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The nutritional status of both women and men before conception has profound implications for the growth, development, and long-term health of their offspring. Evidence of the effectiveness of preconception interventions for improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies for intervention that are likely to be scalable and have positive effects on a range of health outcomes: supplementation and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies, we suggest a model specifying pathways to effect. Pathways are incorporated into a life-course framework using individual motivation and receptiveness at different preconception action phases, to guide design and targeting of preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be engaged with maternal health services. Interventions to improve women's nutritional status and health behaviours at all preconception action phases should consider social and environmental determinants, to avoid exacerbating health and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and symbolic connection between improved preconception maternal health and nutrition, and offspring health. We suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception health, to harness the political will and leadership necessary to turn high-level policy into effective coordinated action.

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.

\"Choosing All Together\" (CHAT), is a community engagement tool designed to give the public a voice in how best to allocate limited resources to improve population health. This process evaluation explored the mechanisms through which CHAT generates community engagement. The CHAT tool was adapted and implemented for use in two rural communities (Nanoro, Burkina Faso, and Navrongo, Ghana) and one urban township (Soweto, South Africa) to prioritize maternal and child nutrition interventions. Community discussions were audio-recorded, transcribed, and translated into English. Twenty-two transcripts, including six each from Navrongo and Soweto and 10 from Nanoro, were analysed thematically to generate data driven codes and themes to explain mechanisms underlying the CHAT process. The process evaluation was based on the UK MRC process evaluation guidance. Seven themes describing the functions and outcomes of CHAT were identified. Themes described participants deliberating trade-offs, working together, agreeing on priorities, having a shared vision, and increasing their knowledge, also the skills of the facilitator, and a process of power sharing between participants and researchers. Participants came to an agreement of priorities when they had a shared vision. Trained facilitators are important to facilitate meaningful discussion between participants and those with lower levels of literacy to participate fully. CHAT has been shown to be adaptable and useful in prioritising maternal and child nutrition interventions in communities in Burkina Faso, Ghana, and South Africa. Conducting CHAT in communities over a longer period and involving policy-makers would increase trust, mutual respect and develop partnerships.

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.

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.

Background As part of the UK government’s obesity strategy, the Food (Promotion and Placement) (England) Regulations 2021 were implemented in October 2022 to restrict the prominent placement of products high in fat, sugar, or salt (HFSS) in most retail settings. Local authority (LA) officers have been tasked with enforcement of these regulations. This qualitative study examined the perspectives of LA officers including, trading standards, environmental health, and public health officers to understand enforcement approaches and requirements to optimise business compliance with the regulations. Methods Semi-structured interviews were conducted via MS Teams with a purposive sample of LA officers across England. Data were analysed using inductive thematic analysis. Results The 22 participants comprised 13 officers from Trading Standards, six from Environmental Health, and three from Public Health teams. The key messages include the following: (i) the regulations are complex and do not align with existing enforcement approaches, (ii) officers’ professional background will result in variable enforcement practices, and (iii) compliance assessment is an arduous task. LAs are facing resource and workforce constraints and have to prioritise regulations addressing high health risks (e.g., allergens). Therefore, officers will mostly apply a light touch approach to enforcement, raising awareness and engaging with businesses rather than issuing notices. To develop a consistent enforcement approach across LAs, officers asked for (i) further leadership from central government in the form of funding, training, and tools to determine in-scope businesses and products, (ii) cross-departmental collaboration to raise the regulations’ priority at local and regional levels, and (iii) greater consumer demand for healthier retail environments. Conclusion It is crucial to address both structural challenges such as resource allocation, workforce, and prioritisation issues as well as the inherent complexity of the regulations to strengthen enforcement efforts. Our findings highlight the necessity of supporting enforcement activities at national and regional government levels to avoid potential false conclusions about ineffectiveness of regulations. Highlights • The UK Food (Promotion and Placement) regulations are perceived as complex and low priority by LA officers • A light touch enforcement approach could undermine effective implementation of the regulations • Funding is required to enable officers to conduct business support visits and encourage compliance • Accredited training for officers is required to facilitate common understanding of regulations • Qualitative methods provided novel insights about enforcement concerns of the pioneering Food (Promotions and Placement) regulations to reduce obesity

Aim To a) evaluate the impact of Making Every Contact Count Healthy Conversation Skills (MECC HCS) training on the confidence and competence of physiotherapists in supporting patient behaviour change, and b) evaluate perceived acceptability, barriers and facilitators to implementing MECC HCS, following training. Methods A before and after evaluation design was employed. MECC HCS training took place in October and December 2021. A range of measures were taken directly before training, directly after training, at 6- to 12- week follow-up and at 6- month follow-up. These measures related to confidence in delivering MECC HCS and supporting behaviour change in patients, competence in doing so, and perceived acceptability of utilising MECC HCS as a brief intervention to support behaviour change in practice. Results MECC HCS training had significant positive impacts on the confidence and competence of physiotherapists in using MECC HCS skills to support patient behaviour change. Physiotherapists found training highly valuable and felt that implementing MECC HCS was acceptable within their practice. ‘Intentions’ and ‘Social/ Professional Role and Identity’ were key enablers to MECC HCS implementation at 6 months post- training. Conclusions MECC HCS training may contribute to closing the gap between evidence-based recommendations and the practice of physiotherapists in relation to health promotion and supporting patient behaviour change and self-management.

Background Placement interventions, characterised by greater availability and more prominent positioning of healthy food products in supermarkets and other food stores, are associated with healthier patterns of purchasing and diet. The WRAPPED intervention study is a natural experiment that aims to evaluate a supermarket placement intervention to improve fruit and vegetable sales, household purchasing and the dietary quality of women and their children. Process evaluation, alongside the evaluation of outcomes, is essential to understand how interventions are implemented, under what circumstances they are effective, and their mechanisms of impact. This study aimed to assess the implementation of the WRAPPED placement intervention. Methods The study adopted a convergent mixed-methods design. Quantitative data extracted from study store planograms (visual representation of stores and product placement) before and after intervention implementation were used to assess the positioning of fresh fruit and vegetables in the first aisle from the front entrance (intervention dose). The availability of fresh fruit and vegetables in each study store was examined from stock-keeping unit (SKU) figures before and after intervention implementation. An intervention implementation survey (IIS) completed with store managers and senior supervisors before and 1- and 6-months post-intervention implementation enabled examination of the context across study stores. Semi-structured interviews with store managers and senior supervisors provided qualitative data about store staff experiences and perceptions of the intervention between 6-months post-intervention implementation. Results The placement intervention was implemented with close adherence to the study protocol. There were marked differences, post-intervention implementation, in the positioning of fresh fruit and vegetables in intervention stores compared with control stores: median distance in intervention stores was 8.0 m (IQR 5.0 to 10.0) compared with 23.8 m (IQR 21.0 to 30.0) in control stores ( P  < 0.0001). The availability of varieties of fresh fruit and vegetables increased in intervention stores post-intervention compared with control stores: median (IQR) among intervention stores was 72 (51, 84) compared with 56.5 (50, 62) in control stores ( P  = 0.03). The mean change from baseline to post-implementation in number of different fruit and vegetables available in intervention stores was 15.3 (SD 16.7) ( P  = 0.01). IIS and interview data demonstrated little difference between intervention and store contexts over time. Reinforcing factors for intervention implementation included: head-office leadership, store staff views and attitudes and increased awareness of the importance of offering healthy food in prominent locations within stores. Conclusion This study demonstrated that placement interventions which promote fresh fruit and vegetables to customers in discount supermarkets can be implemented effectively. These findings are encouraging for the implementation of national food policies which modify retail environments to improve population purchasing and dietary patterns. Trial registration NCT03573973; Pre-results.

Adolescence offers a window of opportunity during which improvements in health behaviours could benefit long-term health, and enable preparation for parenthood—albeit a long way off, passing on good health prospects to future children. This study was carried out to evaluate whether an educational intervention, which engages adolescents in science, can improve their health literacy and behaviours. A cluster-randomised controlled trial of 38 secondary schools in England, UK was conducted. The intervention (LifeLab) drew on principles of education, psychology and public health to engage students with science for health literacy, focused on the message “Me, my health and my children’s health”. The programme comprised: • Professional development for teachers. • A 2–3 week module of work for 13-14-year-olds. • A “hands-on” practical health science day visit to a dedicated facility in a university teaching hospital. Data were collected from 2929 adolescents (aged 13–14 years) at baseline and 2487 (84.9%) at 12-month follow-up. The primary outcome was change in theoretical health literacy from pre- to 12 months post- intervention. This study is registered (ISRCTN71951436) and the trial status is complete. Participation in the LifeLab educational intervention was associated with an increase in the students’ standardised total theoretical health literacy score (adjusted difference between groups = 0.27 SDs (95%CI = 0.12, 0.42)) at 12-month follow-up. There was an indication that intervention participants subsequently judged their own lifestyles more critically than controls, with fewer reporting their behaviours as healthy (53.4% vs. 59.5%; adjusted PRR = 0.94 [0.87, 1.01]). We conclude that experiencing LifeLab led to improved health literacy in adolescents and that they demonstrated a move towards a more critical judgement of health behaviour 12 months after the intervention. Further work is needed to examine whether this leads to sustained behaviour change, and whether other activities are needed to support this change.