Marj Moodie

Background: Current type 2 diabetes management guidelines recommending increasing physical activity nd reducing sitting time are informed by a limited body of evidence from randomised controlled trials (RCT). We investigated the effectiveness of the 6-month intensive “sit less and move more” intervention in adults with type 2 diabetes within the OPTIMISE Your Health RCT.Methods: This single-centre RCT was conducted in Melbourne, Australia. Overweight/obese and physically inactive desk workers aged 35-65 years with type 2 diabetes) were randomised to usual care (waitlist control) or the multicomponent intervention consisting of health coaching, a height-adjustable sit-stand desk, and an activity tracker (Fitbit). Here, we report the co-primary outcomes (glycated haemoglobin: HbA1c and activPAL-measured daily sitting time) at the 6-month primary endpoint. Australian New Zealand Clinical Trials Registry, number ACTRN12618001159246.Findings: Between June 2019 and September 2024, 1,989 potential participants were screened and 145 were randomised to control (n=72, female = 32 [44.4%]) or intervention (n=73, female = 33 [45.8%]). At 6-months, intervention participants had significant reductions in HbA1c (between group difference: -0.51% [-0.87, -0.14]; p=0.007;) and daily sitting time (-75.7 [-107.0, -43.3] min/day; p<0.001) compared to controls.Interpretation: In physically inactive, overweight/obese desk workers with type 2 diabetes, a whole-of-day “sit less and move more” intervention may offer a complementary approach to type 2 diabetes management, producing clinically meaningful improvements in glycaemia while substantially reducing daily sitting time.FundingNational Health and Medical Research Council, Australia

Background: Accessibility barriers contribute to low participation in center-based cardiac rehabilitation. We developed an innovative, comprehensive, dual-phase telerehabilitation program to address this gap (Smartphone Cardiac Rehabilitation, Assisted Self-Management; SCRAM). Objective: The study aimed to determine the effectiveness of SCRAM for increasing maximal aerobic exercise capacity (VO ₂ max). Methods: A multicenter, parallel 2-arm randomized controlled trial recruited clinically stable adults (aged ≥18 y) with diagnosed coronary heart disease at 3 hospitals in Victoria, Australia (Melbourne, Geelong, and Bendigo) from 2018 to 2021. Participants were randomized (1:1), stratified by sex and study site, to receive SCRAM plus usual cardiovascular care (intervention) or usual cardiovascular care alone (control). SCRAM provided 24 weeks of remote exercise supervision, coaching, and behavior change support via smartphone. Usual cardiovascular care included standard medical care and advice to seek a referral to center-based cardiac rehabilitation, which was heavily impacted during the COVID-19 pandemic. Due to the nature of the treatments, participants were not blinded to allocation; primary outcome assessors and biostatisticians were blinded. The primary outcome was VO ₂ max at 24 weeks, analyzed on the principle of intention-to-treat, using linear regression adjusted for baseline and stratification factors on multiple imputed data. Results: Recruitment and data collection were heavily impacted by COVID-19, although SCRAM delivery was sustained throughout. Of 220 required participants, only 123 (56%) were recruited and randomized (intervention n=63, control n=60); 45% (55/123) had missing VO ₂ max at 24 weeks—largely due to enforced COVID-19 restrictions. Mean VO ₂ max at 24 weeks favored SCRAM (26.10, SD 10.72 mL/kg/min) over control (24.65, SD 7.87 mL/kg/min), but the difference was not statistically significant (mean difference=1.61 mL/kg/min, 95% CI –1.38 to 4.61, P =.28). Among secondary outcomes, patients receiving SCRAM had lower diastolic blood pressure at 24 weeks (mean difference=–5.54 mm Hg, 95% CI –10.01 to –1.06). All reported adverse events (control n=6, intervention n=16) were deemed mild or moderate, with only one deemed as possibly related to treatment. There were no deaths or hospitalizations. Conclusions: This was an underpowered trial, but SCRAM did not lead to a clinically important difference in VO ₂ max compared to usual cardiac care. SCRAM was resilient to COVID-19–related disruptions that significantly impacted the delivery of cardiac rehabilitation and supervised exercise training in particular. Further research is needed to conclusively assess treatment effects and understand how virtual cardiac rehabilitation can be translated into routine practice to augment center-based delivery and enhance equity of access.

Parent engagement in community-based obesity prevention interventions (CBOPIs) enhances obesity prevention outcomes. Actions from CBOPIs may also have climate change-related impacts, but little is known about specific elements of CBOPIs that promote parental engagement, and whether parents prefer CBOPIs that aim to address obesity alone or obesity and climate change warrants further investigation. An unlabelled 12-choice task discrete choice experiment (DCE) was undertaken, using a D-efficient design and incorporating two CBOPI alternatives plus an opt-out alternative. CBOPIs were described by six attributes: cost, aim, involvement, effectiveness, convenience, and social opportunities. Attributes were informed by a literature review of enablers and barriers to parent participation. The survey was electronically distributed to parents of primary-school-aged children in each Australian state and territory during April–May 2024. Data were analysed using conditional logit models, and willingness-to-pay for attributes was estimated. Parents (n = 438) preferred less costly CBOPIs (P < .001) that aim to address both healthy lifestyles and climate change (P = .086). Parents preferred short-term, manageable disruptions to family schedules to accommodate CBOPI participation (P = <.001) over no intervention. They were willing to pay an additional $3.97 per fortnight (∼$104.000 per year) for CBOPI participation to be convenient (standard error 1.380, P = .004). Our findings suggest that parents preferred CBOPIs that aim to address both healthy lifestyles and climate change. This suggests that incorporating climate change action into CBOPIs may increase parent support and consequently support CBOPI outcomes for both obesity prevention and climate change action.

Background: Community-based obesity prevention interventions (CBOPIs) demonstrate promise as effective, cost-effective approaches to prevent obesity. Whilst CBOPI actions often focus on obesity-related outcomes, they may also have positive impacts on climate change. Actions that simultaneously address obesity and climate change are known as double-duty actions. For example, switching to active modes of transport benefits individual health, while also reducing emissions from vehicle use. Support from CBOPI funding decision-makers is crucial for intervention success; the factors influencing funding decisions are currently not well understood. This study aimed to identify factors that influence funding decisions within organisations, to determine whether funders recognise double-duty actions in CBOPIs, and which double-duty actions are preferred. Methods: Potential participants with CBOPI funding decision-making roles were purposively sampled and invited to participate. Potential interview participants from government and non-government organisations were identified by search engine (Google) and invited via email to partake in an interview. Sixty-five invites were emailed and seven interviews with eight participants were conducted between April–May 2023. The participating stakeholders all had health roles; four State-wide and four local government. Semi-structured interviews with eight participants were conducted over Zoom between February-May 2023. Interviews were transcribed using Zoom Transcription and analysed with the assistance of NVivo. Reflexive Thematic Analysis underpinned the data analysis and the Social Ecological Model was used to further develop the theory. Results: Results suggested that participants recognised double-duty actions and believed inclusion of climate change action in CBOPIs would improve both intervention outcomes and participant acceptability. However, participants believed that stringent funding models limit flexibility to include climate change action. This could be mitigated by incorporating climate change into strategic health plans. Community partnerships may also be an effective tool to enhance double-duty actions in CBOPIs, as they allow participants to tailor interventions to community concerns including climate change. Conclusion: CBOPIs that use double-duty actions to intentionally target obesity prevention and climate change action may play an important role in addressing two critical public health issues at the community level. Whilst CBOPI funders are supportive of double-duty actions, modifications from strategy and partnerships may be required to realise the successful implementation.

BACKGROUND Accessibility barriers contribute to low participation in center-based cardiac rehabilitation. We developed an innovative, comprehensive, dual-phase telerehabilitation program to address this gap (Smartphone Cardiac Rehabilitation Assisted Self-Management; SCRAM). OBJECTIVE To determine the effectiveness of SCRAM for increasing maximal aerobic exercise capacity (VO2max). METHODS A multi-center, parallel two-arm randomized controlled trial recruited clinically stable adults (aged 18+ years) with diagnosed coronary heart disease at three hospitals in Victoria, Australia (Melbourne, Geelong, Bendigo) from 2018-2021. Participants were randomized (1:1), stratified by sex and study site, to receive SCRAM plus usual cardiovascular care (intervention), or usual cardiovascular care alone (control). SCRAM intervention provided 24 weeks of remote exercise supervision, coaching, and behavior change support via smartphone. Usual cardiovascular care included standard medical care and advice to seek a referral to centre-based cardiac rehabilitation (CR), which was heavily impacted during the COVID-19 pandemic. Due to the nature of the treatments, participants were not blinded to allocation; primary outcome assessors and biostatisticians were blinded. The primary outcome was VO2max at 24 weeks, analyzed on the principle of intention-to-treat, using linear regression adjusted for baseline and stratification factors on multiple imputed data. RESULTS Recruitment and data collection were heavily impacted by COVID-19, although SCRAM delivery was sustained throughout. Of 220 required participants, only 123 (56%) were recruited and randomized (intervention n=63, control n=60); 45% had missing VO2max at 24 weeks—largely due to enforced COVID-19 restrictions. VO2max at 24 weeks favored SCRAM, but this was not statistically significant (mean difference=1.61 ml/kg/min; 95% CI [-1.38, 4.61], P=.28). Among secondary outcomes, patients receiving SCRAM had lower diastolic blood pressure at 24 weeks (mean difference=-5.54 mmHg; 95% CI [-10.01, -1.06]). CONCLUSIONS SCRAM was resilient to COVID-19-related disruptions to CR delivery but, while findings were inconclusive, it did not lead to a clinically important difference in VO2max. Further research is needed to conclusively assess treatment effects and understand how virtual CR delivery models can be translated into routine practice. CLINICALTRIAL Australian New Zealand Clinical Trials Registry (ACTRN): 12618001458224

Purpose To systematically summarise the recent literature on the cost and cost effectiveness of interventions implemented to reduce violence against women (VAW) and decision frameworks guiding resource allocation. Method A scoping review of scholarly and grey literature on the cost-effectiveness and/or resource allocation for interventions addressing intimate partner violence (IPV), dating violence and non-partner sexual violence perpetrated against women aged 15 years and over. All settings and contexts were eligible, with papers published in English between 2010 and March 2023 included. Results Nineteen papers fulfilled the inclusion criteria reporting the cost, cost savings and/or cost effectiveness of 24 interventions to prevent IPV and to a lesser extent, other forms of interpersonal violence. Among the 16 economic evaluation studies reviewed, four types of interventions were cost effective in multiple settings or studies, including community activism (Uganda, Ghana), gender transformative interventions with couples and individuals (Ethiopia, Rwanda), specific justice and law enforcement measures (USA) and a combined personnel training, support, and referral programme in General Practice in the UK. Other interventions were cost effective in a single study or had conflicting evidence. Three remaining papers conducted a partial evaluation or cost appraisal providing limited information on the cost or cost-savings of other implemented interventions. No frameworks on resource allocation for the prevention of VAW were identified. Conclusion While there is some evidence of cost effectiveness emerging for interventions implemented in specific contexts, overall, we find the recent evidence on costs and cost effectiveness of interventions for the prevention of VAW to be limited. Embedding economic evaluation in future effectiveness trials will build critical evidence needed to inform policy and resource allocation decisions based on the value-for-money of interventions. Modelling the benefits and costs of interventions to better understand the societal impacts of programmes at scale is a further research opportunity.

Aim: Community-based obesity prevention interventions (CBOPIs) target the causes of obesity. Actions implemented in CBOPIs could simultaneously impact both climate change and obesity, making them a potentially important approach. To date, limited work has been undertaken to identify and categorise double-duty actions (those that simultaneously influence obesity and climate change) in CBOPIs. The prevalence of double-duty actions in CBOPIs is currently unknown. This paper outlines the development and application of the DoublE-duty actions in CommunIty-baSed obesity InterVEntions (DECISIVE) framework to address this gap. Subjects and methods: A scoping review focusing on obesity and climate change was performed, and the results informed the development of DECISIVE. DECISIVE was applied to studies included in the Cochrane review of obesity prevention interventions in children, and both the published and unpublished data of a completed intervention. Results: The scoping review identified one study and one systematic review which contributed to the development of DECISIVE. The framework lists nine double-duty actions, plus an ‘Other’ action. Each action’s potential impact on both obesity and climate change is summarised and example strategies are provided. Reduce the availability and consumption of ultra-processed foods was the most prevalent double-duty action when applying DECISIVE to published studies. Conclusion: DECISIVE is the first framework to recognise double-duty actions on obesity and climate change in CBOPIs. The development of DECISIVE holds important implications for community stakeholders who may be able to better identify, incorporate, and promote double-duty actions. This may enhance stakeholder acceptability, feasibility, and value-for-money of interventions.

Background: This study assesses the long-term cost-effectiveness of this screening protocol from a healthcare system perspective. Methods: Australians presenting to private oral healthcare practices recruited to the iDENTify study were included as the study population. A Markov model preceded by a decision tree was developed to assess the intervention’s long-term cost-effectiveness when rolled out to all eligible Australians, and measured against ‘no-intervention’ current practice. The model consisted of four health states: normoglycaemia; pre-diabetes; type 2 diabetes and death. Intervention reach of various levels (10%, 20%, 30%, and 40%) were assessed. The model adopted a 30-year lifetime horizon and a 2020 reference year. Costs and benefits were discounted at 5% per annum. Results: If the intervention reached a minimum of 10% of the target population, over the lifetime time horizon, each screened participant would incur a cost of $38,462 and a gain of 10.564 QALYs, compared to $38,469 and 10.561 QALYs for each participant under current practice. Screening was associated with lower costs and higher benefits (a saving of $8 per person and 0.003 QALYs gained), compared to current standard practice without such screening. Between 8 and 34 type 2 diabetes cases would be avoided per 10,000 patients screened if the intervention were taken up by 10% to 40% of private oral healthcare practices. Sensitivity analyses showed consistent results. Conclusions: Implementing type 2 diabetes screening in the private oral healthcare setting using a simple risk assessment tool was demonstrated to be cost-saving. The wider adoption of such screening is recommended.

Summary: Food retail strategies to improve the healthiness of food and beverage options may increase purchasing of healthier options and improve diets. Consumer demand for healthier options is an important determinant of the successful implementation and maintenance of healthy food retail interventions. A systematic review of peer‐reviewed literature was undertaken to explore whether consumers are willing to pay more for healthier foods and to determine the key factors that influence willingness to pay. Fifteen studies reported the results of 26 experiments providing willingness to pay estimates for healthier food products across a range of food retail environments. Twenty three out of the 26 experiments included in this review (88.5%) found consumers would pay a 5.6% to 91.5% (mean 30.7%) price premium for healthier foods. Studies consistently found a positive willingness to pay for foods with reduced fat and wholegrains with additional fruit and vegetables, while willingness to pay for foods with reduced salt or a combination of low fat and sugar, or salt showed mixed results. Adults over 60 years, females, those living with obesity, and consumers who aim to maintain a healthy lifestyle were more likely to pay a price premium for healthier food, whereas younger consumers, consumers with healthy weight, and consumers with higher levels of education were less likely to pay higher prices. The results of this review contribute to our understanding of consumer preferences for healthier products and provide information to retailers on consumer surplus (benefits) associated with the provision of healthier food alternatives.