James Fagg

Does greener mean thinner? Associations between neighbourhood greenspace and weight status among adults in England

Objective:To investigate associations between neighbourhood greenspace and weight status, and to explore the contribution of physical activity to these associations.Design:Cross-sectional observational study over two time-periods.Subjects:Participants were adults (aged 18 years+) in from a nationally representative sample of the English population for the time periods 2000–2003 (n=42 177) and 2004–2007 (n=36 959).Measurements:Weight status was defined as body mass index (BMI) category according to WHO classification. Neighbourhood greenspace was measured using the Generalised Land use Database for England that defines greenspace as parks, open spaces and agricultural land, excluding domestic gardens. Multinomial logistic regression models were used to estimate associations between neighbourhood greenspace and BMI and, in eligible sub-samples, to investigate the contribution of total physical activity to these. All models were adjusted for age, sex, social class, economic activity, neighbourhood income deprivation and urban/rural status.Results:In 2000–2003 there was a counterintuitive association between greenspace and BMI. Residence in the greenest areas was significantly associated with increases in overweight (12%) and obesity (23%). In 2004–2007, there was a small protective effect of greenspace for those living in the greenest areas, but this was not statistically significant. Markers of total physical activity did not attenuate associations. Tests for interactions with urban/rural status confirmed that significant associations between neighbourhood greenspace and obesity were only present in urban areas in 2000–2003.Conclusion:Better evidence for the utility of greenspace in the prevention of weight gain is required before greenspace interventions are developed.

From trial to population: a study of a family-based community intervention for childhood overweight implemented at scale

Objectives:To assess how outcomes associated with participation in a family-based weight management intervention (MEND 7–13, Mind, Exercise, Nutrition..Do it!) for childhood overweight or obesity implemented at scale in the community vary by child, family, neighbourhood and MEND programme characteristics.Methods/Subjects:Intervention evaluation using prospective service level data. Families (N=21 132) with overweight children are referred, or self-refer, to MEND. Families (participating child and one parent/carer) attend two sessions/week for 10 weeks (N=13 998; N=9563 with complete data from 1788 programmes across England). Sessions address diet and physical activity through education, skills training and motivational enhancement. MEND was shown to be effective in obese children in a randomised controlled trial (RCT). Outcomes were mean change in body mass index (BMI), age- and sex-standardised BMI (zBMI), self-esteem (Rosenberg scale) and psychological distress (Strengths and Difficulties Questionnaire) after the 10-week programme. Relationships between the outcome and covariates were tested in multilevel models adjusted for the outcome at baseline.Results:After adjustment for covariates, BMI reduced by mean 0.76 kg m−2 (s.e.=0.021, P<0.0001), zBMI reduced by mean 0.18 (s.e.=0.0038, P<0.0001), self-esteem score increased by 3.53 U  (s.e.=0.13, P<0.0001) and psychological distress score decreased by 2.65 U (s.e.=0.31, P<0.0001). Change in outcomes varied by participant, family, neighbourhood and programme factors. Generally, outcomes improved less among children from less advantaged backgrounds and in Asian compared with white children. BMI reduction under service conditions was slightly but not statistically significantly less than in the earlier RCT.Conclusions:The MEND intervention, when delivered at scale, is associated with improved BMI and psychosocial outcomes on average, but may work less well for some groups of children, and so has the potential to widen inequalities in these outcomes. Such public health interventions should be implemented to achieve sustained impact for all groups.

After the RCT: who comes to a family-based intervention for childhood overweight or obesity when it is implemented at scale in the community?

Background When implemented at scale, the impact on health and health inequalities of public health interventions depends on who receives them in addition to intervention effectiveness. Methods The MEND 7–13 (Mind, Exercise, Nutrition…Do it!) programme is a family-based weight management intervention for childhood overweight and obesity implemented at scale in the community. We compare the characteristics of children referred to the MEND programme (N=18 289 referred to 1940 programmes) with those of the population eligible for the intervention, and assess what predicts completion of the intervention. Results Compared to the MEND-eligible population, proportionally more children who started MEND were: obese rather than overweight excluding obese; girls; Asian; from families with a lone parent; living in less favourable socioeconomic circumstances; and living in urban rather than rural or suburban areas. Having started the programme, children were relatively less likely to complete it if they: reported ‘abnormal’ compared to ‘normal’ levels of psychological distress; were boys; were from lone parent families; lived in less favourable socioeconomic circumstances; and had participated in a relatively large MEND programme group; or where managers had run more programmes. Conclusions The provision and/or uptake of MEND did not appear to compromise and, if anything, promoted participation of those from disadvantaged circumstances and ethnic minority groups. However, this tendency was diminished because programme completion was less likely for those living in less favourable socioeconomic circumstances. Further research should explore how completion rates of this intervention could be improved for particular groups.

Neighbourhood deprivation and adolescent self-esteem: Exploration of the ‘socio-economic equalisation in youth’ hypothesis in Britain and Canada

Material deprivation is an important determinant of health inequalities in adults but there remains debate about the extent of its importance for adolescent wellbeing. Research has found limited evidence for an association between adolescent health and socio-economic status, leading authors to suggest that there is an ‘equalisation’ of health across socio-economic groups during the adolescent stage of the life-course. This paper explores this ‘equalisation’ hypothesis for adolescent psychological wellbeing from a geographical perspective by investigating associations between neighbourhood deprivation and self-esteem in Britain and Canada. Data from the British Youth Panel (BYP) and the National Longitudinal Survey of Children and Youth (NLSCY) on adolescents aged 11–15 for the time period 1994–2004 were used to estimate variations in low self-esteem between neighbourhoods using multilevel logistic regression. Models were extended to estimate associations between self-esteem and neighbourhood deprivation before and after adjustment for individual and family level covariates. Moderation by age, sex, urban/rural status, household income and family structure was investigated. There were no significant differences in self-esteem between the most deprived and most affluent neighbourhoods (Canada unadjusted OR = 1.00, 95% CI 0.76, 1.33; Britain unadjusted OR = 1.25, 95% CI 0.74, 2.13). The prevalence of low self-esteem was higher (in Canada) for boys in the least deprived neighbourhoods compared to other neighbourhoods. No other interactions were observed. The results presented here offer some (limited) support for the socio-economic equalisation in youth hypothesis from a geographical perspective: with specific reference to equalisation of the relationship between neighbourhood deprivation and self-esteem and psychological health in early adolescence. This contrasts with previous research in the United States but supports related work from Britain. The lack of interactions with key social and economic variables suggests that findings might apply across a range of family circumstances and different communities in Britain and Canada. Policy implications are discussed.

Co-occurrence and clustering of health conditions at age 11: cross-sectional findings from the Millennium Cohort Study

Objectives To identify patterns of co-occurrence and clustering of 6 common adverse health conditions in 11-year-old children and explore differences by sociodemographic factors. Design Nationally representative prospective cohort study. Setting Children born in the UK between 2000 and 2002. Participants 11 399 11-year-old singleton children for whom data on all 6 health conditions and sociodemographic information were available (complete cases). Main outcome measures Prevalence, co-occurrence and clustering of 6 common health conditions: wheeze; eczema; long-standing illness (excluding wheeze and eczema); injury; socioemotional difficulties (measured using Strengths and Difficulties Questionnaire) and unfavourable weight (thin/overweight/obese vs normal). Results 42.4% of children had 2 or more adverse health conditions (co-occurrence). Co-occurrence was more common in boys and children from lower income households. Latent class analysis identified 6 classes: ‘normative’ (57.4%): ‘atopic burdened’ (14.0%); ‘socioemotional burdened’ (11.0%); ‘unfavourable weight/injury’ (7.7%); ‘eczema/injury’ (6.0%) and ‘eczema/unfavourable weight’ (3.9%). As with co-occurrence, class membership differed by sociodemographic factors: boys, children of mothers with lower educational attainment and children from lower income households were more likely to be in the ‘socioemotional burdened’ class. Children of mothers with higher educational attainment were more likely to be in the ‘normative’ and ‘eczema/unfavourable weight’ classes. Conclusions Co-occurrence of adverse health conditions at age 11 is common and is associated with adverse socioeconomic circumstances. Holistic, child focused care, particularly in boys and those in lower income groups, may help to prevent and reduce co-occurrence in later childhood and adolescence.