Our aim is to investigate the association between visit-to-visit variability of nine risk factors and incident cardiovascular disease (CVD) in a large multi-ethnic population cohort study. We used the Multi-Ethnic Study of Atherosclerosis cohort. We included individuals with no previous history of CVD, with at least three repeated measurements on each risk factor including total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, triglyceride, Chol/HDL-C ratio, diastolic blood pressure, systolic blood pressure (SBP), and body mass index (BMI). Visit-to-visit variability was estimated via the variability independent of the mean. A Cox proportional hazards model was used to estimate the association between visit-to-visit variability and the hazard of developing CVD. There was a statistically significant association between visit-to-visit variability in SBP, BMI, HDL-C, and the rate of incident CVD. This rate was higher in individuals with high visit-to-visit variability for SBP (HR, 1.28; 95% CI, 1.01-1.63; P = .04), BMI (HR, 1.58; 95% CI, 1.25-2.00; P < .001), and HDL-C (HR, 1.3; 95% CI, 1.03-1.65; P = .025), compared to those with low visit-to-visit variability. Our findings suggest that visit-to-visit variability in some CVD risk factors could be independently associated with incident CVD and may be useful to clinicians in risk stratification.

BACKGROUND:A rapidly evolving evidence base suggests that exposure to outdoor air pollution is a risk factor for the onset of dementia, with an upturn in publications since 2022. We sought to synthesise and critically assess this evidence base accounting for the latest studies. METHODS:In this systematic review and meta-analysis, we searched MEDLINE, Embase, Cochrane Library, CINAHL, Global Health, PsycINFO, Scopus, and Web of Science Core Collection from database inception up to Oct 23, 2023, for primary observational studies of adults (aged ≥18 years) that provided a quantitative analysis of the association between long-term (≥1 year) exposure to outdoor air pollutants and a subsequent physician diagnosis of dementia. When three or more independent studies reported an exposure-outcome pair, effect estimates of the association were extracted and harmonised to a prespecified exposure increment, and included in inverse-variance weighted random-effects meta-analyses. Between-study inconsistency was assessed using the I2 statistic and the Cochran Q test. Study-level risk of bias and confidence in the overall body of evidence were assessed with the Office of Health Assessment and Translation tool, and publication bias was examined. The protocol for this review was registered with PROSPERO, CRD42023414413. FINDINGS:The search generated 15 619 records, of which 51 studies met the inclusion criteria for data extraction. After excluding studies due to population overlap and missing continuous effect estimates, 32 studies reported on exposure-outcome pairs that met the threshold of three or more studies, and were included in meta-analyses of adjusted effect estimates for incident dementia and/or in subgroup analyses of dementia subtypes. In meta-analyses of incident dementia, we identified a dementia diagnosis to be significantly associated with long-term exposure to PM2·5 (21 studies, n=24 030 527, pooled adjusted hazard ratio (HR) per 5 μg/m3 increase in exposure, 1·08 [95% CI 1·02-1·14]; I2=95%), nitrogen dioxide (16 studies, n=17 228 429, pooled adjusted HR per 10 μg/m3 increase, 1·03 [1·01-1·05]; I2=84%), and black carbon/PM2·5 absorbance (six studies, n=19 421 865, pooled adjusted HR per 1 μg/m3 increase, 1·13 [1·01-1·27]; I2=97%). We found no significant association for exposure to nitrogen oxides (five studies, n=241 409, pooled adjusted HR per 10 μg/m3 increase, 1·05 [0·97-1·13]; I2=44%), PM10 (four studies, n=246 440, pooled adjusted HR per 15 μg/m3 increase, 1·52 [0·80-2·87]; I2=82%), or annual ozone (four studies, n=419 972, pooled adjusted HR per 45 μg/m3 increase, 0·82 [0·35-1·92]; I2=69%), with moderate to considerable heterogeneity between studies in these pooled analyses. Of the 32 studies overall, three (9%) had a probably high risk of bias in one of seven domains; all other studies had ratings of probably to definitely low risk of bias. The overall certainty of evidence of studies in the systematic review was moderate. INTERPRETATION:This analysis adds to the body of evidence that outdoor air pollutants are risk factors for dementia, indicating that reduced exposure to pollution could reduce dementia rates and stricter air quality standards would likely provide substantial health, social, and economic benefits. FUNDING:European Research Council under the Horizon 2020 research and innovation programme and the EU's Horizon Europe Framework Programme.

OBJECTIVE:To investigate whether substituting different intensities of physical activity (PA) for sedentary time (ST) can benefit the prevention of type 2 diabetes (T2D) across varying levels of T2D genetic susceptibility. PARTICIPANTS AND METHODS:We included 73,272 White British participants from the UK Biobank without prevalent T2D. Wrist-worn accelerometry was used to derive sleep, ST, light PA, and moderate-to-vigorous PA (MVPA) based on machine learning. Polygenic risk scores for T2D were computed based on 138 genome-wide important, unrelated genetic markers. We used compositional isotemporal substitution modeling in logistic regression, with adjustment for putative confounders. Accelerometer data were collected between June 1, 2013, and December 23, 2015. Follow-up continued until December 9, 2022 (England/Wales) and December 19, 2022 (Scotland). RESULTS:Over a median 8.1-year follow-up, 1399 incident T2D cases were identified. Reallocating 30 minutes/day of ST into time-equivalent light PA and MVPA was associated with 5% (odds ratio, 0.95; 95% CI, 0.94 to 0.97) and 18% (odds ratio, 0.82; 95% CI, 0.79 to 0.85) lower odds of T2D, respectively, independent of genetic risk. Shifting 15 minutes/day of ST to MVPA or 60 minutes/day of ST to light PA was associated with similar odds of T2D. CONCLUSION:Irrespective of genetic susceptibility to T2D, replacing ST with equivalent physically active time (either at light or moderate-to-vigorous intensity) is associated with lower T2D odds. Individuals at all genetic risk levels may achieve the same degree of T2D odds reduction by substituting a larger volume of light PA for ST as they would by replacing ST with a smaller volume of MVPA.

BACKGROUND:Out-of-home (OOH) food tends to be energy-dense and nutrient-poor. In response, England implemented a mandatory calorie labelling policy in the OOH sector. We evaluated changes in consumer behaviours after the policy was implemented in April 2022. METHODS:We employed a natural experimental design to assess pre-post changes in noticing and using nutrition information, and behaviours associated with menu labelling. We compared changes in England to comparator jurisdictions without similar policies. Data included four consecutive years (2019-2022) from the International Food Policy Study; participants were adults aged 18 years or older. Mixed effects logistic regression models assessed pre-post changes in binary outcomes, and mixed effects negative binomial regression assessed changes in frequency of OOH eating. RESULTS:In England, noticing nutrition information increased from 16.0% (95% CI 15.6 to 16.4) in 2020 to 19.7% (95% CI 19.1 to 20.2) in 2021 and to 25.8% (95% CI 25.5 to 26.1) in 2022. This increase was 4.8% points (95% CI 2.5 to 7.1) higher in England versus the comparator group. Using nutrition information increased in England from 8.0% (95% CI 7.5 to 8.4) in 2020 to 11.8% (95% CI 10.9 to 12.6) in 2021 and to 13.5% (95% CI 13.1 to 13.9) in 2022. There was a 2.7% points (95% CI 2.0 to 3.4) greater increase in England versus the comparator group from 2020 to 2021. Ordering something different was the only behaviour associated with nutrition information that increased after implementation of the policy in England: from 12.6% (95% CI 12.4 to 12.7) in 2020 to 15.2% (95% CI 14.7 to 15.6) in 2021 and to 17.7% (95% CI 17.6 to 17.8) in 2022. There was a 2.8% points (95% CI 1.8 to 3.9) greater increase in England versus the comparator group from 2021 to 2022. Frequency of OOH eating did not change after policy implementation. CONCLUSIONS:The introduction of mandatory calorie labelling in England led to increases in self-reported noticing and using, with the key behavioural impact on ordering something different. Additional strategies may be required to maximise the public health benefits of calorie labelling.

Dietary guidelines recommend replacing saturated fatty acid with unsaturated fats, particularly polyunsaturated fatty acids. Cohort studies do not suggest a clear benefit of higher intake of polyunsaturated fatty acids but, in contrast, higher circulating linoleic acid (LA) levels—reflective of dietary LA intake, are associated with a reduced risk of type 2 diabetes. However, genetic variants in the fatty acid desaturase 1 gene (FADS1) may influence individual responses to plant-based fats. We explored whether FADS1 variants influence the relationships of LA and α-linolenic acid (ALA) intakes and nut consumption with plasma phospholipid fatty acid profiles and type 2 diabetes risk in a large-scale cohort study and a randomized controlled trial. In the EPIC-InterAct case-cohort (7,498 type 2 diabetes cases, 10,087 subcohort participants), we investigated interactions of dietary and plasma phospholipid fatty acids and nut consumption with FADS1 rs174547 in relation to incident type 2 diabetes using weighted Cox regression. In PREDIMED (492 participants in the Mediterranean Diet + Nuts intervention group, 436 participants in the control group), we compared changes in plasma phospholipid FAs from baseline to year 1. In EPIC-InterAct and PREDIMED, nut consumption was positively associated with LA plasma levels and inversely with arachidonic acid, the latter becoming stronger with increasing number of the minor rs174547 C allele (p interaction EPIC-InterAct: 0.030, PREDIMED: 0.003). Although the inverse association of nut consumption with diabetes seemed stronger in participants with rs174547 CC-genotype (HR: 0.73, 95

Background:In Chinese adults, there is a considerable burden of sedentary behaviour. This study aimed to estimate the implications of reallocating sedentary leisure-time to non-sedentary behaviours for incident cardiometabolic diseases. Methods:A prospective cohort study of 462,370 Chinese adults (mean age 51 years; 59% female) who were free from diabetes and cardiovascular diseases at baseline. Isotemporal substitution Cox regression models were used to estimate the associations of reallocating self-reported sedentary leisure-time to the same amount of sleep, housework, Taichi, or conventional exercise (e.g., walking, jogging, ball games, swimming) with the risk of incident diabetes, stroke, and myocardial infarction (MI). The results are reported as adjusted hazard ratios and 95% confidence intervals per 30 min/day time exchanges. Potential impact fractions were calculated to estimate the proportional reductions in incident disease cases associated with time substitutions, assuming causality. Findings:During >5.25 million person-years of follow-up, 19,738 incident diabetes, 51,460 stroke, and 6767 MI cases were accrued. Lower disease risks were found for replacement of sedentary leisure-time by sleep (diabetes: 0.97 [0.95-0.99], stroke: 0.98 [0.97-0.99], MI: 0.97 [0.94-0.99]; in participants who slept <7 h/day), housework (diabetes: 0.97 [0.97-0.98], stroke: 0.99 [0.98-0.99], MI: 0.97 [0.95-0.98]), Taichi (diabetes: 0.97 [0.95-0.99], stroke: 0.98 [0.97-0.99], MI: 0.95 [0.92-0.98]), or conventional exercise (diabetes: 0.97 [0.95-0.99], stroke: 0.97 [0.95-0.98], MI: 0.92 [0.88-0.96]). Potential impact fractions ranged from an estimated 3.5% (95% confidence interval: 3.1-3.9%) fewer cases of incident stroke when replacing sedentary leisure-time with housework, to an estimated 9.6% (5.9-13.3%) fewer cases of incident MI when reallocating sedentary leisure-time to conventional exercise. Interpretation:Replacing sedentary leisure-time with behaviours such as housework, Taichi, sleep (in short sleepers) and conventional exercise is associated with lower risks of common cardiometabolic diseases in Chinese adults. Prevention strategies should be developed to promote movement behaviours and optimal levels of sleep at the expense of sedentary leisure-time. Funding:This analysis was supported by a Health and Medical Research Fund (HMRF) Research Fellowship (grant no: 06200087).

Objectives Physical activity is important for health, but the influence of structured, supervised aerobic exercise sessions on habitual physical activity in healthy older adults is unclear.Methods We evaluated habitual physical activity in the Hertfordshire Physical Activity Trial, where healthy older adults were randomised to 36 supervised 1-hour gymnasium sessions on a cycle ergometer at moderate intensity over 12 weeks or to a control group with no intervention. We estimated physical activity energy expenditure (PAEE) and time spent in sedentary behaviour and light and moderate or vigorous physical activity over 7 days at three time points (before, during and immediately after the intervention) with individually calibrated combined heart rate and movement sensing.Results Of 100 randomised participants (44% female, aged 67–76 years), 96% completed follow-up. Midway through the intervention, neither overall PAEE nor time spent at different intensities were different between groups. However, on the 3 days of the week that the structured exercise sessions occurred (Monday, Wednesday, Friday), the exercise group had a 9.1 kJ kg-1 day-1 ((2.5, 15.7), p=0.007) increase in PAEE, a reduction in sedentary time and increased time spent at light and moderate or vigorous physical activity, compared with the control group.Conclusions Three 1-hour bouts per week of structured aerobic exercise increased daily physical activity on the days they occurred, but not overall physical activity across the whole week. Population-wide strategies such as better cycling and walking infrastructure may increase physical activity in healthy older adults more effectively than treatment with structured exercise programmes.Trial registration number ISRCTN60986572.

Prediction of coronary heart disease (CHD) risk through standard equations relying on laboratory-based clinical markers has proven challenging and needs advancement. This study aims to derive and cross-validate novel CHD-risk prediction models based on lifestyle behaviours including wearables and polygenic risk scores (PRS), with comparison to the established Pooled Cohort Equations (PCE) and Systematic COronary Risk Evaluation 2 (SCORE2). This study included 291,151 white British individuals of UK Biobank. Cox regression was applied to derive Lifestyle-Based Model (LBM) for CHD-risk prediction incorporating age, sex, body mass index, dietary intake score (0-3; derived from self-reported food types), smoking status, and physical activity (wearable-device-derived Euclidean Norm Minus One). Weighted PRS for CHD was calculated based on 300 genetic variants. Over a median 13.8-year follow-up, 13,063 CHD incidence cases were ascertained. The C-index (indicative of discrimination) of the LBM, PCE and SCORE2 was 0.713 (95% Confidence Interval [CI]: 0.703-0.722), 0.714 (95% CI: 0.705-0.724) and 0.709 (95% CI: 0.700-0.719). Adding PRS to LBM, PCE and SCORE2 increased the C-index to 0.733 (95% CI: 0.724-0.742), 0.726 (95% CI: 0.716-0.735) and 0.721 (95% CI: 0.711-0.730). The LBM with and without PRS both demonstrated good calibration, demonstrating by p-values of 0.997 and 0.999. The addition of PRS to LBM marginally improved calibration, with the slope increasing from 0.981 to 0.983. Integrating PRS rendered a positive categorical net reclassification improvement (cut-off point: 7.5%) of 4.30% for LBM. The non-laboratory-based LBM, integrating wearable-based and anthropometric data, demonstrated moderate cardiovascular risk prediction accuracy, though external validations remain to be explored.

Background The WHO recommends taxes on sugar sweetened beverages (SSBs) to improve population health. We examined changes in volume of and amount of sugar in purchases of soft drinks according to household income and composition, 19 months following the implementation of the UK soft drinks industry levy.Methods Data were from the Kantar Fast Moving Consumer Goods panel, a market research panel which collects data on weekly household purchases (mean weekly number of households=21 908), March 2014–November 2019. Interrupted time series analysis of volume and sugar purchases was used to estimate absolute and relative differences in the volume and amount of sugar in soft drinks, confectionery and alcohol purchased weekly by household income (<£20 000, £20–50 000 or >£50 000) and composition (presence of children (<16 years) in the household (yes or no)), 19 months after soft drinks industry levy (SDIL) implementation, compared with the counterfactual scenario based on pre-announcement trends and using a control group (toiletries).Results By November 2019, purchased weekly sugar in soft drinks fell by 7.46 g (95% CI: 12.05, 2.87) per household but volumes of drinks purchased remained unchanged, compared with the counterfactual. In low-income households, weekly sugar purchased in soft drinks decreased by 14.0% (95% CI: 12.1, 15.9) compared with the counterfactual but in high-income households increased by 3.4% (1.07, 5.75). Among households with children, sugar purchased decreased by 13.7% (12.1, 15.3) but increased in households without children by 5.0% (3.0, 7.0). Low-income households and those with children also reduced their weekly volume of soft drinks purchased by 5.7% (3.7, 7.7) and 8.5% (6.8, 10.2) respectively. There was no evidence of substitution to confectionary or alcohol.Conclusion In the second year following implementation of the SDIL, effects on sugar purchased were greatest in those with the highest pre-SDIL purchasing levels (low-income households and those with children). The SDIL may contribute to reducing dietary inequalities.Trial registration number ISRCTN18042742. Registered: August 2017.

Introduction:Eating from out-of-home food outlets (OHFO) is common and linked to poor dietary quality, weight gain and obesity. In response, England implemented mandatory calorie labelling regulations in April 2022. The aim of this evaluation study was to examine pre-post changes in the energy content of menu items from large OHFO in England after the labelling policy. Methods:Energy content of menu items from large OHFO in England was obtained using MenuTracker, a longitudinal database of online menus. Data were collected in two waves: September 2021 (prepolicy) and September 2022 (postpolicy). Linear mixed regression models were used to estimate pre-post changes in mean energy content (kcal) for all items by food group and by chain type. We also examined reformulation by estimating energy content for removed, continuous and new items. Results:Overall, a small reduction of 9 (-2.0%) (95% CI: -16 to -1) kcal in mean energy content per item was observed postpolicy. Significant mean reductions per item were found in beverages (-36 (-16.4%); 95% CI: -52 to -21 kcal), burgers (-103 (-11.1%); 95% CI: -150 to -56 kcal) and mains (-30 (-4.2%); 95% CI: -48 to -12 kcal). By chain type, significant mean reductions per item were seen in pubs, bars and inns (-52 (-8.8%); 95% CI: -68 to -36 kcal), restaurants (-23 (-4.9%); 95% CI: -42 to -5 kcal) and sports and entertainment venues (-49 (-13.4%); 95% CI: -79 to -19 kcal). Changes were driven by the removal of higher kcal items (458 kcal, 95% CI: 394 to 523) and addition of lower kcal new items (434 kcal, 95% CI: 370 to 499). There was no significant change in energy content for continuously available items, indicating limited evidence of reformulation. Conclusions:The 2022 mandatory calorie labelling policy in England led to a small reduction in the mean energy content of menu items, primarily driven by the removal of higher calorie items and the addition of lower calorie items. Further research is needed to assess long-term effects and strategies to enhance policy impact.

AIMS:To assess longitudinal trends in total and cause-specific mortality rates and in hospitalisation rates for diabetes complications among people with type 2 diabetes in England between 2009 and 2019; and to assess how trends differ by patient characteristics. MATERIALS AND METHODS:A sequential cohort study of people with type 2 diabetes aged ≥20 years was performed using data from the National Diabetes Audit. Discretised Poisson regression models, adjusted for age, sex, ethnicity, socio-economic deprivation and diabetes duration, were used to calculate total and cause-specific mortality rates, as well as hospitalisation rates for myocardial infarction, stroke, heart failure, kidney and liver disease. RESULTS:Total mortality declined in people aged 20-74 years (rate ratio [RR] 0.96, 95% CI 0.95-0.97) and aged ≥75 years (0.93, 0.92-0.94) between 2009-2011 and 2018-2019, predominantly due to reductions in cardiovascular deaths. Over the same time period, in those aged 20-74 years, total mortality declined in people of South Asian (0.92:0.0.87-0.96) but was unchanged in people of White (1.00: 0.99-1.01) ethnicities. Total mortality declined more in people living in the least (0.91:0.88-0.94) compared to the most (0.97:0.95-1.00) deprived areas. A composite endpoint of cardiovascular hospitalisations and mortality increased between 2009-2011 and 2018-2019 in those aged 20-49 years (1.20:1.14-1.27) and 50-74 years (1.04:1.03-1.05) but declined in those aged ≥75 years (0.85:0.84-0.86). Rates of hospitalisation for kidney and liver disease increased in all age groups. CONCLUSIONS:By examining longitudinal trends in mortality and hospitalisations according to different characteristics in people with type 2 diabetes in England, we have identified important targets for improvement through changes in health policy and care delivery.

OBJECTIVE: Continuous glucose monitoring (CGM) is increasingly used in gestational diabetes mellitus (GDM) but optimal metrics, ranges and targets in this population are undefined. We assessed associations between CGM metrics and pregnancy outcomes in gestational diabetes. RESEARCH DESIGN AND METHODS: During the DiGest study, 425 women with GDM (diagnosed at median (IQR) 25.1 (18.3- 27.7) weeks) and BMI ≥25kg/m2 received a dietary intervention, with masked Dexcom G6 CGM at 29 (n=361), 32 (n=215) and 36 weeks (n=227) gestation. For this secondary analysis, we used logistic regression, receiver-operator-curves and Youden index to assess associations and predictive ability of CGM metrics including pregnancy-specific time-in-range (TIRp; 63-140mg/dL; 3.5-7.8mmol/L) and pregnancy outcomes. RESULTS: CGM metrics at 29 weeks were significantly associated with LGA and SGA. Participants achieving mean glucose <110mg/dL (6.1mmol/L), TIRp ≥90% or pregnancy-specific time-above-range (TARp) <10% at 29 weeks had a significantly lower risk of LGA (OR 0.41 (95%CI 0.22-0.77); OR 0.38 (0.20-0.70); OR 0.39 (0.20-0.73) and SGA (OR 0.26 (0.08-0.79); OR 0.30 (0.10-0.91); OR 0.19 (0.06-0.62)). TARp<10% and mean nocturnal glucose <110mg/dL were associated with reduced odds of preterm birth (OR 0.40 (0.17-0.94); OR 0.42 (0.19-0.97)). A stricter range (63-120mg/dL; 3.5-6.7mmol/L) had similar performance overall, but had no single statistically-robust TIR/TAR target across all outcomes. CONCLUSIONS: In women with GDM, CGM mean glucose <110mg/dL (6.1mmol/L), ≥90% TIRp or <10% TARp using a range of 63-140mg/dL (3.5-7.8mmol/L) at 29 weeks of gestation was associated with a low risk of suboptimal offspring outcomes.

Reduced-energy diets promote weight loss and improve long-term outcomes in type 2 diabetes but are untested in gestational diabetes. We aimed to identify if weight loss in pregnancy improves perinatal outcomes in gestational diabetes. We performed a multicentre parallel, randomized, controlled, double-blind trial of energy restriction in women with singleton pregnancies, gestational diabetes and body mass index >= 25 kg m(-)(2). Participants were randomized to receive a standard-energy control diet (2,000 kcal d(-1)) or reduced-energy intervention diet (1,200 kcal d(-1)) from enrollment (29 weeks) until delivery, provided as weekly diet boxes (40% carbohydrate, 35% fat, 25% protein). The randomization was performed in a 1:1 ratio, stratified by center and blinded to the participants and study team. Primary outcomes were maternal weight change from enrollment to 36 weeks and offspring birth weight. In total, 425 participants were randomized to the control (n = 211) or intervention (n = 214). Outcome data were available for 388 of 425 (90.1%) participants at 36 weeks and 382 of 425 (89.8%) at delivery. There was no evidence of a difference in maternal weight change to 36 weeks between groups (intervention effect -0.20 (95% confidence interval -1.01, 0.61); P > 0.1) and offspring standardized birth weight (intervention effect 0.005 (-0.19, 0.20); P > 0.1). A reduced-energy diet was safe in pregnancy. ISRCTN registration no. 65152174.

Objectives Interventions for obesity that require individual behaviour change, such as behavioural weight management interventions, may contribute to health inequalities. We explored if there was evidence of inequalities in the attendance at and effectiveness of behavioural weight management interventions in adults.Design Two-stage individual participant data meta-analysis.Data sources Eligible studies were extracted from a previous systematic review and an updated search was completed on PubMed.Eligibility criteria UK-based randomised controlled trials of behavioural weight management interventions suitable for use in primary care, published until 31 December 2021.Data extraction and synthesis Multivariable regression analyses were conducted with weight at 12-month follow-up as the primary outcome and included an interaction between inequality characteristic and trial arm (control or intervention). Each model was adjusted for baseline weight, age and gender. Estimated interactions were combined across trials using a random-effects meta-analysis. Intervention attendance was defined as number of in-person sessions attended. Risk of bias was assessed using Cochrane’s RoB 2 tool.Results Data from 13/16 eligible weight loss trials were analysed (complete case data n=5531 participants). The effect of the intervention on weight at 12 months was greater in male participants (−2.58 kg (95% CI −3.52 to 1.64)) than female participants (−1.71 kg (95% CI −2.79 to –0.63); p value for interaction=0.02, tau2=0) and greater for participants of white ethnicity (−2.74 kg (95% CI −4.30 to –1.19)), than those from an ethnic minority background (0.03 kg (95% CI −1.29 to 1.35); p interaction=0.04, tau2=0). Age, education, occupation, place of residence and household income did not significantly moderate effectiveness. We did not find evidence of inequalities in intervention attendance by ethnicity, occupation, gender/sex, area-level socioeconomic deprivation or age.Conclusions Behavioural weight management interventions had smaller effects in people from ethnic minority backgrounds and larger effects in men. There was no evidence of other differences in intervention effectiveness or adherence. This is the first synthesis study to access individual participant data and quantitatively assess inequalities in these interventions. Future research should further explore reasons for differences in outcomes and consider how to prevent behavioural weight management interventions from potentially exacerbating health inequalities.

ABSTRACT 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 Type 2 diabetes (T2D) is a major risk factor for atherosclerotic cardiovascular disease (ASCVD). This study examined the interplay between watching television and T2D genetic risk for risk of ASCVD. Methods We included 346 916 White British individuals from UK Biobank. A weighted polygenic risk score for T2D was calculated on the basis of 138 genetic variants associated with T2D. Time spent watching television was self‐reported and categorized into 2 groups: ≤1 h/d and ≥2 h/d. Over a median 13.8‐year follow‐up, 21 265 incident ASCVD events were identified. Models using Cox regression with age as the underlying time scale adjusted for potential confounders (demographic, anthropometric, lifestyle factors, and medication use) were fit. Results Compared with watching television for ≤1 h/d, watching ≥2 h/d was associated with 12% (95% CI, 1.07–1.16) higher hazards of ASCVD, independently of T2D genetic risk. Joint analyses (with low T2D genetic risk and ≤1 h/d of television viewing as reference) indicated that medium and high T2D genetic risk was not associated with higher hazards of ASCVD as long as television viewing was ≤1 h/d. The P values for multiplicative and additive interactions between T2D genetic risk and television viewing were 0.050 and 0.038, respectively. The 10‐year absolute risk of ASCVD was lower for high T2D genetic risk combined with ≤1 h/d of television viewing (2.13%) than for low T2D genetic risk combined with ≥2 h/d of television viewing (2.46%). Conclusions Future clinical trials of lifestyle‐modification interventions targeting specific types of screen‐based sedentary activities could be implemented to individuals at high genetic risk of T2D for primary prevention of ASCVD.

BACKGROUND:Diet and physical activity are important determinants of energy balance, body weight and chronic health conditions. Peoples' health and behaviour are shaped by their environment. For example, the availability of unhealthy takeaway food in residential neighbourhoods and the ability to easily walk to a range of local destinations (high "walkability") influence diets and physical activity levels. Most existing evidence on the associations between residential neighbourhood and adiposity is cross-sectional and examines either walkability or takeaway availability, but not both in combination.We examined the cross-sectional and longitudinal associations of residential neighbourhood walkability and takeaway food availability with markers of adiposity separately and combined. METHODS:With data from the Fenland Study (Cambridgeshire, UK; n = 12,435), we used linear regression to estimate associations for walkability and takeaway availability separately and in mutually adjusted models, in addition to combining both into a measure of neighbourhood supportiveness for active living and healthy eating. Objective measures of BMI were examined cross-sectionally at baseline (2005-2015) and as change between baseline and follow-up (2014-2020). Additional outcomes (percentage body fat, waist circumference and hip circumference) were also examined both cross-sectionally and longitudinally. RESULTS:Complete case analyses indicated that neighbourhoods with greater walkability and lower takeaway availability were associated with lower BMI (n = 10,607) and more favourable trends over time (n = 5508). For example, compared with the lowest exposure group (Q1), Q4 of walkability and takeaway food availability was associated with a difference in BMI of -0.69 kg/m2 (95% CI = -1.09 to -0.29) and 0.99 kg/m2 (95% CI = 0.58 to 1.39) respectively. These associations were more consistent when both neighbourhood measures were included in mutually adjusted models. The combined supportiveness measure was associated with lower BMI. High walkability and low takeaway availability were also associated with lower body fat percentage, waist circumference and hip circumference. CONCLUSIONS:These findings are consistent with the residential environment having a role in shaping people's health and behaviour. Living in an area that supports walking and cycling and affords less access to unhealthy food may support people to maintain a healthy lifestyle. It was important to consider walkability and takeaway food availability together because to examine them separately risks unobserved confounding by the other. Future research could incorporate additional environmental measures, especially those likely to be correlated.

BACKGROUND:Dietary diversity may affect type 2 diabetes (T2D) but no studies have examined protein diversity by source. We examined five diversity scores and the 10-year risk of T2D and effect modification. METHODS:A prospective study of 10 363 incident T2D cases and a representative sub-cohort of 13 937 individuals sampled from a cohort of 340 234 participants in eight European countries (1993-2007). Five diversity scores were derived from self-reported diet data (gr/day): diversity of food groups (range: 0-5); and diversity within subtype of vegetables (0-4); meat/alternatives (0-6); animal-protein (0-8); and plant-protein sources (0-5). Country-specific hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained by using Prentice-weighted Cox regression and combined by using mixed-effects models. Models were stratified by sex (male/female) and obesity status (body mass index ≥ 30 kg/m2; waist circumference ≥ 88 cm for females and ≥102 cm for males). RESULTS:Daily intake of five food groups (versus up to three) was linked to lower T2D incidence overall [HR 0.86 (95% CI 0.75, 0.98)], in females [0.86 (0.77, 0.96)], and in people without central obesity [0.79 (0.70, 0.89)]. Three or more subtypes of plant protein were inversely associated with T2D overall [0.78 (0.65, 0.98)], in females [0.75 (0.62, 0.90)] and people without central obesity [0.82 (0.68, 1.00)]. Additionally, consuming three subtypes of vegetables was inversely associated with T2D overall [0.90 (0.83, 0.98)] and in males [0.85 (0.73, 0.99)]. CONCLUSION:Diabetes prevention may benefit not only from a diet consisting of five different food groups, but also from a diet that is diverse in plant-protein sources, with specific benefits for female Europeans and those without central obesity.