Andrew John Hill

Background: Previous research has documented weight bias in some young children and suggested environmental influences. The present study focused on children’s own cognitive development. The aim was to test whether weight bias would differ according to children’s levels of theory of mind (ToM). Methods: One hundred and thirty-nine children (54% girls), aged four to six years, read a storybook that contained an assessment of ToM and required choices between story characters that differed in body weight. Children were also asked to give reasons for their choices. Children’s responses were coded by content and emotional valence. Results: Children showed significant weight bias against the character with obesity in pro- and anti-social story situations. A significantly greater proportion of children with high ToM showed weight bias, particularly in the pro-social scenario. Weight bias was evident in the reasons given for character choices with reference to character emotion being most common. There were no differences in these reasons by level of ToM. Conclusions: In contrast with what was hypothesised, it was those with a higher ToM who showed greater weight bias. Future research could examine whether children’s own exposure to weight bias influences this relationship and how this may change with age. Building understanding of how children’s own cognitive development interplays with the lived experience of societal weight bias will be important to those working in paediatric healthcare and education.

Background: Behavioural weight management programmes can prevent type 2 diabetes and reduce risk factors for complications and medication use in those with type 2 diabetes. However, few are sufficiently scalable, and weight is typically regained. We evaluated whether scalable behavioural weight management programmes can achieve and maintain weight loss and reduce type 2 diabetes incidence and complications in two populations: people at high risk, and those recently diagnosed. Objectives: To quantify the impact of scalable behavioural weight management programmes on type 2 diabetes incidence, related complications and health resource use (work package 1). To develop and test the feasibility and acceptability of a scalable weight loss maintenance programme (work package 2). Design and methods: Work package 1: Work package 1.1: to evaluate the effectiveness and cost-effectiveness of a scalable behavioural weight management programme for individuals at risk of type 2 diabetes, we conducted a 5-year follow-up of the Weight loss Referrals for Adults in Primary care randomised controlled trial ( N = 1267). Work package 1.2: to evaluate the effectiveness and cost-effectiveness of a scalable weight loss programme for individuals recently diagnosed with type 2 diabetes, we conducted a new randomised controlled trial ( N = 577). For both trials, we evaluated effectiveness (change in weight and glycated haemoglobin) and within-trial cost-effectiveness from a National Health Service perspective. Semistructured interviews explored the experiences of participants and practitioners. Work package 1.3: using the National Institute for Health and Care Research School for Public Health Research Diabetes Prevention microsimulation model, we evaluated the lifetime cost-effectiveness of the interventions evaluated in work package 1.1 and work package 1.2. To reduce uncertainty and increase confidence in our findings, we compared findings to a separate microsimulation model (National Health Service Health Checks model). Work package 2: Work package 2.1: we used an evidence-, theory- and person-based approach to develop a programme for weight loss maintenance (Supporting Weight Management). Work package 2.2: we evaluated the feasibility and acceptability of Supporting Weight Management in a 6-month randomised controlled trial ( N = 61) with embedded qualitative study of participants ( N = 28) and coaches ( N = 2). Work package 2.3: we used the School for Public Health Research Diabetes model and expected value of sample information methods to estimate the value of alternative trial designs in reducing uncertainty in the cost-effectiveness estimates. Setting and participants: Adults living with overweight and obesity who are at risk of type 2 diabetes or who have a recent diagnosis. Primary care and community settings in England. Interventions: Scalable behavioural interventions for weight management. Work package 1.1: brief advice, 12-week weight watchers or 52-week weight watchers. Work package 1.2: six-month weight watchers with tailored diabetes education and dietitian support via telephone [diabetes education and behavioural weight management programme (intervention group in the GLoW trial)] or diabetes education only. Work package 2: Supporting Weight Management (a digital, acceptance-based, guided self-help programme for weight loss maintenance) or standard advice (leaflet on weight loss maintenance). Main outcome measures: Primary outcomes were weight or glycated haemoglobin. Secondary outcomes included healthcare resource use, quality of life and psychosocial measures. Results: Work package 1.1: mean 5-year weight change was: −0.46 (standard deviation 8.31) kg in the brief intervention group, −1.95 (9.55) kg in the 12-week programme group and − 2.67 (9.81) kg in the 52-week programme. The adjusted difference in weight change between groups was not statistically significant. During the trial, the 12-week programme incurred the lowest cost and produced the highest quality-adjusted life-years. Qualitative interviews identified key differences in the cognitive and behavioural strategies used by ‘maintainers’ and ‘regainers’. Work package 1.2: we found no evidence for an intervention effect on change in glycated haemoglobin but diabetes education and behavioural weight management programme participants lost more weight than diabetes education at 6 [−1.77 (−2.86 to −0.67) kg] and 12 months [−1.38 (−2.56 to −0.19) kg]. During the trial, diabetes education and behavioural weight management was cost-effective compared with diabetes education. Qualitative interviews identified how the intervention was effective and key barriers to effectiveness. Work package 1.3: in the lifetime cost-effective analysis, 52-week weight watcher was cost-effective compared with brief intervention, 12-week weight watcher and a simulated do-nothing scenario, producing more health benefit and cost savings. A lifetime cost-effectiveness of diabetes education and behavioural weight management compared with diabetes education was cost-effective with an incremental cost-effectiveness ratio of £2290 per quality-adjusted life-year gained. Work package 2.1: we codeveloped the Supporting Weight Management intervention for weight loss maintenance. It involves 14 psychoeducational sessions delivered via a web-based platform over 18 weeks, and telephone support from trained, non-specialist coaches. Work package 2.2: pre-trial average weight loss was 8 kg; during the trial Supporting Weight Management participants lost a further 2.2 (± 6.4 standard deviation) kg and control participants gained 2.2 (± 6.6) kg. Supporting Weight Management participants described that Supporting Weight Management reinforced existing knowledge and supported skill development for weight loss maintenance. Work package 2.3: the simulated justifiable cost of a weight maintenance intervention was £104.64 (body mass index ≥ 28) and £88.14 (type 2 diabetes), based on a cost-effectiveness threshold of £20,000. A large prospective randomised controlled trial to evaluate Supporting Weight Management was found to be cost-effective in expected value of sample information analysis. Limitations: The coronavirus disease discovered in 2019 pandemic resulted in changes to study and intervention procedures, delayed recruitment, and higher-than-anticipated attrition. The ethnic profile of participants limits the generalisability of findings to minority ethnic groups. Conclusions: This research supports scalable behavioural weight management programmes as cost-effective for preventing and treating type 2 diabetes. Findings highlight the need for targeted support for maintaining weight loss. Acceptance-based guided self-help is an acceptable and feasible approach to support weight maintenance. Future work: We have identified a range of research needs going forward, including developing and testing interventions to prevent weight regain and improve long-term health economic outcomes, improving the reach into and engagement with under-represented groups, as well as enhancing and validating long-term health economic models using real-world weight trajectories to better predict lifetime cost-effectiveness and equity impacts. Study registration: The study WRAP is registered as ISRCTN64986150; GLoW is registered as ISRCTN18399564 and the SWiM feasibility study is registered as ISRCTN12685964. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0216-20010) and is published in full in Programme Grants for Applied Research ; Vol. 14, No. 22. See the NIHR Funding and Awards website for further award information.

Background: Weight stigma and weight discrimination refer to the negative attitudes and behaviours towards people with higher weight, because of their body size. Experiences of weight stigma in healthcare settings and within weight management interventions contribute to poor psychological and physical health and healthcare avoidance. This study aimed to develop a checklist for healthcare professionals and providers of weight management interventions to minimize weight stigmatisation, to the extent possible, in these interventions and settings. Methods: Based on existing literature on the contributors to weight stigma in healthcare, members of the Eating Disorders In Weight-Related Therapy (EDIT) Collaboration Weight Stigma Working Group drafted and refined the checklist items using an iterative process. The items were then pilot-tested by two reviewers. A 21-item checklist, organized into four domains: (1) planning and personnel; (2) intervention design and content; (3) outcomes and monitoring; and (4) additional components, was validated via an online survey. Healthcare professionals, researchers, and individuals with lived experience of higher weight evaluated the clarity, relevance, and importance of each item. The Content Validity Index (CVI), Content Validity Ratio (CVR), and participant feedback were used to refine the final version of the checklist. Results: Respondents ( n = 28, 79% women, M _age = 44, SD = 10.6) completed the survey. Most items were rated as clear, and 20 out of 21 items were deemed relevant to the checklist’s aim (CVI range 0.61–1.0). Four items were rated as essential, with many remaining items rated as ‘important but not essential’. The final checklist consists of nine items across three sections: (A) essential elements of planning/design, (B) additional considerations, and (C) feedback on the service. Conclusion: The EDIT Weight Stigma Reduction Checklist has value in assisting providers to design, deliver, and implement weight management interventions to take a priori action to minimise weight stigma in practice.

Emotional eating and food cravings are common among adults living with overweight or obesity. This study investigated these in relation to weight-management success and reports on strategies for managing emotional eating. An online survey was completed by 3,834 adults on a community weight management programme. Measures included negative and positive emotional eating and food craving. Objectively measured body weight over the previous 12 weeks grouped participants into Higher (>10%, N=962), Moderate (5-10%, N=2156), and Lower (<5%, N=716) weight loss groups. Open questions explored strategies for managing emotional eating. Respondents were mostly female (92.0%), mean age=57.2 years, and BMI=32.1 kg/m2. Results showed participants had lost 3.7 BMI units over the previous 12 weeks. Higher weight loss was strongly associated with lower negative and positive emotional eating, fewer food cravings and control difficulties. Prominent themes for managing emotional eating were distraction (31.7%) and physical activity along with healthier food substitutions, planning and positive mindset. Group social support was also highlighted. Greater weight loss was associated with less negative and positive emotional eating. Distraction, food swaps, planning and positive mindset were strategies for managing emotional eating and cravings. These data highlight the perceived importance of group-based social support in weight management

Objective: To understand delivery features and intervention strategies of adolescent weight management interventions which may influence eating disorder risk. Methods: Systematic searches in four databases and two trial registries to identify randomised controlled trials in adolescents with overweight/obesity measuring eating disorder risk pre‐ and post‐intervention. Delivery features and intervention strategies were coded from published descriptions using a project‐specific codebook, validated by trial investigators and narratively synthesised. Results: Of 11 860 records screened, 23 trials, with 54 intervention arms, were included in the analysis. Most interventions focused on weight loss and maintenance (54%) and were informed by a cognitive behavioural framework (43%). Interventions commonly targeted an individual with a support person (70%). Median intervention duration was 26 weeks, with weekly (35%) or staged (e.g., weekly, then monthly) visit (41%) frequency. Interventions had a mean (SD) of 30 (16.1) intervention strategies. Most included healthy eating education (89%), physical activity education (89%) and problem‐solving barriers to dietary change (80%). Few included mental health strategies (17%). Interventions included ‘dietary prescription’ (65%), and 78% promoted ‘healthful/helpful eating behaviours’. Conclusion: Weight management interventions are complex and vary in delivery approach and strategies used to change behaviors. Characterising interventions is a critical first step to understanding how weight management interventions' influence eating disorder risk.

Background: Eating disorders (EDs) and self-harm (SH) are both associated with distress, poor psychosocial functioning, and increased risk of mortality. Much of the literature discusses the complex interplay between SH and ED behaviours where co-occurrence is common. The onset of both is typically seen during teenage years into early adulthood. A better understanding of the functions of these behaviours is needed to guide effective prevention and treatment, particularly during the crucial developmental years. An earlier review has explored the functions of self-harm, but an equivalent review for eating disorder behaviours does not appear to have been completed. Objectives: This evidence synthesis had two objectives. First, to identify and synthesise published first-hand accounts of the reasons why people engage in eating disorder behaviours with the view to develop a broad theoretical framework of functions. Second, to draw comparisons between the functions of eating disorder behaviours and self-harm. Methods: A qualitative evidence synthesis reporting first-hand accounts of the reasons for engaging in eating disorder behaviours. A ‘best fit’ framework synthesis, using the a priori framework from the review of self-harm functions, was undertaken with thematic analysis to categorise responses. Results: Following a systematic search and rigorous screening process, 144 studies were included in the final review. The most commonly reported functions of eating disorder behaviours were distress management (affect regulation) and interpersonal influence. This review identified significant overlap in functions between self-harm and eating disorder behaviours. Gender identity, responding to food insecurity, to delay growing up and responding to weight, shape, and body ideals were identified as functions more salient to eating disorder behaviours. Similarly, some self-harm functions were not identified in the eating disorder literature. These were experimenting, averting suicide, personal language, and exploring/maintaining boundaries. Conclusions: This evidence synthesis identified a prominent overlap between psychological functions of eating disorder behaviours and self-harm, specifically in relation to distress management (affect regulation). Despite clear overlap in certain areas, some functions were found to be distinct to each behaviour. The implications for delivering and adapting targeted interventions are discussed.

Background/objectives: Individuals with severe mental illness (SMI) have a reduced life expectancy of 15–25 years. This is due to a number of modifiable and non-modifiable risk factors. Levels of overweight and obesity in this group are 1.8 times higher than in the general population and diet quality is poor. Excess weight is linked to a range of serious long-term physical and mental health conditions. This paper presents the findings of a large cross-sectional survey of adults living with SMI. The survey aimed to understand the current weight, weight gain and diet quality of this group and secondly, to explore the association between weight change, diet quality, antipsychotic medication and weight management. Methods: Five hundred and twenty-nine participants (58% male, mean age 49.3) living with SMI completed the survey. Results: Results showed 42% of the sample were living with obesity and almost half reported having gained 6 kg or more at least once in their adult life. Overall, 6% of the sample reported eating no fruit or vegetables and the same proportion had the highest consumption of carbonated drinks. There was no difference by weight category. Those taking antipsychotic medication and currently managing their weight were more likely to experience weight gain or fluctuation. Conclusions: These results suggest that excess weight and poor diet quality are a major problem in adults with SMI and that current weight management provision is ineffective in addressing the specific needs of people living with SMI.

Background/objectives: Individuals with severe mental illness (SMI) have a reduced life expectancy of 15-25 years. This is due to a number of modifiable and non-modifiable risk factors. Levels of overweight and obesity in this group are 1.8 times higher than in the general population and diet quality is poor. Excess weight is linked to a range of serious long-term physical and mental health conditions. This paper presents the findings of a large cross-sectional survey of adults living with SMI. The survey aimed to understand the current weight, weight gain and diet quality of this group and secondly, to explore the association between weight change, diet quality, antipsychotic medication and weight management. Methods: Five hundred and twenty-nine participants (58% male, mean age 49.3) living with SMI completed the survey. Results: Results showed 42% of the sample were living with obesity and almost half reported having gained 6kg or more at least once in their adult life. Overall, 6% of the sample reported eating no fruit or vegetables and the same proportion had the highest consumption of carbonated drinks. There was no difference by weight category. Those taking antipsychotic medication and currently managing their weight were more likely to experience weight gain or fluctuation. Conclusions: These results suggest that excess weight and poor diet quality are a major problem in adults with SMI and that current weight management provision is ineffective in addressing the specific needs of people living with SMI.

Background: Most weight lost during weight‐loss programmes is eventually regained. Interventions based on Acceptance and Commitment Therapy (ACT) demonstrate good evidence for long‐term weight loss, but are often costly and difficult to scale up. Guided self‐help programmes delivered using technology and non‐specialist coaches could increase scalability, but it is unclear whether delivering ACT‐based interventions in this way is feasible and acceptable. Methods: In this feasibility study, 61 people who recently completed a behavioral weight management intervention (BWMI) for weight management were randomly allocated to SWiM (“Supporting Weight Management”: 4‐month digital guided self‐help ACT‐based intervention for weight loss maintenance) or a standard care group (leaflet about maintaining weight loss) using a 2:1 allocation ratio. At baseline and 6 months, participants completed measures of weight, mental health, eating behavior, and other psychosocial variables. Participants completed an intervention evaluation questionnaire. At 3 and 6 months, qualitative interviews were conducted with participants from both trial arms and SWiM coaches. The analysis integrated statistics and thematic analysis, informed by the Medical Research Council (MRC) framework for process evaluations. Since this was a feasibility study, analyses focused on process outcomes instead of interpreting statistical significance. Results: Eighty‐eight percent (36/41) of participants allocated to SWiM completed at least the first session and 22 (54%) completed all sessions. At 6 months, mean weight change was −2.2 (+/−6.4 SD) kg in SWiM participants and +2.2 (+/−6.6) kg in standard care participants. Descriptively, eating behavior and mental health scores improved in SWiM participants but not in standard care participants. In interviews, SWiM participants noted that they reinforced their existing knowledge while acquiring new skills and strategies, which were felt to contribute to positive behavioral changes. Conclusion: The SWiM intervention is practical and well‐received, and shows promise in supporting weight loss maintenance, though evaluation in a larger trial is needed to assess effectiveness. Trial Registration: ISRCTN12685964

Background: Binge eating disorder (BED) is the most common eating disorder. It is strongly associated with obesity and presents a barrier to effective weight management. This study examined clients’ and Guides’ experiences of a guided self-help (GSH) intervention for adults with binge eating and obesity, delivered prior to weight management. Methods: Participants were recruited through a behavioural weight management programme and were offered GSH prior to starting. Nine clients with binge eating and four Guides who supported clients were interviewed about their experiences of receiving or facilitating GSH, using an adapted version of the Client Change Interview (CCI)—a semi-structured schedule reflecting on helpful/unhelpful aspects and of the intervention and attributions of change. Interviews were transcribed and analysed using reflexive thematic analysis. Results: Themes were organized under 3 main headings. First, GSH offered something new for both parties and was positively received. Clients were unlikely to have had the space to talk about binge eating before and Guides were positive about offering one-to-one support. Second, participants spoke about a range of positive changes to binge eating and how clients felt about themselves and their social relationships. Third, there was agreement on the importance of clients’ relationship with their Guide, the intervention materials, and a helpful mindset as factors facilitating change. Barriers were some aspects of the intervention and the complexity of clients’ lives. Conclusions: Offering GSH targeting binge eating prior to weight management was well received. Some tailoring of the approach is recommended, specifically in terms of training for Guides to help in early client engagement. Further research should determine whether the opportunity of GSH for those with binge eating improves the acceptability and effectiveness of later-offered weight management, and the best sequencing of interventions.