for Health and (1+). Clinical 3. All primary care settings should Excellence. ensure that systems are in place to There is a paucity of implement the local obesity strategy. evidence on the This should enable health professionals effectiveness of Children and interventions among adults with specific training, including public health practitioners working singly and lower socioeconomic as part of multidisciplinary teams, to groups and BMEGs. provide interventions to prevent and manage obesity. There is a paucity of evidence in children and 4. All primary care settings should: young people; the

Version 1 3 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales -address the training needs of staff generalisability of involved in preventing and managing evidence in adults to obesity children and young -allocate adequate time and space for people remains unclear, staff to take action interventions vary by -enhance opportunities for health age, gender, social status professionals to engage with a range of and ethnicity (3 studies organisations and to develop 2+). multidisciplinary teams. Early years 5. Local health agencies should identify There is limited evidence appropriate health professionals and that interventions which ensure that they receive training in: focus on the prevention -the health benefits and the potential of obesity through effectiveness of interventions to improvements to diet and prevent obesity, increase activity levels activity appear to have a and improve diet (and reduce energy small but important intake) impact on body weight -the best practice approaches in that may aid weight delivering such interventions, including maintenance (4 RCTs tailoring support to meet people’s 1+, 2++). needs over the long term -the use of motivational and Improvements in the counselling techniques. food service to pre-school children can result in Training will need to address barriers to reductions in dietary health professionals providing support intakes of fat and and advice, particularly concerns about improved weight

Version 1 4 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales the effectiveness of interventions, outcomes (1 SR 1+). people’s receptiveness and ability to change and the impact of advice on Family-based relationships with patients. interventions that target improved weight 6. Interventions to increase physical maintenance in children activity should focus on activities that and adults, focusing on fit easily into people’s everyday life diet and activity, can be (such as walking), should be tailored to effective, at least for the peoples individual preferences and duration of the circumstances and should aim to intervention. improve people’s belief in their ability Effectiveness is to change (for example, by verbal associated with number persuasion, modelling exercise of behavior change behavior and discussing positive techniques taught (1 SR effects). Ongoing support (including 1++, I RCT 1+) appropriate written materials) should be given in person or by phone, mail or School-based internet. interventions The evidence on the 7. Interventions to improve diet (and effectiveness of multi- reduce energy intake) should be multi- component school-based component (for example, including interventions to prevent dietary modification, targeted advice, obesity (addressing the family involvement and goal setting), promotion of physical be tailored to the individual and provide activity, modification of ongoing support. dietary intake and reduction of sedentary

Version 1 5 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales 8. Interventions may include behaviours) is equivocal. promotional, awareness-raising Some identified activities, but these should be part of a interventions long-term, multi-component demonstrated a reduction intervention rather than one-off in mean BMI and the activities (and should be accompanied prevalence of obesity by targeted follow-up with different while the intervention population groups). was in place, but this finding was not universal. 9. Health professionals should discuss UK-based evidence in weight, diet and activity with people at particular is lacking (6 times when weight gain is more likely, studies 1+, 4 studies such as during and after pregnancy, 2+). the menopause and while stopping smoking. School-based physical activity interventions 10. All actions aimed at preventing (physical activity excess weight gain and improving diet promotion and reduced (including reducing energy intake) and television viewing) may activity levels in children and young help children maintain a people should actively involve parents healthy weight (3 studies and carers. 1+, 4 studies 2+, 2- ).

11. All interventions to support There is limited evidence smoking cessation should: from one UK-based study - ensure people are given information to suggest that on services that provide advice on interventions to reduce prevention and management of obesity consumption of

Version 1 6 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales if appropriate carbonated drinks - give people who are concerned about containing sugar may their weight general advice on long- have a role in reducing term weight management, in particular the prevalence of encouraging increased physical activity. overweight and obesity (1 RCT 1++). Community settings Workplace 12. All community programmes to Worksite behavior prevent obesity, increase activity levels modification and improve diet (including reducing programmes, that include energy intake) should address the health screening with concerns of local people from the counselling/education can outset. Concerns might include the result in short-term availability of services and the cost of weight loss. Weight loss changing behavior, the expectation that may be regained post healthier foods do not taste as good, intervention (10 RCTs dangers associated with walking and and 1 CCT. Majority 1+ ). cycling and confusion over mixed messages in the media about weight, Payroll incentive schemes diet and activity. (such as free gym membership) are either 13. Health professionals should work only effective in the short with shops, supermarkets, restaurants, term (during the period cafes and voluntary community of the intervention) or services to promote healthy eating ineffective for weight choices that are consistent with existing control (3 RCTs 1+). good practice guidance and to provide

Version 1 7 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales supporting information. There is inconclusive 14. Health professionals should support evidence for the and promote community schemes and effectiveness of facilities that improve access to workplace-based physical physical activity, such as walking or activity interventions on cycling routes, combined with tailored weight outcomes (4 RCTs information, based on an audit of local (all 1+) and 1 study 2+ needs. +).

15. Health professionals should support The effectiveness of and promote behavioural change healthier food provision programmes along with tailored advice in workplaces on weight to help people who are motivated to outcomes remains change become more active, for unclear (1 Study 2+). example by walking or cycling instead of driving or taking the bus. Health professional led interventions 16. Families of children and young Sustained health- people identified as being at high risk professional-led of obesity – such as children with at interventions in primary least one obese parent – should be care or community offered ongoing support from an settings, focusing on diet appropriately trained health and physical activity or professional. Individual as well as general health family-based interventions should be counselling can support considered, depending on the age and maintenance of a maturity of the child. healthy weight (1 SR, 8 RCTs mostly 1+).

Version 1 8 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales Preschool, childcare & family settings 17. Any programme to prevent obesity Interventions which in preschool, childcare or family provide support and settings should incorporate a range of advice on physical components (rather than focusing on activity and diet are more parental education alone), such as: likely to be effective for -diet : interactive cookery weight outcomes than demonstrations, videos and group interventions which focus discussions on practical issues such as on physical activity alone. meal planning and shopping for food There is no reliable and drink evidence for diet alone -physical activity: interactive (11 RCTs mostly 1+, demonstrations, videos and group 2+). discussions on practical issues such as ideas for activities, opportunities for Although the majority of active play, safety and local facilities. studies included predominantly white, 18. Family programmes to prevent higher social status and obesity, improve diet (and reduce reasonably motivated energy intake) and/or increase physical individuals, there is some activity levels should provide ongoing, evidence that tailored support and incorporate a interventions can also be range of behavior change techniques. effective among lower Programmes should have a clear aim to social groups (3 RCTs, improve weight management. 1++, 1+,1+)

19. Health professionals such as There is some evidence occupational health staff and public that primary care staff

Version 1 9 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales health practitioners should establish may hold negative views partnerships with local businesses and on the ability of patients support the implementation of to change behaviours, workplace programmes to prevent and and their own ability to manage obesity. encourage change (4 studies, grade 3). Local authority and partners There is a body of 1. As part of their roles in regulation, evidence from UK-based enforcement and promoting wellbeing, qualitative research that local authorities, primary care trusts time, space, training, (PCTs) or local health boards and local costs and concerns about strategic partnerships should ensure damaging relationships that preventing and managing obesity with patients may be is a priority for action – at both barriers to action by strategic and delivery levels – through health professionals (GPs community interventions, policies and and pharmacists) (6 objectives. Dedicated resources should grade 3 studies). be allocated for action. There is some evidence 2. Local authorities should set an from the UK that patients example in developing policies to are likely to welcome the prevent obesity in their role as provision of advice employers, by following existing despite concerns by guidance. health professionals about interference or 3. Local authorities should engage with damaging the the local community, to identify relationship with patients

Version 1 10 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales environmental barriers to physical (2 grade 3 studies). activity and healthy eating. This should involve: Broader community an audit, with the full range of partners interventions including PCTs or local health boards, There is no evidence on residents, businesses and institutions the effectiveness of and assessing the affect of their policies broader environmental on the ability of their interventions on the communities/subgroups to be maintenance of a physically active and eat a healthy diet. healthy weight and prevention of obesity. 4. Local authorities should work with local partners, such as industry and There is little evidence of voluntary organisations, to create and benefit from locally manage more safe spaces for incidental implementable multi- and planned physical activity, component city- and addressing as a priority any concerns state-wide interventions about safety, crime and inclusion. to prevent cardiovascular disease on weight 5. Local authorities should facilitate outcomes (3 studies 2+). links between health professionals and other organisations to ensure that local Specific groups public policies improve access to There is a dearth of healthy foods and opportunities for evidence on the physical activity. effectiveness of interventions among 6. Local authorities and transport BMEGs in the UK. All authorities should provide tailored identified RCTs were

Version 1 11 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales advice such as personalised travel undertaken in the USA, plans to increase active travel among the majority among people who are motivated to change. African/black Americans.

7. Local authorities, through local The effectiveness of strategic partnerships, should interventions among encourage all local shops, lower-income and other supermarkets and caterers to promote vulnerable groups healthy food and drink. remains unclear

8. All community programmes to There is a dearth of prevent obesity, increase activity levels evidence on the and improve diet (and reduce energy effectiveness of intake) should address the concerns of interventions among local people. Concerns might include individuals with a the availability of services and the cost disability but limited of changing behavior, the expectation short-term evidence to that healthier foods do not taste as suggest that intervention good, dangers associated with walking may prevent excessive and cycling and confusion over mixed weight gain in overweight messages in the media about weight, adults with Down’s diet and activity. syndrome (1+).

9. Community-based interventions There is some evidence should include awareness-raising that interventions to promotional activities, but these should prevent excess be part of a longer-term, multi- pregnancy weight gain component intervention rather than may be effective among

Version 1 12 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales one-off activities. lower-income groups but the impact of baseline Early years settings weight remains unclear (1+, 2++). 1. All nurseries and childcare facilities should ensure that preventing excess On balance, smoking weight gain and improving children’s cessation interventions diet and activity levels are priorities. incorporating weight management may 2. All action aimed at preventing excess increase continuous weight gain, improving diet (and abstinence rates but the reducing energy intake) and increasing long-term impact on activity levels in children should involve weight, and the impact parents and carers. on diet and physical activity levels, remains 3. Nurseries and other childcare unclear (2 studies 1++, 4 facilities should: studies 1+, 2++). -minimise sedentary activities during play time, and provide regular There is a body of opportunities for enjoyable active play evidence that exercise and structured physical activity (walking, other aerobic sessions training, resistance -implement Department for Education training, strength training and Skills, Food Standards Agency and with weights machines or Caroline Walker Trust§ guidance on combinations) can food procurement and healthy catering. improve body composition and result in 4. Staff should ensure that children eat a small loss of body

Version 1 13 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales regular, healthy meals in a pleasant, weight and fat in sociable environment free from other postmenopausal women. distractions (such as television). This effect seemed to be Children should be supervised at optimal when combined mealtimes and, if possible, staff should with a weight-reducing eat with children. diet (SR 1++).

Schools There is limited evidence that a weight 1. All schools should ensure that management programme improving the diet and activity levels of addressing diet and children and young people is a priority activity during the for action to help prevent excess menopause can prevent weight gain. A whole-school approach excess weight gain in should be used to develop life-long menopausal women (1+ healthy eating and physical activity +). practices. There is limited evidence 2. Head teachers and chairs of to suggest that governors, in collaboration with parents continuing a regular and pupils, should assess the whole exercise regimen and school environment and ensure that the following an appropriate, ethos of all school policies helps healthy diet throughout children and young people to maintain pregnancy can result in a healthy weight, eat a healthy diet and significantly less total be physically active, in line with weight gain and existing standards and guidance. significantly less increases in the sum of

Version 1 14 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales 3. Head teachers and chairs of skinfolds (2 studies 1+, governors should ensure that teaching, 2+, 2-). support and catering staff receive training on the importance of healthy- There is a paucity of school policies and how to support their evidence on the implementation. effectiveness of interventions to manage 4. Schools should establish links with weight, improve dietary relevant organisations and intake and or improve professionals, including health activity levels among professionals and those involved in vulnerable groups. local strategies and partnerships to promote sports for children and young Management in Non- people. clinical settings In both children and 5. Interventions should be sustained, adults, there is a paucity multicomponent and address the whole of good-quality evidence school, including after-school clubs and on the effectiveness of other activities. Short-term interventions in non- interventions and one-off events are clinical settings, insufficient on their own and should be particularly men. part of a long-term integrated programme There is moderate evidence that a multi- 6. Staff delivering physical education, component commercial sport and physical activity should group programme may promote activities that children and be more effective than a young people find enjoyable and can standard self-help

Version 1 15 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales take part in outside school, through programme. It remains into adulthood. Children’s confidence unclear whether the and understanding of why they need to branded commercial continue physical activity throughout group programme for life (physical literacy) should be which there is evidence developed as early as possible. of effectiveness (WeightWatchers) is 7. Children and young people should more or less effective eat meals (including packed lunches) in than other branded school in a pleasant, sociable commercial programmes environment. Younger children should (1++, 1-). be supervised at mealtimes and, if possible, staff should eat with children. There is no strong evidence to support the 8. Staff planning interventions should use of meal replacement consider the views of children and products over a standard young people, any differences in low-calorie diet (2-, 1-). preferences between boys and girls, and potential barriers. There is limited evidence that interventions to 9. Where possible, parents should be manage obesity based involved in school-based interventions. in workplace settings can be effective, though Workplace weight loss may be small in the long term (1+, 5 1. All workplaces, particularly large studies 1-, 2-). organisations, e.g. NHS, local authorities, should address the There is some evidence

Version 1 16 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales prevention and management of obesity that because of the considerable impact on computer/email/internet- the health of the workforce and based programmes associated costs to industry. accompanied by greater ongoing support – in 2. Workplaces should provide person, by post or email opportunities for staff to eat a healthy – may be more effective diet and be more physically active. than those without (4 studies 1+, 2 studies 1-, 3. Incentive schemes (such as policies 2-). on travel expenses, the price of food and drinks sold in the workplace and The effectiveness of contributions to gym membership) that commercial and are used in a workplace should be computer-based weight sustained and part of a wider loss programmes in men programme to support staff in remains unclear managing weight, improving diet and increasing activity levels. There is limited evidence that a diverse range of 4. Workplaces providing health checks novel, multi-component for staff should ensure that they community-based address weight, diet and activity, and interventions may be provide ongoing support. effective in the management of 5. Action to improve food and drink obesity, including a provision in the workplace, including peer-led programme and restaurants, hospitality and vending a group-based and machines, should be supported by individual-based weight

Version 1 17 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales tailored educational and promotional loss programme in a programmes, such as a behavioural religious-based setting, a intervention or environmental changes. home-based exercise programme Management of obesity (accompanied by regular group sessions) and 1. Primary care organisations and local programme providing authorities should recommend to information through patients, or consider endorsing, self- interactive television (2 help, commercial and community studies 1+, 3 studies 2-). weight management programmes only if they follow best practice (see There is a paucity of guideline). evidence on the effectiveness of 2. Health professionals should discuss interventions to manage the range of weight management obesity in children based options with people who want to lose or in non-clinical settings; maintain their weight, or are at risk of the evidence that was weight gain, and help them decide identified was generally what best suits their circumstances and for children aged 8–12 what they will be able to sustain in the years of age and at the long term. extreme end of obesity. There is no UK-based 3. General practices and other primary evidence available on the or secondary care settings effectiveness of recommending commercial, community interventions to manage and/or self-help weight management obesity in children and programmes should continue to young people in non-

Version 1 18 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales monitor patients and provide support clinical settings. and care. There is limited evidence 4. Health professionals should check that interventions that any commercial, community or provided by school staff self-help weight management can aid the programmes they recommend to management of patients meet best-practice standards obesity in children and (See rec1, section 1.6.9.2). young people, at least in the short term, but this may be less effective than a more intensive intervention delivered in a clinical setting (2 studies 2-).

There is insufficient evidence to compare the effectiveness of interventions with or without family involvement in non- clinical settings (2 studies 1+, 2 studies 1-, 2+, 2 studies 2-).

There is some evidence that home-based

Version 1 19 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales interventions may be more effective when accompanied by behavior modification material and ongoing support. However, the replicability of this intervention on a wider scale remains unclear (2 studies 1+, 1-).

No evidence was identified which considered the effectiveness of exercise referral programmes to manage overweight or obesity in children and young people

Among both children and adults, interventions in non-clinical settings that are shown to be effective in terms of weight management, are likely to demonstrate significant improvements

Version 1 20 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales in participants’ dietary intakes (most commonly fat and calorie intake) or physical activity (Adults: 6 studies 1+, 3 studies 1-, 3 studies 2-, Children: 1+, 2-).

It remains unclear whether the effectiveness of programmes in children or adults varies by age, gender, ethnicity or social status or whether participants have previously tried to lose or maintain their weight.

There is insufficient evidence to identify strategies in non-clinical settings that are associated with the long- term maintenance of weight and continuation of improved behaviours among overweight and

Version 1 21 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales obese adults and children.

Version 1 22 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales

2 Amorim Primary: Weight Preliminary evidence from this review Six trials involving 245 This intervention is C. There is . Adegboye, AR; reduction in suggests that both diet and exercise together women were included. Only implemented locally some Linne, Y; women carrying and diet alone help women to lose weight 1 trial provided long-term in some areas but evidence Lourenco, P, excess weight after childbirth. Nevertheless, it may be data. All but 1 trial were does not have a supporting 2007. after childbirth. preferable to lose weight through a conducted in the US. Most consistent national the use of Secondary: combination of diet and exercise as this involved calorie restricted programme or a co- this Weight reduction maternal body improves maternal cardio-respiratory fitness diets but 1 involved nutrition ordinated approach intervention after pregnancy composition; and preserves fat-free mass, while diet alone education. All involved but it is not through dietary breastfeeding reduces fat-free mass. This needs aerobic exercise conclusive advice, dietary performance; confirmation in large trials. The magnitude of programmes but only 3 were counselling, cardio-respiratory postpartum weight loss was moderate supervised. There was prescription of a fitness; infant (approximately 3 kg) and the clinical considerable clinical

Version 1 23 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales calorie-restricted weight gain and importance of the intervention programme heterogeneity between trials. diet, exercise growth; and other remains unclear, particularly for women who Women who exercised did counselling, child and were already overweight or obese before not lose significantly more structured maternal pregnancy. weight than women in the exercise outcomes. For women who are breastfeeding, more usual care group (one trial; n programmes evidence is required to confirm whether diet = 33; MD 0.00 kg; 95% or exercise, or both, is not detrimental for confidence interval (CI) -8.63 Cochrane either mother or baby. to 8.63). Women who took Database of Methodological short-comings of some trials, part in a diet (one trial; n = Systematic especially the small sample size, the small 45; MD -1.70 kg; 95% CI Reviews. number of studies reviewed for each -2.08 to -1.32), or diet plus Women outcome, and the diversity in the nature, exercise programme (four duration and frequency of the interventions trials; n = 169; MD -2.89 kg; argue caution in applying these encouraging 95% CI -4.83 to -0.95), lost results. significantly more weight than women in the usual care. There was no difference in the magnitude of weight loss between diet and diet plus exercise group (one trial; n = 43; MD 0.30 kg; 95% CI -0.60 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. The available data are insufficient to infer important risks or other potential benefits for the mother or infant.

Version 1 24 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales 3 Flodgren, G et Patient Most of the included trials had RCTs involving fully This intervention F. The . al, 2010. outcomes: Main methodological or reporting weaknesses and qualified health may be evidence is outcome=body were heterogeneous in terms of participants, professionals, working implemented locally inconsistent Interventions weight. interventions, outcomes, and settings, so it is with overweight or obese in some areas but and it is not change either Others=body difficult to draw any firm conclusions about adults. All patients in an does not have a possible to or both the mass index the effectiveness of the interventions. The included study had to be consistent national draw a behaviour of (BMI); beneficial effects of the intervention reported recruited in the context programme or a co- conclusion by 3 studies may be influenced by bias ordinated approach but it tends health satisfaction of a healthcare setting consequent to poor methodological quality. towards no professionals with provider and only studies that had The better quality studies showed little effect effect and the practice or standard care as the of the intervention. Omission of the health organisation healthcare professionals' attitudes towards overweight comparator arm of the of care to provision; or obese people is a limitation of the studies study were included. promote psychological included in this review. All of the evaluated Six RCTs included, involving weight outcomes (self- interventions would need further investigation more than 246 health reduction in esteem, stress, before it was possible to recommend them as professionals and 1324 overweight depression, effective strategies. overweight or obese patients. and obese dietary Four of the trials targeted people - restraint); professionals and two Information & morbidity targeted the organisation of care. Most of the studies had training, skill (measures of methodological or reporting mix, service disease status weaknesses indicating a delivery and sick risk of bias. Meta-analysis of leave); three trials that evaluated measures of educational interventions Cochrane body fat; aimed at GPs suggested Database of effects on risk that, compared to standard Systematic factors care, such Reviews. (differences in interventions could reduce

Version 1 25 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales cholesterol the average weight of levels, blood patients after a year (by 1.2 Working adults pressure); kg, 95% CI -0.4 to 2.8 kg); patient however, there was behaviour moderate (attendance unexplained heterogeneity levels at weight between their results (I2 = 41%). One trial found that management or reminders could change physical doctors’ practice, resulting in exercise a significant reduction in programmes); weight among men (by 11.2 the number of kg, 95% CI 1.7 to 20.7 kg) withdrawals but not among women (who from reduced weight by 1.3 kg, treatment. 95% CI -4.1 to 6.7 kg). The Health three included studies professional included all had different outcomes: end-points (six, 12, and 18 measures of months) could have biased health the results due to the short- practitioners' term character of weight loss. behaviour, In all included studies, knowledge, samples were dominated by attitudes, or women (62%-100%), which satisfaction. may represent selection bias. If the imbalance was due to men’s reluctance to seek health care or their unwillingness to participate, it

Version 1 26 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales is possible that only highly motivated men were included. However, the motivation of participants is unknown. One trial found that patients may lose more weight after a year if the care was provided by a dietitian (by 5.6 kg, 95% CI 4.8 to 6.4 kg) or by a doctor-dietitian team (by 6 kg, 95% CI 5 to 7 kg), as compared with standard care. One trial found no significant difference between standard care and either mail or phone interventions in reducing patients’ weight. 4 Oude Luttikhuis, H Primary: While there are limited quality data to 64 RCTs included (5230 Elements of the B. This . et al, 2009 Measured height recommend one treatment program to be participants). Lifestyle intervention are intervention & weight favoured over another, this review shows that interventions focused on funded for national is supported Interventions to family-based combined behavioural and physical activity and implementation, but by moderate treat Secondary: lifestyle interventions compared to standard sedentary behaviour in 12 is dependent on to good obesity in body fat care or self-help can produce a significant studies, local components quality children and distribution, and clinically meaningful reduction in diet in 6 studies, and 36 that are variable evidence of adolescents: metabolic overweight in children (under 12 years) and concentrated on its lifestyle (dietary, changes (or adolescents. In obese adolescents, behaviourally orientated effectiveness, physical activity, markers of future consideration should be given to the use of treatment programs. Three but note behavioural disease), either orlistat or sibutramine, as an adjunct to types of drug interventions limits to

Version 1 27 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales therapy), drug or behaviour lifestyle interventions, although this approach (metformin,orlistat and generalisabilit surgical change, needs to be carefully weighed up against the sibutramine) were found in y of the interventions, participants potential for adverse effects. In adolescents 10 studies. No surgical findings views, self- the effect size remained significant at 12 intervention was eligible for esteem, health months after beginning of the intervention, inclusion. Most of the Cochrane status and well demonstrating included studies were too Database of being, quality of that beneficial effects of the behavioural small to have the power to Systematic life, harm program persisted in the longer-term. It is a detect efficacy. Reviews. associated with priority to develop interventions that account Meta-analyses indicated a the process or for differences throughout child and reduction in overweight at 6 outcomes, cost adolescent development. An important and 12 months follow up in: i) Children and effectiveness finding in this review was the lack of lifestyle interventions young adults interventions for preschool-aged children and involving children; and the relatively low number of lifestyle ii) lifestyle interventions in interventions targeted at adolescents. adolescents with or without the addition of orlistat or With many of the studies included in this sibutramine. Most studies review, it is unlikely that the implications for demonstrated beneficial practice can be directly extrapolated from effects of interventions on one group to another. The practicalities of child adiposity from baseline delivering effective advice to the end of intervention or on lifestyle changes to obese children and follow up but all studies adolescents will vary included in this review had with the wide span of social, ethnic and some methodological economic circumstances, as well as with the weaknesses and varied many variations in available resources for greatly in intervention design, local outcome measurements and health service delivery. In terms of validity, a methodological quality. number of the studies had small sample sizes, a likelihood of small study biases,

Version 1 28 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales relatively high drop-out rates, and unadjusted outcome measurements. The findings from many of the included studies may be non- generalisable owing to sampling problems - the majority of research in the field has been conducted in motivated, middle class, Caucasian populations. 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. 5 Shaw, KA et al, Primary This review synthesised results from studies Data from 41 RCTs were Elements of the B. This . 2006. outcomes: that had an ‘exercise prescription’ where included: 3476 participants. intervention are intervention weight or another different exercise regimes were ‘prescribed’ Although significant funded for national is supported Exercise indicator of body as arms of the trials, for comparison of heterogeneity in some of the implementation by moderate prescription- any mass (e.g. body different types of exercise or of exercise main effects’ analyses limited (National Referral to good form of physical mass with/without other interventions. This was not ability to pool effect sizes Scheme for quality activity index, waist an evaluation of ‘exercise on prescription’ or across some studies, a exercise evidence of performed on a measurement, exercise referral schemes. The results of this number of pooled effect sizes prescription only), its repeated basis waist-to-hip ratio), review support the use of exercise as a were calculated. When but implementation effectiveness for an defined morbidity and weight loss intervention, particularly when compared with no treatment, is dependent on period of time mortality, well- combined with dietary change. In this study exercise resulted in small local components (with/without being and quality high and low intensity exercise were weight losses across studies. which are variable dietary of life. associated with weight loss, both when Exercise combined with diet combined with dietary weight loss methods resulted in a greater weight advice) Secondary and when undertaken without dietary reduction than diet alone outcomes: change. However, the results support the (WMD - 1.0 kg; 95% Cochrane serum lipids, hypothesis that vigorous activity is more confidence interval (CI) -1.3

Version 1 29 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales Database of serum glucose, effective than moderate or light intensity to -0.7). Increasing exercise Systematic systolic and exercise in inducing weight loss. intensity increased the Reviews. diastolic blood However, high intensity exercise was only magnitude of weight loss pressure, adverse significantly better than (WMD -1.5 kg; 95% CI -2.3 effects. low intensity exercise at inducing weight loss to -0.7). There were Obese or when undertaken without dietary change. significant differences in overweight When diet was also modified, exercise other outcome measures intensity did not significantly affect the degree such as serum lipids, blood adults of weight loss. Diet (low calorie or low fat) pressure and fasting plasma was demonstrated to be significantly more glucose. Exercise as a sole effective at facilitating weight loss than weight loss intervention exercise in this meta-analysis. Exercise resulted in significant combined with diet also has a positive effect reductions in diastolic blood on cardiovascular risk factors, but exercise pressure (WMD -2 mmHg; was associated with improved cardiovascular 95% CI -4 to -1), triglycerides disease risk factors even if no weight is lost. (WMD - 0.2 mmol/L; 95% CI While this review did not show any long-term -0.3 to -0.1) and fasting morbidity and mortality benefits associated glucose (WMD - 0.2 mmol/L; with exercise, exercise was shown to 95% positively impact the intermediate outcomes CI -0.3 to -0.1). Higher that are commonly associated with intensity exercise resulted in cardiovascular disease. greater reduction in fasting serum glucose than lower However, all included studies had intensity exercise (WMD -0.3 methodological weaknesses, with only 4 mmol/L; 95% CI -0.5 to -0.2). studies reporting randomisation, only 3 No data were identified on reporting blinded outcome assessment and adverse events, quality of only 2 reporting ‘intention to treat’ analysis. life, morbidity, costs or on 25 of the 41 trials were 4 months or less in mortality. duration.

Version 1 30 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales

6 Tuah, NAA et al, Primary: TTM SOC and a combination of physical A total of five studies met the This intervention G. There is . 2010. Maintained activity, diet and other interventions resulted inclusion criteria. The trials may be some weight loss, in minimal weight loss (about 2 kg or less), were heterogeneous, implemented locally evidence Dietary and health-related and there was no conclusive evidence for particularly in terms of in some areas but suggesting physical quality of life sustainable weight loss. The impact of TTM interventions and outcomes does not have a that this exercise Secondary: self- SOC as theoretical framework in weight loss and had small to medium consistent national intervention interventions reported change management may depend on how it is used sample sizes, with 3910 programme or a co- is ineffective based on the in diet or physical as a framework for intervention and in participants evaluated in ordinated approach in relation to trans-theoretical activity, change in combination with other strategies like diet total. They were conducted in the primary model/ Stages of anthropometric and physical activities. In general, the community settings, were outcome but Change (TTM measures, death, findings of the review are generalisable to mainly delivered by health it is not SOC) morbidity, overweight and obese adults who are professionals and had short conclusive Cochrane adverse events, undergoing lifestyle modification to medium term follow up Database of costs programmes for weight loss, specifically (one year or less). The total Systematic programmes which number of participants Reviews. are based on TTM SOC in community randomised to intervention settings. groups was 1834 and 2076 Adults were randomised to control groups. All trials had some methodological weaknesses and all but one study had an overall high risk of bias for one or more key domains. The trials varied in length of intervention from six weeks to 24 months, with a median length of nine months. The intervention was found to have limited impact on

Version 1 31 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales weight loss (about 2 kg or less). There was no conclusive evidence for sustainable weight loss. However, TTM SOC and a combination of physical activity, diet and other interventions tended to produce significant outcomes (particularly change in physical activity and intake of fruit and vegetables). TTM SOC was used inconsistently as a theoretical framework for intervention in the trials. 7 Waters, E et al, Primary Strong evidence to support beneficial effects This review includes 55 Elements of the B. This . 2011. outcomes of child obesity prevention programmes on studies (all controlled study intervention are intervention • weight and BMI, particularly for programmes targeted to design but not all funded for national is supported Educational, height children aged six to 12 years in home or randomised), the majority of implementation by moderate health promotion • body fat % healthcare settings. The best estimate of which targeted children aged (through the MEND to good and /or • BMI effect on BMI was of a 0.15kg/m2 reduction 6-12 years. Only 6 were UK- programme), but quality psychological/fa • ponderal index which would correspond to a small but based. Of implementation is evidence of mily/behavioural • skin-fold clinically important shift in population BMI if the 55 included studies, dependent on local its therapy/ thickness sustained over several years. However, given 41were interventions components which effectiveness counselling/ • prevalence of the unexplained heterogeneity and the implemented for 12 months are variable management overweight and likelihood of small study bias, these findings or less, seven for 1 to 2 interventions obesity must be interpreted cautiously. A broad years, and seven were which focus on range of programme components were used implemented diet, physical Secondary in included studies and it was not possible to for more than two years. activity or outcomes distinguish which of these components Thirty studies had a high risk

Version 1 32 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales lifestyle support, • activity levels contributed most to the beneficial effects of bias for one or more or both for • dietary intake observed. domains. preventing (using validated However, the more effective interventions Across all domains, most obesity/ further measures such included: studies were rated as either weight gain as diaries etc) low or unclear risk of bias, • change in Curriculum on healthy eating, physical with the proportion of studies Cochrane knowledge activity and body image integrated into rated in these categories Database of • environment regular curriculum for each domain ranging from Systematic change (such as • More sessions for physical activity and the approximately 70%to 90%. Reviews. food provision development of service) fundamental movement skills throughout the The meta-analysis included • stakeholders 37 studies of 27,946 children School child school week views of the • Improved nutritional quality of foods made and demonstrated that intervention and available to students programmes were effective other evaluation • Creating an environment and culture that at reducing adiposity, findings support children eating nutritious foods and although not all individual • measures of being active throughout each day interventions were effective, self-esteem, • Providing support for teachers and other and there was a high level of health status and staff to implement health promotion observed heterogeneity well being, strategies and activities (e.g. professional I2=82%). quality of life development, capacity building activities) Overall, children in the • harm associated • Engaging with parents to support activities intervention group had a with the process in the home setting to encourage children to standardised mean or outcomes of be more active, eat more nutritious foods and difference in adiposity the spend less time in screen-based activities (measured as BMI or zBMI) intervention of -0.15kg/m2 (95% • cost Study and evaluation designs need to be confidence interval (CI): effectiveness/cost strengthened, and reporting extended to -0.21 to -0.09). Intervention s of the capture process and implementation factors, effects by age subgroups intervention outcomes in relation to measures of equity, were -0.26kg/m2 (95% CI:-

Version 1 33 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales longer term outcomes, potential harms and 0.53 to 0.00) (0-5 years), costs. -0.15kg/m2 (95% CI -0.23 to -0.08) (6-12 years), and -0.09kg/m2 (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. 8 Wieland, SL et al, Primary Given the small number of studies (18 total) 17 RCT and 1 quasi- U. Implementation B. This . 2012. outcomes: Body and the many permutations of intervention randomised trials of 4+ status is unknown intervention weight , or body goal, intervention components, control weeks duration. 14 weight is supported Interactive mass index condition and timing, firm conclusions were loss studies included with a by moderate computer- (BMI), waist hard to make and were typically based on a total of 2537 participants, to good based circumference, relatively small number of studies. However, and four weight maintenance quality interventions health-related overall, compared to no intervention or studies with a total of 1603 evidence of for weight quality of life, minimal interventions (pamphlets, usual participants. Treatment its

Version 1 34 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales loss or weight well-being and care), interactive computer-based duration was between four effectiveness maintenance patient interventions appeared to be an effective weeks and 30 months. 12 in overweight Satisfaction intervention for weight loss and weight were US based, 2 Australia or obese maintenance. Compared to in-person based and all carried out in people. Secondary interventions, interactive computer-based out-patient or community outcomes: interventions result in smaller weight losses settings. Across all Physical activity- and lower levels of weight maintenance. The participants 27%weremen related outcomes, amount of additional weight loss, however, is and 73%were women. Due Cochrane diet-related relatively small and of brief duration, making to the methodological quality Database of outcomes, cost- the clinical significance of these differences of some trials and the Systematic effectiveness, unclear. heterogeneity of some Reviews. adverse events. analyses, the overall quality of the evidence on weight Working age loss and weight maintenance adults according to the GRADE approach ranged between ’moderate’ and ’low’.

At six months, computer- based interventions led to greater weight loss than minimal interventions (mean difference (MD) -1.5 kg; 95% confidence interval (CI) -2.1 to -0.9; two trials) but less weight loss than in-person treatment (MD 2.1 kg; 95% CI 0.8 to 3.4; one trial). At six months, computer-based interventions were superior

Version 1 35 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Obesity

Study Details Outcome Main findings Results Current Evidence measures Implementation Grading Wales to a minimal control intervention in limiting weight regain (MD -0.7 kg; 95% CI -1.2 to -0.2; two trials), but not superior to infrequent in- person treatment (MD 0.5 kg; 95% -0.5 to 1.6; two trials). No consistent differences in dietary or physical activity behaviours between intervention and control groups in either weight loss or weight maintenance trials were observed.

Version 1 36 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

4. Comparability of key messages with other evidence reviews: The Community Guide The Community Guide is a product of the US Community Preventative Task Force. The Community Preventive Services Task Force was established by the U.S. Department of Health and Human Services (DHHS) in 1996 to develop guidance on which community-based health promotion and disease prevention interventions work and which do not work, based on available scientific evidence. The Centers for Disease Control and Prevention (CDC) is the DHHS agency that provides the Task Force with technical and administrative support following a systematic review process. These recommendations are made in a US policy and services context and may not apply fully to the UK. In the field of Obesity, the following recommendations have been made:

Obesity Prevention and Control: Provider-Oriented Interventions

Provider Education: Educational interventions directed at healthcare providers Insufficient Evidence designed to increase their knowledge as well as change attitudes and practices October 2007 in addressing overweight and obesity among clients.

Provider Feedback: Assessing health care providers’ delivery of weight management screening and treatment to their clients, and providing feedback on their performance. The provider behaviours that are generally targeted for improvement are: Insufficient Evidence  Collection and recording of weight-related measures (e.g., weight, body mass index) October 2007  Delivery of advice about weight loss  Efforts to assist clients in their weight loss attempts

Version 1 37 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Provider Reminders: use of systematic reminders to improve providers’ delivery of weight management screening and treatment to their clients. The reminders can be delivered in several ways, such as using chart stickers, vital sign stamps, medical record flow sheets, checklists, or electronic alerts. The Insufficient Evidence following provider behaviours are generally targeted for improvement: October 2007  Collection and recording of weight-related measures (e.g., weight, BMI)  Delivery of advice about weight loss  Efforts to assist clients in their weight loss attempts

Provider Education with a Client Intervention: a two-part intervention that involves: Insufficient Evidence  Educating healthcare providers to increase knowledge, improve attitudes and February 2008 change how they help clients address overweight and obesity, plus  Having healthcare providers actually use a method to help their clients lose weight

Multi-component Provider Interventions : designed to increase knowledge and Insufficient Evidence change attitudes and practices of healthcare providers in addressing overweight February 2008 and obesity among clients. These interventions use more than one of the following strategies: education, feedback, reminders, or office systems and support mechanisms. Interventions may be delivered by:  Lecture or seminar

Version 1 38 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

 Written materials  Training workshops  Electronic alerts  Feedback reports  Videos

Multi-component Provider Interventions with Client Interventions : designed to increase knowledge and change attitudes and practices of healthcare providers in addressing overweight and obesity among clients. These interventions use more than one of the Insufficient Evidence following strategies: education, feedback, reminders, or office systems and support February 2008 mechanisms. The interventions in this review also include components directed at clients themselves (e.g., lifestyle education, behavioural interventions).

Obesity Prevention and Control: Interventions in Community Settings

Interventions to Reduce Screen Time (e.g. time in front of a TV)

Behavioural Interventions to Reduce Screen Time: Behavioural interventions to Recommended reduce screen time (time spent watching TV, videotapes, or DVDs; playing January 2008 video or computer games; and surfing the internet) can be single-component or multi-component and often focus on changing screen time through classes aimed at improving children’s or parents’ knowledge, attitudes, or skills. These interventions may include:

Version 1 39 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

 Skills building, tips, goal setting, and reinforcement techniques  Parent or family support through provision of information on environmental strategies to reduce access to television, video games, and computers  A “TV turnoff challenge” in which participants are encouraged not to watch TV for a specified number of days

Mass Media Interventions to Reduce Screen Time: These types of interventions use mass media to reduce screen time, time spent watching TV, videotapes, or DVDs; playing video or computer games; or surfing the Internet. In these campaigns, one or more components is designed to: Insufficient Evidence  Increase knowledge about screen time January 2008  Influence attitudes  Change behaviour by transmitting messages through newspapers, radio, television, and billboards

Technology-Supported Interventions (e.g., computer or web applications) Multi- component Coaching or Counselling Interventions: Technology-supported multi- component coaching or counselling interventions use technology to facilitate or mediate interactions between a coach or counsellor and an individual or group, with a goal of influencing weight-related behaviours or weight-related outcomes. These interventions often also include other components, which may be technological or non-technological. Technology-supported components may include use of the following:

Version 1 40 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

 Computers (e.g., internet, CD-ROM, e-mail, kiosk, computer program)  Video conferencing  Personal digital assistants  Pagers  Pedometers with computer interaction  Computerized telephone system interventions that target physical activity, nutrition, or weight. Non-technological components may include use of the following:  In-person counselling  Manual tracking  Printed lessons  Written feedback Because of differences in implementation and intended outcomes, interventions aimed at reducing weight were considered separately from those intended to maintain weight loss.

Recommended To Reduce Weight June 2009

Recommended To Maintain Weight Loss June 2009

Version 1 41 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Interventions in Specific Settings

Worksite Programs: Worksite nutrition and physical activity programs are designed to improve health-related behaviours and health outcomes. These Recommended programs can include one or more approaches to support behavioural change February 2007 including informational and educational, behavioural and social, and policy and environmental strategies.

School-Based Programs: These interventions are conducted in the classroom and may seek to increase physical activity and/or improve nutrition, both in Insufficient Evidence school and at home. Classroom and physical education teachers may receive October 2003 special training to carry out the programs.

Version 1 42 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group 5. Conclusions: The priority area of obesity comprises awareness raising, prevention and management. The evidence sources utilised in this summary include NICE recommendations which draw from mixed sources of evidence, not all good quality systematic reviews, as well as other systematic reviews. The assessment of current implementation in Wales is based on a subjective assessment by the Evidence Review Team using personal knowledge and the information available to them, this may not be the full picture.

Systematic reviews of the reported effectiveness of interventions reveal a lack of high quality, reliable, studies that have shown a direct effect on Body Mass Index, weight loss or maintenance or obesity prevalence. Those studies that have shown an impact are often limited to easily controlled settings such as schools and workplaces, where individuals and small groups can be observed and these interventions have not yet been widely replicated or delivered at a scale that offers a clear option for public health strategies. Further, significant heterogeneity in intervention, setting and outcome measures makes it unlikely that the implications for practice can be directly extrapolated to the Welsh context without careful consideration of the ‘local’ factors which might impact on effectiveness. . There is little UK-based evidence on the effectiveness of multi-component interventions among key at-risk groups (for example, young children and families and black and minority ethnic groups), vulnerable groups (for example, looked-after children and young people, lower-income groups and people with disabilities) and people at vulnerable life stages (for example, women during and after pregnancy and people stopping smoking).

For many behaviour change measures, the evidence is equivocal but some consistent messages emerge to suggest that effective interventions are likely to be those which are multifaceted, inter-agency, intense, aimed at multiple behaviours, individually-tailored, followed up, supported by/ involve family and social groups and which involve feedback, advice, and goal-setting.

Tackling obesity will require a multi-faceted, multi-agency strategic approach which integrates effective interventions aimed at specific groups or settings with wider measures aimed at tackling the obesogenic environment. A national strategic framework for obesity prevention and treatment (incorporating a Standard Evaluation Framework) which cross-links to nutrition and physical activity strategies, could provide the framework for local obesity strategy and delivery plans, aiding greater consistency in delivery (where appropriate to local circumstances) and monitoring across Wales. The conclusions of the Nutrition and Physical activity Priority Area evidence reviews are directly relevant and should be read in conjunction with this review.

Version 1 43 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Interventions with evidence of effectiveness currently being implemented in Wales

NICE (2006) guidance suggests that family-based combined behavioural and lifestyle modification intervention have the potential to be effective in weight maintenance, at least for the duration of the intervention and other evidence (evidence table 4) also suggests that similar interventions can produce a significant and clinically meaningful reduction in overweight in children (under 12 years) and adolescents when compared with ‘standard care’ or self-help. This therefore suggests that the MEND programme has the potential to be effective in that it delivers a family-based combined behavioural and lifestyle modification intervention, however, evidence about the MEND programme per se is not strong and effectiveness has only been demonstrated in relation to short-term outcomes (refer to the MEND initiative assessment report). Evidence of effectiveness across different population sub-groups is lacking. There is likely to be considerable variation in local factors in Wales, which may impact upon recruitment and retention and thus on cost- effectiveness, for some areas/groups. MEND in Wales appears to sit alongside rather than being integrated with, other obesity related health improvement initiatives. This may be because it has been implemented as a ‘treatment’ rather than a health improvement initiative.

There is some evidence of limited effectiveness of exercise referral schemes (see the NERS Initiative Assessment Report). The Welsh National Exercise Referral Scheme (NERS) is implemented within all Local Health Boards. The National Coordinator for NERS is working to address local variability in implementation, to further target those with chronic conditions including obesity (including pilots for maternal obesity in one or two areas), and to incorporate a nutritional element alongside physical activity.

Interventions with evidence of effectiveness not currently being implemented, or with limited implementation or where no information was available

NICE (2006) guidance concludes that there is some evidence that provision of healthier food and increased opportunities for physical activity to pre-school children can be beneficial in helping maintain weight however, the extent to which this occurs is unknown and likely to vary across different settings.

NICE (2006) guidance suggests that school-based physical activity interventions (physical activity promotion and reduced television viewing) may help children maintain a healthy weight. Behavioural interventions to reduce screen time are also recommended by the US Community Guide for obesity prevention and control.

Version 1 44 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group Another source (evidence table 7) finds strong evidence for the effectiveness of obesity prevention interventions over short-term to medium periods, especially in non-overweight children aged 6-12 in the home or healthcare setting, however the heterogeneity of included studies makes it difficult to identify specific effective interventions, although generic components are identified. The Healthy Schools Scheme may include interventions to prevent obesity including promoting physical activity and reducing screen time, but the extent to which this occurs is unknown and likely to vary across the different local health boards.

NICE (2006) guidance suggests that worksite behaviour (diet and physical activity) modification programmes, that include health screening with counselling/education have the potential to be effective in supporting weight loss, in the short-term. The US Community Guide, also recommends worksite nutrition and physical activity programs designed to improve health-related behaviours and health outcomes. Initiatives within the Healthy Working Wales programme may include worksite behaviour (diet and physical activity) modification programmes, that include health screening with counselling/education but the extent of this provision is unknown.

NICE (2006) guidance recommends the provision of sustained advice and support focusing on diet and physical activity or general health counselling by health- professionals in primary care or community settings, for supporting maintenance of healthy weight. This is likely to occur across Wales, but the extent to which this is sustained, level of intensity, goal-setting and follow-up is unknown and likely to be variable.

Other evidence (evidence table 8) suggests that computer-based interactive interventions can be effective in supporting weight-loss or maintenance, compared with leaflets or ‘usual care’ where in-person interventions are not available. The US Community Guide recommends a range of technology supported tools alongside individual or group interventions for supporting weight loss or maintenance. There is no national provision of, or policy for use of, such technology.

NICE (2006) guidance suggests that there is moderate evidence that a multi- component commercial group programme may be more effective than a standard self-help programme in supporting weight loss. The extent of participation in such programmes across Wales is unknown.

Interventions for which there is evidence of limited, or no, effect, which are being implemented in Wales

Version 1 45 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group There is some evidence (evidence table 6) to suggest that use of the Trans- theoretical Model/Stages of Change (TTMSOC) in weight loss programmes does not result in maintained weight loss, although the exact way in which it is used could affect this. The extent to which programmes based on this model are being implemented across Wales is unknown but there may be local programmes in place.

Similarly, evidence (evidence table 3) suggests that some interventions to change healthcare provider activity to promote weight loss, are not likely to be effective, but the extent to which this relates to interventions in place across Wales is unknown. Qualitative research suggests that primary care staff may hold negative views on the ability of patients to change behaviours, and their own ability to encourage change. Time, space, training, costs and concerns about damaging relationships with patients may be barriers to action. This needs to be taken into account when considering the role of primary care in weight management.

Interventions across the life-course

Prenatal/maternal health/early years: There is limited evidence to suggest that continuing a regular exercise regimen and following an appropriate, healthy diet throughout pregnancy can result in significantly less total weight gain and significantly less increases in the sum of skinfold thicknesses.

There is limited evidence that interventions for early years which focus on the prevention of obesity through improvements to diet, particularly through provision of healthier food, and activity appear to have a small but important impact on body weight that may aid weight maintenance.

Family: Family-based combined behavioural and lifestyle interventions can be effective in reducing overweight in children (under 12 years) and adolescents. There is some evidence that use of either orlistat or sibutramine, as an adjunct to lifestyle interventions, is useful in obese adolescents but this should be viewed with caution due to the potential for adverse effects and up to date guidance on the use of these treatment should be sought.

There is limited evidence that behavioural interventions to reduce screen time (time spent watching TV, videotapes, or DVDs; playing video or computer games; and

Version 1 46 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group surfing the internet) ie. through classes aimed at improving children’s or parents’ knowledge, attitudes, or skills, can be effective, particularly for pre-school children.

School aged children: There is a lack of evidence, particularly UK-based evidence, on the effectiveness of interventions to manage obesity in children and young people in non-clinical settings.

Interventions that are shown to be effective in terms of weight management, are likely to demonstrate significant improvements in participants’ dietary intakes (most commonly fat and calorie intake) or physical activity.

The evidence on the effectiveness of multi-component school-based interventions to prevent obesity (addressing the promotion of physical activity, modification of dietary intake and reduction of sedentary behaviours) is equivocal, although there is some evidence that school-based physical activity interventions (physical activity promotion and reduced television viewing) may help children maintain a healthy weight.

No evidence was identified which considered the effectiveness of exercise referral programmes to manage overweight or obesity in children and young people.

There is limited evidence (from one UK-based study) to suggest that interventions to reduce consumption of carbonated drinks containing sugar may have a role in reducing the prevalence of overweight and obesity.

Adults: There is some evidence that exercise, particularly of vigorous activity, can be effective in inducing weight loss amongst obese or overweight adults and that low calorie or low fat diets can be more effective at facilitating weight loss than exercise. However, interventions which provide behavioural therapy, support and advice on physical activity and diet are more likely to be effective for weight outcomes than interventions which focus on physical activity alone.

Worksite behaviour modification programmes, that include health screening with counselling/education can result in short-term weight loss although weight loss may be regained post intervention.

Version 1 47 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group Sustained health-professional-led interventions in primary care or community settings, focusing on diet and physical activity or general health counselling can support maintenance of a healthy weight.

Interactive computer-based interventions can be an effective intervention for weight loss and weight maintenance but are less effective than in-person interventions.

There is moderate evidence that a multi-component commercial group programme may be more effective than a standard self-help programme.

There is a paucity of good-quality evidence on the effectiveness of interventions in non-clinical settings, particularly amongst men and the effectiveness of commercial and computer-based weight loss programmes in men remains unclear.

There is limited evidence that a weight management programme addressing diet and activity during the menopause can prevent excess weight gain in menopausal women

Although the majority of studies included predominantly white, higher social status and reasonably motivated individuals, there is some evidence that interventions can also be effective among lower social groups, including interventions to prevent excess pregnancy weight gain. However, there is a lack of evidence on the effectiveness of interventions among BMEGs and individuals with a disability in the UK and the effectiveness of interventions among lower-income and other vulnerable groups remains unclear.

Version 1 48 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group References

Amorim Adegboye A et al, 2007. Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane Database of Systematic Reviews (3) CD005627 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005627.pub2/pdf

Flodgren G et al, 2010. Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese adults. Cochrane Database of Systematic Reviews (3) CD000984 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000984.pub2/pdf

National Institute for Health and Clinical Excellence, 2006. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. London: NICE. CG43. Available at: http://www.nice.org.uk/nicemedia/live/11000/30365/30365.pdf

Oude Luttikhuis H et al, 2009. Interventions for treating obesity in children. Cochrane Database of Systematic Reviews (1) CD001872 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001872.pub2/pdf

Shaw K et al, 2006. Exercise for overweight or obesity. Cochrane Database of Systematic Reviews (4) CD003817 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003817.pub3/pdf

Tuah Net al, 2010. Transtheoretical model for dietary and physical exercise modification in weight loss management for overweight and obese adults. Cochrane Database of Systematic Reviews (10) CD008066 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008066.pub2/pdf

U.S. Department of Health and Human Services Community Preventive Services Task Force. The Community Guide. Available at: http://www.thecommunityguide.org/nutrition/index.html

Waters E et al, 2011. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews (12) CD001871

Version 1 49 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001871.pub3/pdf

Wieland S et al, 2012. Interactive computer-based interventions for weight loss or weight maintenance in overweight or obese people. Cochrane Database of Systematic Reviews (8) CD007675 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007675.pub2/pdf

Version 1 50 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group Appendix 1: Evidence grading scheme A. This intervention is supported by NICE Recommended Intervention OR good evidence of its effectiveness systematic review, of moderate to good and is recommended for use in the quality studies, with meta-analysis of majority UK of studies favouring intervention effect B. This intervention is supported by systematic review of moderate to weak moderate to good quality evidence of studies with meta-analysis favouring its effectiveness intervention effect or narrative review including moderate to good quality studies with majority demonstrating positive effect C. There is some evidence supporting systematic review of moderate to poor quality the use of this intervention but it is not studies with majority favouring intervention conclusive D. The evidence is inconsistent and it Systematic review with significant weakness is not possible to draw a conclusion and high risk of bias (positive results) or but there is some evidence of effect review of moderate quality with inconsistent findings in favour of the intervention E. There is good evidence to suggest Moderate to good quality systematic review that this intervention has a sound of observational or qualitative studies which theoretical basis or that work in this suggest that the intervention addresses a area is likely to have an impact but significant risk factor or determinant of the this has not been demonstrated in behaviour of interest trials (this would apply particularly to pilot or novel interventions) F. The evidence is inconsistent and it Systematic review with studies judged as is not possible to draw a conclusion significant weak/risk of bias (evidence of no but it tends towards no effect effect) or review of moderate quality studies with inconsistent findings in favour of no effect G. There is some evidence systematic review of moderate to poor quality suggesting that this intervention is studies with majority favouring no effect ineffective but it is not conclusive H. There is moderate to good systematic review of moderate to weak evidence that this intervention is studies with meta-analysis, majority of unlikely to be effective studies in favour of control/no effect K. There is high quality evidence of NICE specifically recommends this ineffectiveness or a specific intervention should not be adopted or there is recommendation that these high quality review level evidence from meta- interventions should not be introduced analysis of good quality studies that in the UK demonstrates no effect Appendix 2: Implementation grading scheme

Version 1 51 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Current Implementation in Wales The intervention is funded for widespread national implementation in Wales (e.g. dedicated staffing, implemented in all HB areas (this can include targeted implementation)) OR this policy/legislative approach has been implemented in Wales Elements of the intervention are funded for national implementation, but implementation is dependent on local components which are variable Elements of the intervention are funded for national implementation, but monitoring information is not available to confirm widespread adoption/reach or information suggests implementation is sub-optimal This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach OR is implementation nationally on an ad-hoc basis P This intervention is currently being implemented on a pilot basis U Implementation status is unknown Implementation is not currently taking place

Version 1 52 November 2012