OBJECTIVES:This study aimed to explore what motivates parents to address their own weight and support their child to reach or maintain a healthy weight, how parents assess their child's weight and the impact of a parent addressing their own weight on their child. METHODS:In this mixed-methods study, Slimming World members (a UK-based adult commercial weight management programme) who had children aged 5-11 years old were invited to complete an online survey and telephone interview. This included parent-reported measures of Body Mass Index (BMI) and their child's weight status, physical activity and dietary behaviours. Quantitative survey data were summarised descriptively using percentages to identify associations of both parental weight management motivating factors and child weight concerns with parent weight category. Qualitative telephone interview analyses followed an inductive thematic approach. RESULTS:Improving health (81%) and dissatisfaction with appearance (81%) were the most common motivators for parents to address their own weight. 67% of parents who were worried about their child's weight felt more motivated to help their child reach a healthier weight since they had taken steps to address their own weight. Weight-related adverse experiences during the parents' lives were an important driver to address their child's weight, as were health concerns. Parents assessed their child's weight mainly through clothing size and visual comparison with peers rather than weighing. Concern about a child's weight increased with parental BMI and child age. Since the parents addressed their own weight, 48% reported their child's diet was healthier, and 27% that their child was more physically active. CONCLUSION:Parents addressing their own weight are particularly motivated to help their child reach or maintain a healthy weight. Targeted, child-oriented interventions at this time may enhance the reported indirect benefits on children.

Objective To explore whether parents’ attendance at a commercial adult weight management programme (WMP) offers an opportunity to identify and signpost families to child weight management support, if appropriate to a child’s weight status.Design Mixed methods study including a cross-sectional online survey and semistructured telephone interviews.Setting and participants Parents attending Slimming World (UK-based adult commercial WMP), with one or more children aged 5–11 years, were invited to take part. There were 396 survey and 18 telephone interview participants.Results Most parents (78%) attending the adult WMP and worried about their child’s weight were receptive to being offered support for their child. Nearly all (98%) of these parents were happy for the adult WMP to signpost to this support. Nearly half of parents (47%, n=122/262) not worried about their child’s weight were still interested in a child height and weight check. The preferred intervention format and delivery possibilities differed among parents, with ‘no-one size fits all’, while recognising that change takes time, and weekly sessions may be too frequent. Parents were clear that the focus of support should be on healthy lifestyle not weight. Many parents felt a parent ‘peer support’ group would be helpful.Conclusions Parents actively addressing their own weight, through an adult WMP, are receptive to being offered and signposted to support for their child, where they have concerns about their child’s weight. These findings support a new referral pathway into child weight management services, through parents attending an adult WMP.

Background Perinatal depression (PND) describes depression experienced by parents during pregnancy or in the first year after a baby is born. The EQ-5D instrument (a generic measure of health status) is not often collected in perinatal research, however disease-specific measures, such as the Edinburgh Postnatal Depression Scale (EPDS) are widely used. Mapping can be used to estimate generic health utility index values from disease-specific measures like the EPDS. Objective To develop a mapping algorithm to estimate EQ-5D utility index values from the EPDS. Methods Patient-level data from the BaBY PaNDA study (English observational cohort study) provided 1068 observations with paired EPDS and EQ-5D (3-level version; EQ-5D-3L) responses. We compared the performance of six alternative regression model types, each with four specifications of covariates (EPDS score and age: base, squared, and cubed). Model performance (ability to predict utility values) was assessed by ranking mean error, mean absolute error, and root mean square error. Algorithm performance in 3 external datasets was also evaluated. Results There was moderate correlation between EPDS score and utility values (coefficient: – 0.42). The best performing model type was a two-part model, followed by ordinary least squared. Inclusion of squared and cubed covariates improved model performance. Based on graphs of observed and predicted utility values, the algorithm performed better when utility was above 0.6. Conclusions This direct mapping algorithm allows the estimation of health utility values from EPDS scores. The algorithm has good external validity but is likely to perform better in samples with higher health status.

OBJECTIVE:With one in five children in England living with obesity, we mapped the geographical distribution and format of child weight management services provided by acute National Health Service (NHS) trusts across England, to identify breadth of service provision.DESIGN:A cross-sectional survey.SETTING:The survey was sent to acute NHS trusts (n=148) in England in 2020, via a freedom of information request.PARTICIPANTS:Responses were received from 139 of 148 (94%) acute NHS trusts, between March 2020 to March 2021.OUTCOME MEASURES:The survey asked each acute NHS trust whether they provide a weight management service for children living with obesity. For those trusts providing a service, data were collected on eligibility criteria, funding source, personnel involved, number of new patients seen per year, intervention duration, follow-up length and outcome measures. Service characteristics were reported using descriptive statistics. Service provision was analysed in the context of ethnicity and Index of Multiple Deprivation score of the trust catchment area.RESULTS:From the 139 survey respondents, 23% stated that they provided a weight management service for children living with obesity. There were inequalities in the proportion of acute NHS trusts providing a service across the different regions of England, ranging from 4% (Midlands) to 36% (London). For trusts providing a service, there was variability in the number of new cases seen per year, eligibility criteria, funding source, intervention format and outcome measures collected. A multidisciplinary approach was not routinely provided, with only 41% of services reporting ≥3 different staff disciplines.CONCLUSION:In 2020/2021, there were geographical inequalities in weight management service provision by acute NHS trusts for children living with obesity. Services provided lacked standardisation, did not routinely offer children multidisciplinary care and were insufficient in size to meet need.

Background This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care. Methods We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted. Results Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3-4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3-4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions. Conclusions When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.

Estimates of depression prevalence in pregnancy and postpartum are based on the Edinburgh Postnatal Depression Scale (EPDS) more than on any other method. We aimed to determine if any EPDS cutoff can accurately and consistently estimate depression prevalence in individual studies.

Background: There is evidence that depressive symptom severity is associated with prognosis but existing studies have usually been for people on a single treatment so we lack evidence for this effect independent of treatment. There are other factors that we will call ‘disorder severity’ such as duration and comorbidity that have been reported as associated with prognosis, but current evidence does not indicate if these associations are independent of treatment and symptom severity. Methods: Medline, Embase, PsycINFO and Cochrane Central were searched from inception to 20th March 2019 for randomised controlled trials (RCTs) of adults seeking treatment for depression from their general practitioners, that used the Revised Clinical Interview Schedule (CIS-R) so that there was uniformity in the measurement of disorder severity factors. Individual participant data were gathered from 12 RCTs. Two-stage random-effects meta-analyses were undertaken calculating effect estimates within each study and then pooling across these to ascertain the independent association between each potential prognostic factor and depressive symptoms at 3-4 months post-baseline, remission and depressive symptoms at 6-8 months post-baseline. Risk of bias was calculated using QUIPS and quality was assessed using GRADE. Findings: Baseline depressive symptom severity was strongly associated with prognosis independent of treatment; there was a 27∙5%(95%CI: 25∙0 to 30∙1) difference in depressive symptoms at 3-4 months per one standard deviation increase in baseline score, equivalent to about eight Beck Depression Inventory points or five PHQ-9 points. The duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment were also associated with prognosis independent of depressive symptom severity, though the association with antidepressant treatment was less robust. For participants with all four of these factors, there was a difference of 39∙9%(95%CI: 12∙6 to 74∙0) in their score at 3-4 months. Risk of bias was low in all studies, quality was high and heterogeneity was within acceptable limits for all but two prognostic indicators. A number of sensitivity analyses did not alter our conclusions. Interpretation: Depressive symptom severity had a strong association with prognosis independent of treatment. The duration of depressive symptoms, duration of anxiety symptoms, panic disorder and past antidepressant use were all associated with prognosis independent of depressive symptom severity and treatment. Consideration of these prognostic indicators could be clinically important for determining prognosis and inform patients and clinicians about likely outcomes in the clinical management of depression. Funding Statement: This work was supported by the Wellcome Trust through a Clinical Research Fellowship to JB (201292/Z/16/Z), Medical Research Council (Programme for IW: MC_UU_12023/21), MQ Foundation (for ZC: MQDS16/72), the Higher Education Funding Council for England, the National Institute of Health Research (NIHR), NIHR University College London Hospitals Biomedical Research Centre (RS, KC, PB, and SP), University College London (GA, GL), University of Pennsylvania (RDR), Vanderbilt University (SDH), University of Southampton (TK), University of Exeter (EW), and University of York (SG). Declaration of Interests: All authors declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work. Ethics Approval Statement: PROSPERO registration: CRD42019129512.

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ObjectiveTo assess how lifestyle weight management programmes for children aged 4–16 years in England are commissioned and evaluated at the local level.DesignThis was a mixed-methods study comprising an online survey and semistructured telephone interviews.SettingAn online survey was sent to all local authorities (LAs) in England regarding lifestyle weight management services commissioned for children aged 4–16 years. Online survey data were collected between February and May 2016 and based on services commissioned between April 2014 and March 2015. Semistructured telephone interviews with LA staff across England were conducted between April and June 2016.ParticipantsCommissioners or service providers working within the public health department of LAs.Main outcome measuresThe online survey collected information on the evidence base, costs, reach, service usage and evaluation of child lifestyle weight management services. The telephone interviews explored the nature of child weight management contracts commissioned by LAs, the type of outcome data collected and whether these data were shared with other LAs or organisations, the challenges faced by these services, and the perceived ‘markers of success’ for a programme.ResultsThe online survey showed that none of the participating LAs was aware of any peer-reviewed evidence supporting the effectiveness of their specific commissioned service. Despite this, the telephone interviews revealed that there was no national formal sharing of data to enable oversight of the effectiveness of commissioned services across LAs in England to help inform future commissioning decisions. Challenges with long-term data collection, service engagement, funding and the pressure to reduce the prevalence of obesity were frequently mentioned.ConclusionsRobust, independent, cost-effectiveness analyses of obesity strategies are needed to determine the appropriate allocation of funding to lifestyle weight management treatment services, population-level preventative approaches or development of whole system approaches by an LA.

Abstract Introduction Complementary and alternative medicine (CAM), often accessed privately, can be integrated with conventional care. Little is known about current integration in the UK National Health Service (NHS). We provide an overview of integrated CAM services accessed from UK primary care for musculoskeletal and mental health conditions, to identify key features and barriers and facilitators to integration. Methods Descriptive analysis of integrated services accessed from primary care providing CAM alongside conventional NHS care for musculoskeletal and/or mental health problems. A purposive sample was identified through personal contacts, social media, literature/internet searches, conferences, and patient/professional organisations. Questionnaires, documentary analysis and stakeholder meetings collected data on the service’s history, features, integration, success and sustainability. Data was tabulated. Results From 38 sites identified, twenty sites were selected. Acupuncture and homeopathy were most common, followed by massage, osteopathy and mindfulness. GPs were often instrumental initiating services. NHS staff enthusiasm facilitated integration, as did an NHS setting, patient/public support, and being adjunctive to an NHS service. The main barriers to integration were funding, negative perceptions of CAM from the clinicians, funders and lobby groups, and local NHS staff attitudes/lack of knowledge. Reduced funding was often why services closed. Conclusions Various models for integrating CAM with UK primary care were identified. Social prescribing and NHS/patient co-funded CAM may be potentially sustainable models for future integration. Lack of funding and negative perceptions of CAM remain the primary challenge to integration. Evaluating effectiveness and cost-effectiveness of integrated services is vital to ensure sustainability.

Objective To identify potentially effective complementary approaches for musculoskeletal (MSK)–mental health (MH) comorbidity, by synthesising evidence on effectiveness, cost-effectiveness and safety from systematic reviews (SRs). Design Scoping review of SRs. Methods We searched literature databases, registries and reference lists, and contacted key authors and professional organisations to identify SRs of randomised controlled trials for complementary medicine for MSK or MH. Inclusion criteria were: published after 2004, studying adults, in English and scoring >50% on Assessing the Methodological Quality of Systematic Reviews (AMSTAR); quality appraisal checklist). SRs were synthesised to identify research priorities, based on moderate/good quality evidence, sample size and indication of cost-effectiveness and safety. Results We included 84 MSK SRs and 27 MH SRs. Only one focused on MSK–MH comorbidity. Meditative approaches and yoga may improve MH outcomes in MSK populations. Yoga and tai chi had moderate/good evidence for MSK and MH conditions. SRs reported moderate/good quality evidence (any comparator) in a moderate/large population for: low back pain (LBP) (yoga, acupuncture, spinal manipulation/mobilisation, osteopathy), osteoarthritis (OA) (acupuncture, tai chi), neck pain (acupuncture, manipulation/manual therapy), myofascial trigger point pain (acupuncture), depression (mindfulness-based stress reduction (MBSR), meditation, tai chi, relaxation), anxiety (meditation/MBSR, moving meditation, yoga), sleep disorders (meditative/mind–body movement) and stress/distress (mindfulness). The majority of these complementary approaches had some evidence of safety—only three had evidence of harm. There was some evidence of cost-effectiveness for spinal manipulation/mobilisation and acupuncture for LBP, and manual therapy/manipulation for neck pain, but few SRs reviewed cost-effectiveness and many found no data. Conclusions Only one SR studied MSK–MH comorbidity. Research priorities for complementary medicine for both MSK and MH (LBP, OA, depression, anxiety and sleep problems) are yoga, mindfulness and tai chi. Despite the large number of SRs and the prevalence of comorbidity, more high-quality, large randomised controlled trials in comorbid populations are needed.

In 1973 a World Health Organization working party on psychiatry in general practice identified the general practitioner as playing a major role in mental health care. Although there are some logistic problems in getting both sides together, with increasing acceptance of the psychiatrist by the primary care team, the benefits of liaison psychiatry appear to outweigh the costs. The General Health Questionnaire has been used in several studies which aimed to estimate the prevalence of psychiatric morbidity in general practice. Depressed patients may well present a physical symptom to their general practitioner rather than their psychological symptoms. Studies of diagnosis of psychiatric disorder in primary care have concentrated largely on depressive disorders. There is a growing need for the evaluation of the outcome of different modes of management and for what will undoubtedly be the most challenging task, the prevention of mental illness.

BACKGROUND:Comorbidity of musculoskeletal (MSK) and mental health (MH) problems is common but challenging to treat using conventional approaches. Integration of conventional with complementary approaches (CAM) might help address this challenge. Integration can aim to transform biomedicine into a new health paradigm or to selectively incorporate CAM in addition to conventional care. This study explored professionals' experiences and views of CAM for comorbid patients and the potential for integration into UK primary care.METHODS:We ran focus groups with GPs and CAM practitioners at three sites across England and focus groups and interviews with healthcare commissioners. Topics included experience of co-morbid MSK-MH and CAM/integration, evidence, knowledge and barriers to integration. Sampling was purposive. A framework analysis used frequency, specificity, intensity of data, and disconfirming evidence.RESULTS:We recruited 36 CAM practitioners (4 focus groups), 20 GPs (3 focus groups) and 8 commissioners (1 focus group, 5 interviews). GPs described challenges treating MSK-MH comorbidity and agreed CAM might have a role. Exercise- or self-care-based CAMs were most acceptable to GPs. CAM practitioners were generally pro-integration. A prominent theme was different understandings of health between CAM and general practitioners, which was likely to impede integration. Another concern was that integration might fundamentally change the care provided by both professional groups. For CAM practitioners, NHS structural barriers were a major issue. For GPs, their lack of CAM knowledge and the pressures on general practice were barriers to integration, and some felt integrating CAM was beyond their capabilities. Facilitators of integration were evidence of effectiveness and cost effectiveness (particularly for CAM practitioners). Governance was the least important barrier for all groups. There was little consensus on the ideal integration model, particularly in terms of financing. Commissioners suggested CAM could be part of social prescribing.CONCLUSIONS:CAM has the potential to help the NHS in treating the burden of MSK-MH comorbidity. Given the challenges of integration, selective incorporation using traditional referral from primary care to CAM may be the most feasible model. However, cost implications would need to be addressed, possibly through models such as social prescribing or an extension of integrated personal commissioning.

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Background Studies have shown that maternal depression during pregnancy predicts offspring depression in adolescence. Child maltreatment is also a risk factor for depression. Aims To investigate (a) whether there is an association between offspring exposure to maternal depression in pregnancy and depression in early adulthood, and (b) whether offspring child maltreatment mediates this association. Method Prospectively collected data on maternal clinical depression in pregnancy, offspring child maltreatment and offspring adulthood (18–25 years) DSM-IV depression were analysed in 103 mother–offspring dyads of the South London Child Development Study. Results Adult offspring exposed to maternal depression in pregnancy were 3.4 times more likely to have a DSM-IV depressive disorder, and 2.4 times more likely to have experienced child maltreatment, compared with non-exposed offspring. Path analysis revealed that offspring experience of child maltreatment mediated the association between exposure to maternal depression in pregnancy and depression in adulthood. Conclusions Maternal depression in pregnancy is a key vulnerability factor for offspring depression in early adulthood.

Background: objective measures of physical activity and function with a diverse cohort of UK adults in their 70s and 80s were used to investigate relative risk of all-cause mortality and diagnoses of new diseases over a 4-year period.Participants: two hundred and forty older adults were randomly recruited from 12 general practices in urban and suburban areas of a city in the United Kingdom. Follow-up included 213 of the baseline sample.Methods: socio-demographic variables, height and weight, and self-reported diagnosed diseases were recorded at baseline. Seven-day accelerometry was used to assess total physical activity, moderate-to-vigorous activity and sedentary time. A log recorded trips from home. Lower limb function was assessed using the Short Physical Performance Battery. Medical records were accessed on average 50 months post baseline, when new diseases and deaths were recorded.Analyses: ANOVAs were used to assess socio-demographic, physical activity and lower limb function group differences in diseases at baseline and new diseases during follow-up. Regression models were constructed to assess the prospective associations between physical activity and function with mortality and new disease.Results: for every 1,000 steps walked per day, the risk of mortality was 36% lower (hazard ratios 0.64, 95% confidence interval (CI) 0.44-0.91, P = 0.013). Low levels of moderate-to-vigorous physical activity (incident rate ratio (IRR) 1.67, 95% CI 1.04-2.68, P = 0.030) and low frequency of trips from home (IRR 1.41, 95% CI 0.98-2.05, P = 0.045) were associated with diagnoses of more new diseases.Conclusion: physical activity should be supported for adults in their 70s and 80s, as it is associated with reduced risk of mortality and new disease development.

Translational research has become one of the key concepts of medical science in the 21st century, with academics and clinicians coming together in a joint effort to bring findings from basic research into the clinical setting so that they can benefit patients. Channi Kumar may not have recognized this phrase, but his work was truly translational. Indeed his perinatal research programme was bi-directional in its translation. As a clinician and an academic, Channi’s research was informed by his clinical work with mothers suffering from severe mental illness (SMI) following childbirth. He recognized the importance of treating a mother’s mental illness, while at the same supporting her in the care of her baby. His clinical work on the Mother and Baby Unit at the Bethlem Royal Hospital gave rise to research into the understanding of antenatal and postnatal mental illness and its effects on the child as well as into improving services and treatment for women and their babies. In this chapter we will show how two of Channi’s flagship studies, the South London Child Development Study (SLCDS) and a video feedback intervention programme on the Mother and Baby Unit, continue to gather evidence and to inform perinatal guidelines in the 21st century. The SLCDS is unique in that it is one of the first longitudinal studies of women’s mental health and its impact on the children to begin during pregnancy. Specifically, families from two inner-city London General Practice sites were initially recruited into a longitudinal prospective study of emotional disorders related to childbirth when the women were pregnant between 1 January and 31 December 1986. It has followed the lives of 151 families through pregnancy and the index child’s first year, with 86% participating when the index child was 4 years, 89% at 11 years, and 83% at 16 years. At the outset of the study, the mean age of the women was 25.9 years (range 16–43 years); 60% were married, 32% had a regular partner, and 8% were single; 78% were of white British origin; 86% were working class; 30% had no educational qualifications.

The rise in childhood obesity in recent years has been accompanied by a number of initiatives to treat the condition. However, such interventions have often been characterised by poor levels of adherence to treatment and corresponding high attrition rates. This article presents data drawn from qualitative interviews to examine families' reasons for engaging or not engaging with child obesity services. Interviews took place with 15 families whose children attended a UK-based childhood obesity service and 17 families whose children withdrew from treatment. Our data suggested that involvement of children in the decision to attend a clinic was important in building engagement. Specialist diet and exercise advice tailored to individual family circumstance encouraged clinic engagement, but failed to engage some families who felt their personal circumstances had not been considered sufficiently. The clinic environment was viewed as not age appropriate for some children and did not match the expectations of some families. Our findings highlight the value of involving children in the decision to attend an obesity service and practitioners should, as much as possible, tailor advice to the circumstances of each family. Providing clinics for particular age groups in terms of environment and timing may enhance engagement with services.

Interventions promoting physical activity by General Practitioners (GPs) lack a strong evidence base. Recruiting participants to trials in primary care is challenging. We investigated the feasibility of (i) delivering three interventions to promote physical activity in inactive participants and (ii) different methods of participant recruitment and randomised allocation.