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The UK Medical Research Council’s widely used guidance for developing and evaluating complex interventions has been replaced by a new framework, commissioned jointly by the Medical Research Council and the National Institute for Health Research, which takes account of recent developments in theory and methods and the need to maximise the efficiency, use, and impact of research.

The increasing recognition of sarcopenia, the age-related loss of skeletal muscle mass and function (muscle strength and physical performance), as a determinant of poor health in older age, has emphasized the importance of understanding more about its aetiology to inform strategies both for preventing and treating this condition. There is growing interest in the effects of modifiable factors such as diet; some nutrients have been studied but less is known about the influence of overall diet quality on sarcopenia. We conducted a systematic review of the literature examining the relationship between diet quality and the individual components of sarcopenia, i.e., muscle mass, muscle strength and physical performance, and the overall risk of sarcopenia, among older adults. We identified 23 studies that met review inclusion criteria. The studies were diverse in terms of the design, setting, measures of diet quality, and outcome measurements. A small body of evidence suggested a relationship between “healthier” diets and better muscle mass outcomes. There was limited and inconsistent evidence for a link between “healthier” diets and lower risk of declines in muscle strength. There was strong and consistent observational evidence for a link between “healthier” diets and lower risk of declines in physical performance. There was a small body of cross-sectional evidence showing an association between “healthier” diets and lower risk of sarcopenia. This review provides observational evidence to support the benefits of diets of higher quality for physical performance among older adults. Findings for the other outcomes considered suggest some benefits, although the evidence is either limited in its extent (sarcopenia) or inconsistent/weak in its nature (muscle mass, muscle strength). Further studies are needed to assess the potential of whole-diet interventions for the prevention and management of sarcopenia.

Background The current food system in England promotes a population diet that is high in fat, sugar and salt (HFSS). To address this, the UK government has implemented legislation to restrict the promotion of HFSS products in prominent locations (e.g. store entrances, checkouts) in qualifying retailers since October 2022. This study investigated the perceived impact of the legislation for affected stakeholders. Methods A pre-implementation rapid qualitative evaluation of stakeholder interviews. One hundred eight UK stakeholders participated in the study including 34 consumers, 24 manufacturers and retailers, 22 local authority enforcement officers and 28 academic and charitable health representatives. A participatory conference was used to enable policy recommendations to be confirmed by stakeholders. Results Stakeholders perceived the legislation to be a ‘good first step’ towards improving population diet but recognised this needed to be considered amongst a range of long-term obesity policies. Areas of further support were identified and these are presented as six recommendations for government to support the successful implementation of the legislation: (1) provide a free central HFSS calculator, (2) refine legislation to enhance intent and clarity, (3) conduct a robust evaluation to assess intended and unintended outcomes, (4) provide greater support for smaller businesses, (5) provide ring-fenced resources to local authorities and (6) create and communicate a long-term roadmap for food and health. Conclusions This legislation has the potential to reduce impulse HFSS purchases and makes a solid start towards creating healthier retail outlets for consumers. Immediate government actions to create a freely accessible HFSS calculator, support smaller businesses and provide additional resources to local authorities would support successful implementation and enforcement. Independent evaluation of the implementation of the legislation will enable monitoring of potential unintended consequences identified in this study and support refinement of the legislation. A long-term roadmap is necessary to outline strategies to support equal access to healthier and sustainable food across the whole food system within the next 20–30 years.

The Southampton PRegnancy Intervention for the Next Generation (SPRING) aimed to assess the efficacy of vitamin D supplementation and the behaviour change intervention 'Healthy Conversation Skills' (HCS) in improving the nutritional status of pregnant women. This paper describes the implementation of these interventions. Efficacy of HCS in improving diet quality and physical activity was evaluated in subgroups of women who discussed ways to improve these behaviours. In total, 717 pregnant women were recruited from a maternity hospital in Southampton, England. Quantitative data were collected using questionnaires, case report forms, and audio recordings. Following Medical Research Council guidance, fidelity, dose, and reach were evaluated descriptively. Multiple linear regression models were produced for subgroup analyses. Research nurses demonstrated high competence in using HCS. Compliance with intervention protocols for delivering and receiving both interventions was high. Participants took a median of 96% of the supplements and most women (85%) attended all four Healthy Conversations sessions. Women of lower socioeconomic status and from ethnic minorities were under-represented amongst participants. Findings were not sufficient to suggest an effect of HCS on diet quality among those who discussed diet but indicated a marginally beneficial effect on physical activity among those who discussed physical activity. Results suggested a weak dose-dependent effect, with the most pronounced difference in physical activity between the control group and the intervention sub-group with the highest exposure (adjusted difference 0.16 SD (95%-CI -0.03; 0.34)). This process evaluation confirms that the intervention components were delivered with high fidelity and rates of compliance. Altering dietary behaviours proved more challenging than altering physical activity behaviours. Research is needed to explore barriers to healthy eating faced by women during pregnancy and how these can be overcome. This paper also highlights the difficulty of engaging people from ethnic minorities and disadvantaged backgrounds in research.

Background Adolescents are increasingly susceptible to obesity, and thus at risk of later non-communicable diseases, due to changes in food choices, physical activity levels and exposure to an obesogenic environment. This review aimed to synthesize the literature investigating the effectiveness of health education interventions delivered in school settings to prevent overweight and obesity and/ or reduce BMI in adolescents, and to explore the key features of effectiveness. Methods A systematic search of electronic databases including MEDLINE, CINAHL, PsychINFO and ERIC for papers published from Jan 2006 was carried out in 2020, following PRISMA guidelines. Studies that evaluated health education interventions in 10–19-year-olds delivered in schools in high-income countries, with a control group and reported BMI/BMI z-score were selected. Three researchers screened titles and abstracts, conducted data extraction and assessed quality of the full text publications. A third of the papers from each set were cross-checked by another reviewer. A meta-analysis of a sub-set of studies was conducted for BMI z-score. Results Thirty-three interventions based on 39 publications were included in the review. Most studies evaluated multi-component interventions using health education to improve behaviours related to diet, physical activity and body composition measures. Fourteen interventions were associated with reduced BMI/BMI z-score. Most interventions ( n  = 22) were delivered by teachers in classroom settings, 19 of which trained teachers before the intervention. The multi-component interventions ( n  = 26) included strategies such as environment modifications ( n  = 10), digital interventions ( n  = 15) and parent involvement ( n  = 16). Fourteen studies had a low risk of bias, followed by 10 with medium and nine with a high risk of bias. Fourteen studies were included in a random-effects meta-analysis for BMI z-score. The pooled estimate of this meta-analysis showed a small difference between intervention and control in change in BMI z-score (− 0.06 [95% CI -0.10, − 0.03]). A funnel plot indicated that some degree of publication bias was operating, and hence the effect size might be inflated. Conclusions Findings from our review suggest that school-based health education interventions have the public health potential to lower BMI towards a healthier range in adolescents. Multi-component interventions involving key stakeholders such as teachers and parents and digital components are a promising strategy.

To explore influences on diet in a group of community-dwelling older adults in the UK. Data were collected through focus group discussions with older people; discussions were audio-recorded, transcribed verbatim and transcripts analysed thematically. Hertfordshire, UK. Participants were sampled purposively from the Hertfordshire Cohort Study, focusing on those whose diets had been assessed at two time points: 1998-2001 and 2011. Ninety-two adults participated (47 % women; 74-83 years) and eleven focus groups were held. A number of age-related factors were identified that were linked to food choices, including lifelong food experiences, retirement, bereavement and medical conditions, as well as environmental factors (such as transport). There appeared to be variability in how individuals responded to these influences, indicating that other underlying factors may mediate the effects of age-related factors on diet. Discussions about 'keeping going', being motivated to 'not give up', not wanting to be perceived as 'old', as well as examples of resilience and coping strategies, suggest the importance of mediating psychological factors. In addition, discussion about social activities and isolation, community spirit and loneliness, indicated the importance of social engagement as an influence on diet. Interventions to promote healthier diets in older age should take account of underlying psychological and social factors that influence diet, which may mediate the effects of age-related factors.

Previous product placement trials in supermarkets are limited in scope and outcome data collected. This study assessed the effects on store-level sales, household-level purchasing, and dietary behaviours of a healthier supermarket layout. This is a prospective matched controlled cluster trial with 2 intervention components: (i) new fresh fruit and vegetable sections near store entrances (replacing smaller displays at the back) and frozen vegetables repositioned to the entrance aisle, plus (ii) the removal of confectionery from checkouts and aisle ends opposite. In this pilot study, the intervention was implemented for 6 months in 3 discount supermarkets in England. Three control stores were matched on store sales and customer profiles and neighbourhood deprivation. Women customers aged 18 to 45 years, with loyalty cards, were assigned to the intervention (n = 62) or control group (n = 88) of their primary store. The trial registration number is NCT03518151. Interrupted time series analysis showed that increases in store-level sales of fruits and vegetables were greater in intervention stores than predicted at 3 (1.71 standard deviations (SDs) (95% CI 0.45, 2.96), P = 0.01) and 6 months follow-up (2.42 SDs (0.22, 4.62), P = 0.03), equivalent to approximately 6,170 and approximately 9,820 extra portions per store, per week, respectively. The proportion of purchasing fruits and vegetables per week rose among intervention participants at 3 and 6 months compared to control participants (0.2% versus -3.0%, P = 0.22; 1.7% versus -3.5%, P = 0.05, respectively). Store sales of confectionery were lower in intervention stores than predicted at 3 (-1.05 SDs (-1.98, -0.12), P = 0.03) and 6 months (-1.37 SDs (-2.95, 0.22), P = 0.09), equivalent to approximately 1,359 and approximately 1,575 fewer portions per store, per week, respectively; no differences were observed for confectionery purchasing. Changes in dietary variables were predominantly in the expected direction for health benefit. Intervention implementation was not within control of the research team, and stores could not be randomised. It is a pilot study, and, therefore, not powered to detect an effect. Healthier supermarket layouts can improve the nutrition profile of store sales and likely improve household purchasing and dietary quality. Placing fruits and vegetables near store entrances should be considered alongside policies to limit prominent placement of unhealthy foods. ClinicalTrials.gov NCT03518151 (pre-results).

Background Retail food environments in the UK use intense marketing strategies to promote the purchase and consumption of less-healthy foods that are associated with ill-health. To help address this issue, the Food (Promotion and Placement) regulations were introduced in England from October 2022, banning the placement of foods high in fat, salt, or sugar (HFSS) at checkouts, aisle-ends, and entrances in qualifying retail settings. Ahead of their introduction, this study examined health experts’ (i) perspectives on the likely effectiveness of these regulations and (ii) recommendations to enhance their impact. Methods This cross-sectional qualitative study aimed to recruit health experts to partake in focus groups/semi-structured interviews via MS Teams. Data were collected, coded, and analysed by three researchers with input from senior colleagues, using Braun and Clarke’s reflexive thematic analysis method. Results Data were collected between October 2021 and March 2022 from 28 health experts, including public health and food policy academics ( n  = 9) and experts from civil society organisations ( n  = 19). Health experts perceived regulations as a major policy innovation which recognised businesses’ role in driving poor dietary choices that contribute to obesity. They also raised concerns about the outdated nutrient profiling model, limited regulatory scope, and weak enforcement. They were apprehensive about the potential for disproportionate impacts on smaller businesses and certain consumer groups. To enhance the impact of the regulations, they recommended funding independent and diverse evaluations, mandating the reporting of business sales data, and strengthening enforcement efforts. To improve the regulations’ effectiveness, they also suggested establishing mechanisms to refine regulatory guidance and introducing complementary policies within the food system. Conclusions Health experts believed that the regulations represent a significant step to curb the promotion of unhealthy foods in retail environments but will be insufficient on their own to improve population diet. To maximise their impact, a systems approach is essential, addressing shortcomings of the regulations, supporting smaller retailers in adopting health initiatives, and implementing thorough monitoring and evaluation. The regulations must form part of a comprehensive set of policies across various sectors, including manufacturing and retail, to accelerate food system transformation and address the dietary drivers of ill-health.

Background Retail food environments have largely become settings which promote less healthy foods to their customers. In an effort to prompt healthier choices, the UK Government introduced regulations in October 2022 restricting most retailers in England from promoting products high in fat, sugar, or salt (HFSS) at store entrances, aisle-ends, and checkouts, and their online equivalents. Evidence is needed on how businesses approach compliance and adapt to these regulations. This study used in-depth interviews to examine business responses and generate insights to support effective implementation. Methods This cross-sectional qualitative study involved semi-structured interviews with 22 business representatives responsible for interpreting and implementing the regulations. The interviews were conducted via MS Teams/Zoom between August 2021–April 2022, prior to the implementation of regulations. Preparations to implement changes and predicted impact on businesses’ promotional practices were examined. Six researchers collected and analysed the data using an inductive thematic approach. Results Participants’ reactions to regulatory compliance varied according to perceived commercial impact and resource availability. While some businesses explored opportunities for healthful promotions and invested in layout changes, a significant proportion planned to comply only to the letter of the law and were testing alternative strategies for unhealthy promotions. Trade bodies played a crucial role in preparations, supporting member businesses to interpret the regulations and fostering a unified approach to compliance. Anticipated barriers to compliance included challenges such as accurately assessing product scores, reformulating products to meet standards, and ensuring consistent store-level adherence within large businesses. To enhance the regulations’ impact, participants called for (i) smaller in-scope businesses to receive additional technical support from the government, (ii) manufacturers be required to share detailed nutrient information with retailers or a centralised product nutrient profile repository be established, and (iii) out-of-home businesses be required to comply. Conclusions These mandated regulations hold potential to shift food retailers’ priorities from solely profit maximisation, to also supporting public health. However further government action is needed to ensure effective compliance for all business types and sizes. A consistent, long-term policy approach aligned with other food policies and informed by industry expertise to optimise implementation could better support obesity reduction.

There is evidence that food outlet access differs according to level of neighbourhood deprivation but little is known about how individual circumstances affect associations between food outlet access and diet. This study explored the relationship between dietary quality and a measure of overall food environment, representing the balance between healthy and unhealthy food outlet access in individualised activity spaces. Furthermore, this study is the first to assess effect modification of level of educational attainment on this relationship. A total of 839 mothers with young children from Hampshire, United Kingdom (UK) completed a cross-sectional survey including a 20-item food frequency questionnaire to measure diet and questions about demographic characteristics and frequently visited locations including home, children's centre, general practitioner, work, main food shop and physical activity location. Dietary information was used to calculate a standardised dietary quality score for each mother. Individualised activity spaces were produced by creating a 1000m buffer around frequently visited locations using ArcGIS. Cross-sectional observational food outlet data were overlaid onto activity spaces to derive an overall food environment score for each mother. These scores represented the balance between healthy and unhealthy food outlets using weightings to characterise the proportion of healthy or unhealthy foods sold in each outlet type. Food outlet access was dominated by the presence of unhealthy food outlets; only 1% of mothers were exposed to a healthy overall food environment in their daily activities. Level of educational attainment moderated the relationship between overall food environment and diet (mid vs low, p = 0.06; high vs low, p = 0.04). Adjusted stratified linear regression analyses showed poorer food environments were associated with better dietary quality among mothers with degrees (β = -0.02; 95%CI: -0.03, -0.001) and a tendency toward poorer dietary quality among mothers with low educational attainment, however this relationship was not statistically significant (β = 0.01; 95%CI: -0.01, 0.02). This study showed that unhealthy food outlets, like takeaways and convenience stores, dominated mothers' food outlet access, and provides some empirical evidence to support the concept that individual characteristics, particularly educational attainment, are protective against exposure to unhealthy food environments. Improvements to the imbalance of healthy and unhealthy food outlets through planning restrictions could be important to reduce dietary inequalities.