Title: Prevention of obesity at family, community and national level and treatment of obesity in individuals
Funder: Department of Health and Social Care

Abstract: Obesity has profound impact on both the health and wealth of the nation. “Britain is now the most obese nation in Europe. Health inequalities between rich and poor have been getting progressively worse” [HM Government, 2010]. “Overweight and obesity represent probably the most widespread threat to health and wellbeing in the country. Excess weight costs the NHS more than £5 billion year and has serious impact on economic development. The Government’s Healthy Lives, Healthy People: a call to action on obesity in England [2011] stated that to tackle overweight effectively we need to adopt a life course approach and also called for a balance of effort between prevention and treatment and support for those who are overweight or obese. The transition of Public Health in 2013 will see a step-change in public health as budgets are transferred to local government who will have powers to decide on local priorities. With the highest prevalence of overweight and obesity nationally, local government in the north east of England have this as a high priority for local action. My proposed research and leadership programme will contribute to this local action and the national public health priority. I will contribute to the evidence base on effective and cost-effective scalable interventions. This work will be in partnership with policy and practice partners both in the NHS and local government and in collaboration with colleagues in behaviour change psychology, health economics and statistics in Newcastle but with the wide expertise in the membership of new SoPHR. In 2007 Foresight estimated that by 2050 60% of men and 50% of women and 25% of children could be obese and that the financial impact to society would be £45.5 billion/year. Foresight conclude that the obesity epidemic could not be prevented by individual action alone and demands a societal approach with action at individual, family, community and national level. Healthy Lives, Healthy People: a call to action on obesity in England [2011] stated that “We have some way to go before we have convincing evidence of cost-effectiveness across a spectrum of approaches. A more concerted effort is therefore needed to both synthesise and disseminate emerging evidence about effectiveness and cost-effectiveness and to put in place rigorous evaluation of local interventions. My research and leadership plan will address these challenges. I will focus on the prevention of overweight exploring innovative approaches and scalable interventions at family, community and national level and on treatment of obesity at individual level. I bring to this work my knowledge and skills in public health nutrition, my extensive experience in policy and practice relevant research and networks in the PHRC, UKCRC Fuse and SoPHR, my track record in leading multi-disciplinary research teams and the practical perspective of an NHS practitioner as well as my proven leadership skills and potential as a future research leader in the international arena. Work Stream 1 Changing eating behaviour: prevention of obesity Contributors: National Obesity Observatory [NOO] [Public Health England], NHS choices, School Food Trust, Dept. for Education, Food outlet business partners, Nursery school practitioners, Schools, Fuse, SoPHR, PHRC. IMPORTANCE OF THE TOPIC: Changing eating behaviours is central to tackling obesity; one of today’s foremost public health challenges and requires multifaceted solutions which consider the food environment, individual skills and individual choice within that environment. Too many children begin school already overweight or obese and evidence shows that parents are often unable to identify when their child is overweight and so take appropriate action to prevent obesity [reference 7 and 10]. Prevention must begin before school and recent reviews have cited pre-school and family settings for intervention as promising but there is a paucity of evidence on which to based effective early interventions. During primary school years the prevalence of obesity continues to rise yet schools are an opportunity for intervention which has potential to impact across the social spectrum. We are living in an ‘obesogenic environment’; with multiple opportunities to consume high energy dense foods; changing the food environment is an enormous challenge but if can be achieved has high potential gain. Key questions How can help parents to recognise unhealthy body weight in their children and families to take action to prevent childhood obesity? Where and how can we intervene to change food choice? Supporting families to take action The Government are committed to the National Child Measurement Programme [NCMP] and but also to ‘empowering individuals’ by giving feedback to parents [Dept. of Health, 2011]. Yet we know that despite this feedback many parents do not recognise overweight in their children. I am PI of a MRC-NPRI study which will begin in April. This multistage study aims to address the need for improving strategies for increasing parent’s recognition of overweight in their children and informing parents about their child's weight status. It will develop and test tools to improve parents' ability to correctly assess their child's weight status (in line with NCMP criteria), offer an on-line simulation to project a child of given BMI forward as an adult, to increase their knowledge of the health consequences of childhood overweight and provide resources and signposting to support families to take action. Policy and practitioner partners in the study team will ensure that the study outputs are directly transferable to practice and that the research will support the work of the NOO and NHS Choices. Supporting individuals to take action Anecdotal evidence suggests there has been a de-skilling of the UK adult population with respect to culinary abilities, in particular resulting in a cohort of adults, many of whom are unable to cook meals from raw ingredients (‘from scratch’). Recently, a number of interventions have been developed to address this skills gap, most notably Jamie Oliver’s ‘Ministry of Food’. However, such interventions are at a relatively early stage of development with little analysis of their theoretical basis, few rigorous outcome evaluations or translational studies to support their wider implementation. Nevertheless, such interventions may have the potential for a significant population impact, have received widespread approval from the public and may be a potentially valuable contribution to tackling the obesity epidemic. In 2011 the Dept. Health commissioned a scoping exercise by me and others [Prof White and Dr Adams]. Leading from this work we propose an outcome evaluation, involving a randomised controlled trial (RCT), a process, and an economic evaluation and that this RCT is preceded by a feasibility study. Schools in working partnership with families A new Early Years Foundation Stage has requirements for Early Years providers from Sept 2012 and has focus on engagement with parents [Dept. of Health, 2011]. A study to develop and test a nursery based intervention which involves change in food and physical activity using the nursery setting to engage with parents will soon be complete [Fuse PhD studentship]. A full rehearsal pilot will be funded by the PHRC from 2013. This work will include NHS policy and practice partners from early life settings and local government partners responsible for delivery of such interventions. Changing the school food environment Schools offer an opportunity for interventions with potential to act across social spectrum and so reduce inequalities. The Government are committed to statutory nutritional standards for school meals and will work with the School Food Trust [SFT]. I have recently reported on the evaluation of the school food standards with which all schools must comply (work funded by the PHRC of Dept. of Health, report submitted Nov 2011). This work, which was presented at a SFT/WHO international meeting in January, has large policy implications showing that while the impact of standards on both school food and total diet is significant in primary school this is yet to be realised in secondary schools. Barriers exist in secondary school [reference 11] but potential solutions have been demonstrated in Scotland and could be translated to English Schools. I plan to undertake further research on the implementation of standards in secondary schools. I will work the SFT, Dept. of Health and the Dept. for Education as well local authorities to ensure the findings of this work are translated into action. Changing the wider food environment ‘foodscape’ The Foresight review [2007] highlighted the role of our environment in obesity; the ‘obesogenic environment’ has a high prevalence of high energy dense foods and makes it harder for individuals to make healthy food choices. Changing the ‘foodscape’ will be funded by the NIHR SoPHR and will contribute to the SoPHR aim to increase the evidence base for effective public health practice, with a focus on population level interventions to promote healthier diet. A range of interventions attempting to change the out of home ‘foodscape’ (ready-to-eat food provision in out of home food outlets) has been developed, but none has been rigorously evaluated. Working closely with local government, relevant commercial and public sector partners and with policy partners at the Dept. of Health this research will identify potentially effective interventions or intervention components, based on current theory or evidence, and test them for feasibility and acceptability, leading to pilot testing of effectiveness and, ultimately, the development of protocols for definitive outcome evaluations. New Responsibility Deal agreements for local businesses will be evaluated as part of this work which will provide an evidence base for local governments wishing to influence provision in local out of home food outlets. Deliverables from WS1 1. An interactive 3D body image generator with prediction of adult body size along with supporting materials and resources available on NHS choices website 2. An evidence-based scalable preschool and family partnership intervention for prevention of overweight in children 3. An evidence-based approach for effective implementation of school food standards in secondary schools. 4. Toolkit of commercially viable evidence based interventions to be applied by food outlets to improve the nutrient profile of the ‘foodscape’ WS2: Supporting individual behaviour change: treatment of obesity and maintenance of weight loss Contributors: Prof Roy Taylor [consultant endocrinologist] Dr Ruth Bell [public health & maternal obesity], Prof Patrick Olivier [Human-computer interaction], Fuse, Local Government and dietitians delivering weight management.IMPORTANCE OF THE TOPIC: There is urgent need for prevention of overweight and obesity but with almost 1 in 4 adults in England already obese treatment must also be part of the plan to combat obesity. Large health inequalities in prevalence of obesity exist with the poor having the highest prevalence. The health and social consequences to the individual and the economic burden in the treatment of obesity related co-morbidities means that successful local strategies must balance prevention with treatment of overweight and obesity but with so many in need of support to achieve weight loss innovative solutions are required. There is good evidence of effective interventions for weight loss; with appropriate intervention individuals are able to lose weight however most regain this weight and more within 12mths. Effective interventions for maintenance of weight loss are urgently needed if the investment in treatment of obesity is to be successful in reducing individual health risks and the economic benefit of weight loss are to be realised. Key questions How can e-technologies be used in primary care to support weight loss? How can e-technologies to support weight loss maintenance? How do we support patients in the ‘cure’ for T2D’? Achieving weight loss My-dietitian-on-line is an internet weight loss system which has evolved from a commercial system developed in Denmark. The unique aspects of this system is that it involves direct consultation between dietitian and patient in an on-going treatment programme; if effective this has potential to be translated into practice and could be implemented by onward referral at point of identification from primary care and delivered by dietitians commissioned to deliver services. Currently many dietetic services are unable to offer 1:1 patient service for obesity due to limited resources. Application of existing E-technologies offers a potential solution greater increasing the manageable case load of a dietitian. A PhD studentship funded by Fuse is undertaking a full rehearsal pilot of this system in primary care in north east England. The target groups for this pilot work will be obese men [a group who seldom visit their GP or take part in group-based weight loss interventions] and post-natal woman. Working closely with NHS partners in Durham and Darlington dietitians will be trained in the application of the system; patients will be recruited via primary care and will be involved in full evaluation including detailed evaluation on the process of delivery for both practitioners and patients. This work will inform development of full RCT trial in 2014-15. Currently, diagnosis of type 2 diabetes is regarded as an irreversible step on a path of steadily increasing requirement for medications. Recent work by Prof Taylor at Newcastle has established the complete reversibility of the condition by dietary means using liquid very low energy diets [VLED] to achieve dramatic weight loss. Working with Prof Taylor and Dr Sniehotta we will submit a proposal to Diabetes UK to determine the reversibility of longer duration type 2 diabetes, the optimum nature of the long-term follow-up diet, attitudinal and motivational factors which could predict response, and metabolic biomarkers of successful re-establishment of normal glucose control. Reversing type 2 diabetes in even a modest proportion of sufferers would produce enormous benefits for health and well-being. My contribution will be to identify the social and personal characteristics which can prospectively identify those people of short and longer term duration T2DM for whom a very low energy diet (VLED) will reverse diabetes and to determine the most appropriate weight maintenance diet for those successful patients. Maintaining weight loss Effective interventions to support maintenance of weight loss are needed. With recent funding from MRC-NPRI for the ‘Development and Pilot Evaluation of Scalable Interventions to Maintain Body Weight’ we will recruit patients from NHS and commercial weight loss programmes [PI Sniehotta]. The research will use innovative technologies, working with Prof Patrick Olivier [human and computer interaction], to enable real time feedback from and to patients using ecological momentary assessment [EMA]; this will include data on body weight, activity and dietary intake. Appropriate automatic interventions will be triggered if patients begin to gain weight. This work will have direct application to locally commissioned weight management services nationally and will developed working with NHS partners through Fuse and the CLRN. Deliverables from WS2 1. Outcome of a rehearsal pilot of my-dietitian on line which will lead to a RCT to contribute to the evidence-base for scalable and so transferable weight loss interventions available to local authority commissioners. 2. Screening and treatment support for patients with type 2 diabetes treated with VLCD 3. Cost-effective interventions to ‘Maintain Body Weight’ after weight loss available to all NHS patients signposted through primary care and NHS Choices. Work stream 3: Gathering the evidence: robust evaluation of dietary interventions Contributors: Dr Emma Foster, Prof Patrick Olivier Food Standards Agency Scotland, Prof John Mathers [PI LiveWell], local obesity prevention strategies Change4Life, NOO [Public Health England].IMPORTANCE OF THE TOPIC: the 2011 Public Health White papers stated the need to put in place rigorous evaluation of local interventions. To do this we need evaluation tools which are widely available and accessible by local practitioners and commissioners of public health. Characterising habitual dietary intake remains one the most challenging biological measurements. Methods for reliable but inexpensive assessment of dietary exposure in large population groups are essential to monitor change in population diet and to evaluate policy and therapeutic interventions to promote dietary change. Nationally evaluation of locally delivered interventions to improve diet is generally poor; existing methods of dietary assessment are expensive and time consuming or require expert nutritionist input making robust assessment too costly except in research settings. Key question: How can new technologies best be used to evaluate public health interventions? Funding gained to date has supported the development of improved dietary assessment systems and tools. Further research has led to development of SCRAN24 a prototype self-completion 24hr recall system which has been trialled in partnership with NHS colleagues in evaluation of local interventions. With new funding from Foods Standards Agency Scotland (FSAS) and working with colleagues with expertise in human and computer interaction [Prof Olivier] we will take SCRAN24 to the web and develop this to be used the National Survey of young people aged 11-24yrs in Scotland from 2014. Added value will be from opportunity to further develop and test the SCRAN24 system in application in on-line dietary assessment of adults as part of the MRC LLHW programme five year LiveWell Programme [PI Prof Mathers] in which I am a collaborator. LiveWell will develop scalable and transferable interventions to promote sustained behaviour change and so enhance health and wellbeing in later life focusing on the peri-retirement window; this includes a dietary intervention. The result will be an open access web-based dietary assessment system suitable for children and adults which will have wide application in NHS and public health interventions both national and locally. There remains a need for independent methods for assessing dietary intake, such as, biomarkers, which could give a comprehensive and objective assessment of dietary exposure. New technologies such as Sensecams [which produce log of daily activities as series photographs] offer opportunity to both support and validate reports on dietary intake. Work in biomarkers from easily obtainable biological samples [salvia and urine] is advancing though not yet able to be used to assess all aspects on intake. Prof Mathers is at forefront of research on use of metabolomics approaches in this area. There is excellent opportunity through the Human Nutrition Research Centre to bring these two streams of work more closely together in development new dietary assessment methods and testing of new dietary biomarkers. An example of this in a clinical setting is current collaboration with Prof Kamali [NuTH] seeking to find a non-invasive method of assessment of Vitamin K intake in children on warfarin therapy [reference 9]. I have existing links with researchers at forefront of dietary assessment in children in US; there would be opportunity to extend this collaboration and explore use of biomarkers both in UK and US. Deliverables from WS3 1. Open access web-based individual level dietary assessment tool available for use for population monitoring and for evaluation of local and national level interventions 2. Progress on the integration of biomarkers into routine dietary assessment

Lay abstract: Obesity is one of the major public health challenges facing the UK. Professor Adamson's research aims to contribute to prevention of overweight and obesity and the treatment of obesity. Her research will explore changing eating behaviour in population settings, supporting individual behaviour change and gathering evidence to inform policy by robust evaluation of dietary interventions.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;METABOLIC AND ENDOCRINE;ORAL AND GASTROINTESTINAL;STROKE