Long-term weight loss following a randomised controlled trial of a weight management programme for men delivered through professional football clubs: the Football Fans in Training follow-up study

A Systematic Review of the Evidence for Non-surgical Weight Management for Adults with Severe Obesity: What is Cost Effective and What are the Implications for the Design of Health Services?

PURPOSE OF REVIEW

Severe obesity (BMI ≥ 35 kg/m²) increases premature mortality and reduces quality-of-life. Obesity-related disease (ORD) places substantial burden on health systems. This review summarises the cost-effectiveness evidence for non-surgical weight management programmes (WMPs) for adults with severe obesity.

RECENT FINDINGS

Whilst evidence shows bariatric surgery is often cost-effective, there is no clear consensus on the cost-effectiveness of non-surgical WMPs. Thirty-two studies were included. Most were short-term evaluations that did not capture the long-term costs and consequences of ORD. Decision models often included only a subset of relevant ORDs, and made varying assumptions about the rate of weight regain over time. A lack of sensitivity analyses limited interpretation of results. Heterogeneity in the definition of WMPs and usual care prevents formal evidence synthesis. We were unable to establish the most cost-effective WMPs. Addressing these limitations may help future studies provide more robust cost-effectiveness evidence for decision makers.

Football fans' emotional attachment to their clubs as a predictor of weight loss in a prevention programme for men with obesity

Data about which factors in lifestyle interventions facilitate weight loss (WL) success in men is still scarce. The Football Fans in Training (FFIT) programme in Germany attracts men with overweight and facilitates meaningful weight reduction. The goal of this study was to evaluate the possible impact of the fans' emotional attachment to their favourite football clubs on achieving at least 5% WL among the male-only participants. All 791 FFIT intervention participants of 2017 and 2018 were included in the study. We performed two separate logistic regression analyses: (a) baseline values of several participant characteristics as predictors of a 5% WL and (b) change scores of participants' health behaviour characteristics from the course start to end as predictors of the 5% WL. In addition, both models included the Emotional Attachment to a Sports Team (EAST). Analyses were based on the intention-to-treat principle. Higher EAST at baseline was associated with WL success, as was higher WL self-efficacy, lower score in vegetable intake and higher score in food high on carbohydrates. In the second analysis, EAST, an increase in fruit intake, vegetable intake, whole-grain intake and steps per day, as well as a reduction of fatty food intake, were associated with 5% WL success. The predictors are mostly explorative and limited to correlations. The results indicate that EAST was an independent predictor of WL success in the participating football fans. This understanding might be used for tailoring future interventions in sports or similar settings.

Process Evaluation of a Sport-Based Supportive Care Intervention for Testicular Cancer Survivors: A Mixed Methods Study

Testicular cancer survivors report unmet supportive care needs that are associated with poorer physical and mental health, yet engagement in traditional supportive care is low. The Ball’s in Your Court intervention was designed to engage testicular cancer survivors in supportive care by leveraging a community-based sport and exercise model. Age-appropriate, gender-sensitized, and disease specific elements were reflected in the intervention design, setting, content, and delivery. The intervention included five weekly health promotion sessions among a group of testicular cancer survivors. The purpose of this study was to explore the intervention’s (i) feasibility and acceptability, (ii) effects on testicular cancer survivors’ perceived health, and (iii) gain feedback for intervention refinement. A total of 10 testicular cancer survivors participated in the pilot and completed questionnaires on demographics, cancer history, perceived health, and physical activity behavior at baseline (pre-intervention) and perceived health and satisfaction with intervention components (post-intervention). Open-ended feedback surveys were collected after each weekly session and researcher field notes were recorded by three members of the study team. One month following the intervention, a focus group was conducted with intervention participants. All participants were satisfied with the intervention. Content analysis of the qualitative data supported intervention acceptability. Visual analysis conducted at the individual level indicated that perceived health either remained stable or improved from pre- to post-intervention. The Ball’s in Your Court intervention provides a feasible and acceptable approach for the delivery of supportive care aimed at improving testicular cancer survivors’ health and wellness. Recommendations for intervention refinement were provided and require future examination.

An Investigation into the Physical Activity Experiences of People Living with and beyond Cancer during the COVID-19 Pandemic

This study investigated the physical activity experiences of people living with and beyond cancer (PLWBC) during the COVID-19 pandemic. Participants attended the cancer and rehabilitation exercise (CARE) programme delivered by a football community trust. Staff (n = 2) and participants (n = 9) attended semi-structured interviews investigating the PA participation and experiences of attending/delivering different modes of CARE, including exercise classes delivered outdoors and delivered online. Interviews also investigated participant aspirations for returning to CARE sessions delivered in person indoors. The findings show that the COVID-19 pandemic and government restrictions impacted on PA participation, yet exercise sessions provided via CARE offered participants an important opportunity to arrest their inactivity, keep active and maintain their fitness and functionality. Barriers to participation of CARE online included access to IT infrastructure, internet connectivity and IT skills and comfort using IT. Regarding CARE outdoors, the weather, range of equipment, variety of exercises and the lack of toilets and seats were barriers. In the different CARE modes, the skills of delivery staff who were sensitive to the needs of participants, social support, and the need for participants to maintain good mental and social health were important facilitators for engagement and are considerations for programme delivery. CARE helped PLWBC to keep physically active.

From Spreadsheets to Script: Experiences From Converting a Scottish Cardiovascular Disease Policy Model into R

Given the advantages in transparency, reproducibility, adaptability and computational efficiency in R, there is a growing interest in converting existing spreadsheet-based models into an R script for model re-use and upskilling training among health economic modellers. The objective of this exercise was to convert the Scottish Cardiovascular Disease (CVD) Policy Model from Excel to R and discuss the lessons learnt throughout this process. The CVD model is a competing risk state transition cohort model. Four health economists, with varied experience of R, attempted to replicate an identical model structure in R based on the model in Excel and reproduce the intermediate and final results. Replications varied in their use of specialist health economics packages in addition to standard data management packages. Two versions of the CVD model were created in R along with a Shiny app. Version 1 was developed without health economics specialist packages and produced identical results to the Excel version. Version 2 used the heemod package and did not achieve the same results, possibly due to the non-standard elements of the model and limited time to adapt the functions. The R model requires less than half the computational time than the Excel model. Conversion of the spreadsheet models to script models is feasible for health economists. A step-by-step guide for the conversion process is provided and modellers' experience is discussed. Coding without specialist packages allows full flexibility, while specialist packages may add convenience if the model structure is suitable. Whichever approach is taken, transparency and replicability remain the key criteria in model programming. Model conversions must maintain standards in these areas regardless of the choice of software.

Factors Influencing Men's Experiences and Engagement with the Rugby Fans in Training-New Zealand Pilot Trial: A Healthy Lifestyle Intervention for Men

Health promotion programs designed specifically to support men to improve their lifestyle behaviours are required to improve men's health. This study explored factors that influenced men's experiences of, and engagement with, the Rugby Fans in Training-New Zealand pilot trial, a professional sport-based healthy lifestyle intervention for overweight men. Thirty-five men (mean age = 45, SD = 10 years) who completed the 12-week intervention participated in one of eight semi-structured focus groups. Using inductive thematic analysis, five themes represented the meanings in the data. First, a group of like-minded men all in the same boat recognised the importance of being in similar life situations and having similar reasons for joining the programme. Second, the men described the importance of the support and motivation provided by the team atmosphere created through the programme. Third, the motivational coach recognised the characteristics, skills and knowledge of the coach delivering the programme which created engagement with it. Fourth, the education sessions were valued for the knowledge gained and underpinning philosophies that guided them. Finally, the involvement of the rugby franchise influenced commitment to the programme and created initial interest. These results provide evidence for the key components that should be incorporated into the future development of and improvement to healthy lifestyle interventions for men.

Are sex disparities in COVID-19 a predictable outcome of failing men's health provision?

The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, has taken a catastrophic toll on society, health-care systems and the economy. Notably, COVID-19 has been shown to be associated with a higher mortality rate in men than in women. This disparity is likely to be a consequence of a failure to invest in men’s health, as it has also been established that men have a lower life expectancy and poorer outcomes from non-communicable diseases than women. A variety of biological, social and economic factors have contributed to the sex disparities in mortality from COVID-19. A streamlined men’s health programme — with the urologist as the gatekeeper of men’s health — is needed to help prevent future tragedies of this nature.

COVID-19 has been shown to be associated with a higher mortality rate in men than in women. In this Perspectives article, the authors posit that this disparity is due to a failure to invest in men’s health and discuss the biological, social and economic factors that have contributed to the sex disparities in mortality from COVID-19, as well as considering how a streamlined men’s health programme with the urologist in a central role could address these issues.

Investigating the delivery of health improvement interventions through professional football club community trusts-strengths and challenges

Objectives

This study audits health improvement provision delivered in/by English professional Football Club Community Trusts and reports the strengths and challenges around the implementation of interventions.

Study design

Multi-methods design: Data were collected through (i) a review of trust websites (n ​= ​72), (ii) an online survey (n ​= ​34/47.2%) and (iii) semi-structured interviews (n ​= ​11/32.3%) with a sub-sample of trust managers.

Results

The review of websites confirms all trusts provided physical activity-led interventions. The online survey showed most managers were male (n ​= ​23/67.7%) and white British (n ​= ​30/88.2%). Two thirds held management roles, (n ​= ​23/67.6%) and represented Championship (n ​= ​12/35.2%), League 1 (n ​= ​13/38.2%) and League 2 clubs (n ​= ​9/26.5%). Trusts provided physical activity and most provided diet (n ​= ​31/91.2%) as well as smoking (n ​= ​20/58.8%) and alcohol (n ​= ​19/55.9%) interventions. Weight management, (n ​= ​25/73.5%), mental health interventions (n ​= ​28/82.4%) were offered. Trusts provided male-specific (n ​= ​20/58.8%), with fewer providing female-specific interventions (n ​= ​15/44.1%). Most trusts (n ​= ​30/88.2%) evaluated interventions. 80.8% (n ​= ​21/26) used public health guidance for programme design, 69.2% (n ​= ​18/26) delivery, 57.7% (n ​= ​15/26) needs assessment and 50% (n ​= ​13/26) evaluation. Interviews and qualitative reports identified strengths including, using football, the ‘club brand’, ‘meeting health needs’ and ‘working as a strategic collaboration with partners’. Challenges included ‘short-term funding staffing, mainstreaming, and evaluating interventions’.

Conclusion

Football Community Trusts deliver interventions, but challenges were encountered when implementing these programmes.

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Football club community trusts provide important physical activity and health interventions.

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Trusts encounter several challenges when implementing health interventions.

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Challenges include sustaining interventions, funding and adopting public health guidance.

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Trusts do not always view public health guidance as useful.

Does Self-Determination Theory help explain the impact of social prescribing? A qualitative analysis of patients' experiences of the Glasgow 'Deep-End' Community Links Worker Intervention

OBJECTIVES

The Links Worker Programme is a primary care-based social prescribing initiative in Glasgow, Scotland, targeting patients with complex needs in areas of high socioeconomic deprivation. The programme aims to improve wellbeing by connecting patients to appropriate community resources. This study explored the utility of Self-Determination Theory in understanding the reported impacts of the intervention.

METHODS

Thematic analysis of semi-structured interviews with 12 patients (34-64 years, six female) referred to Community Links Practitioners using Self-Determination Theory as a framework. Impact was assessed from participants' description of their personal circumstances before and after interaction with the Community Links Practitioner.

RESULTS

Four patients described no overall change in daily life, two described slight improvement and six described moderate or major improvement. Improvers described satisfaction of the three psychological needs identified in Self-Determination Theory: relatedness, competence and autonomy. This often related to greater participation in community activities and sense of competence in social interaction. Patients who benefitted most described a change towards more intrinsic regulation of behaviour following the intervention.

CONCLUSIONS

Understanding the impact of this social prescribing initiative was facilitated by analysis using Self-Determination Theory. Self-Determination Theory may therefore be a useful theoretical framework for the development and evaluation of new interventions in this setting.

Long-Term Weight Loss Strategies for Obesity

CONTEXT

Obesity is a chronic disease that is difficult to manage without holistic therapy. The therapeutic armamentarium for obesity primarily consists of 4 forms of therapy: lifestyle modification (ie, diet and exercise), cognitive behavioral therapy, pharmacotherapy, and bariatric surgery.

EVIDENCE ACQUISITION

Evidence was consolidated from randomized controlled trials, observational studies, and meta-analyses.

EVIDENCE SYNTHESIS

After 2 years, lifestyle interventions can facilitate weight loss that equates to ~5%. Even though lifestyle interventions are plagued by weight regain, they can have substantial effects on type 2 diabetes and cardiovascular disease risk. Although 10-year percentage excess weight loss can surpass 50% after bariatric surgery, weight regain is likely. To mitigate weight regain, instituting a multifactorial maintenance program is imperative. Such a program can integrate diet, exercise, and pharmacotherapy. Moreover, behavioral therapy can complement a maintenance program well.

CONCLUSIONS

Obesity is best managed by a multidisciplinary clinical team that integrates diet, exercise, and pharmacotherapy. Bariatric surgery is needed to manage type 2 diabetes and obesity in select patients.

A Mixed-Methods Evaluation of CARE (Cancer and Rehabilitation Exercise): A Physical Activity and Health Intervention, Delivered in a Community Football Trust

With increasing cancer survivorship has come an increased necessity to support people living with cancer (PLWC) to have a good quality of life including being physically active. Using mixed methods, the current study aimed to use the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation and Maintenance) to determine how the football community trust delivered CARE (Cancer and Rehabilitation Exercise) intervention was able to increase participants’ physical activity in order to improve their quality of life and regain physiological and psychological function. Quantitative outcome data were collected at baseline, 3 and 6 months using the Cancer Physical Activity Standard Evaluation Framework questionnaire. Semi-structured focus groups (n = 5) captured participants’ (n = 40) lived experience of the reach, effectiveness, adoption, implementation, and maintenance of CARE. Questionnaire data were analysed using repeated measures ANOVAs and qualitative data were thematically analysed. Following diagnosis, CARE was successful in providing participants with a unique and accessible opportunity to become or restart physically activity, by providing a local, socially supportive, and inclusive environment. This resulted in significant increases in physical activity (F_{(1.58, 23)} = 5.98, p = 0.009), quality of life (QoL) (F_(2,36) = 13.12, p = 0.000) and significant reductions in fatigue (F_(1.57,31) = 11.19, p = 0.000) over 6 months. Participants also reported becoming more active, recovering physical function, regaining independence, and enhanced psychological well-being as a result of attending CARE. Key design features of CARE were also identified across RE-AIM. CARE, a football community trust delivered physical activity intervention was successful in significantly improving participants’ QoL and in regaining the physical and psychological functioning of people living with cancer. Results suggest that maintaining engagement in CARE for 6 months and beyond can support people to maintain these changes. Engaging in robust evaluations such as this can help organizations to successfully secure future funding for their programs.

A gender-sensitised weight-loss and healthy living program for men with overweight and obesity in Australian Football League settings (Aussie-FIT): A pilot randomised controlled trial

BACKGROUND

Recent evidence shows that sport settings can act as a powerful draw to engage men in weight loss. The primary objective of this pilot study was to test the feasibility of delivering and to evaluate preliminary efficacy of Aussie-FIT, a weight-loss program for men with overweight/obesity delivered in Australian Football League (AFL) settings, in preparation for a future definitive trial.

METHODS AND FINDINGS

This 6-month pilot trial took place in Perth, Australia. Participants were overweight/obese (Body Mass Index [BMI] ≥ 28 kg/m2), middle-aged (35-65 years old) men. Participants were recruited in May 2018, and the intervention took place between June and December 2018. The intervention involved 12 weekly 90-min face-to-face sessions, incorporating physical activity, nutrition, and behaviour change information and practical activities delivered by coaches at 2 clubs. Data were collected at baseline and immediately postintervention. For trial feasibility purposes, 6-month follow-ups were completed. Outcomes were differences in weight loss (primary outcome) and recruitment and retention rates, self-reported measures (for example, psychological well-being), device-measured physical activity, waist size, and blood pressure at 3 months. Within 3 days of advertising at each club, 426 men registered interest; 306 (72%) were eligible. Men were selected on a first-come first-served basis (n = 130; M age = 45.8, SD = 8; M BMI = 34.48 kg/m2, SD = 4.87) and randomised by a blinded researcher. Trial retention was 86% and 63% at 3- and 6-month follow-ups (respectively). No adverse events were reported. At 3 months, mean difference in weight between groups, adjusted for baseline weight and group, was 3.3 kg (95% CI 1.9, 4.8) in favour of the intervention group (p < 0.001). The intervention group's moderate-to-vigorous physical activity (MVPA) was higher than the control group by 8.54 min/day (95% CI 1.37, 15.71, p = 0.02). MVPA among men attracted to Aussie-FIT was high at baseline (intervention arm 35.61 min/day, control arm 38.38 min/day), which may have limited the scope for improvement.

CONCLUSIONS

Aussie-FIT was feasible to deliver; participants increased physical activity, decreased weight, and reported improvements in other outcomes. Issues with retention were a limitation of this trial. In a future, fully powered randomised controlled trial (RCT), retention could be improved by conducting assessments outside of holiday seasons.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12617000515392.

Men's health clinics: a real need or a marketing strategy

Globally, the life expectancy for men is 5.1 years less than for women. This gender gap in mortality is intrinsically linked to a higher proportion of premature male mortality and is a significant economic, social and healthcare issue. We explore the main causes for premature male death and also discuss the need for a dedicated men's health clinic, especially in the context of potential commercial exploitation.

One small step for man, one giant leap for men's health: a meta-analysis of behaviour change interventions to increase men's physical activity

OBJECTIVE

To determine the effects of behaviour change interventions on men's physical activity (postintervention), sustained change in physical activity behaviour (≥12 months postintervention) and to identify variations in effects due to potential moderating variables (eg, theoretical underpinning, gender-tailored, contact frequency).

DESIGN

Systematic review with meta-analysis. Pooled effect size (Cohen's d) was calculated assuming a random-effects model. Homogeneity and subsequent exploratory moderator analyses were assessed using Q, T² and I².

DATA SOURCES

Medline, EMBASE, CINAHL, SportDiscus and Web of Science to April 2019.

ELIGIBILITY CRITERIA FOR SELECTED STUDIES

Randomised control trials of behaviour change interventions in men (≥18 years) where physical activity was an outcome and data were from men-only studies or disaggregated by sex.

RESULTS

Twenty-six articles described 24 eligible studies. The overall mean intervention effect on men's physical activity was 0.35 (SE=0.05; 95% CI 0.26 to 0.45; p<0.001). This effect size is consistent with an increase of approximately 97 min of total physical activity per week or 980 steps per day. Intervention moderators associated with greater increases in physical activity included objective physical activity outcome measures, a gender-tailored design, use of a theoretical framework, shorter length programmes (≤12 weeks), using four or more types of behaviour change techniques and frequent contact with participants (≥1 contact per week). 12 studies included additional follow-up assessments (≥12 months postintervention) and the overall mean effect was 0.32 (SE=0.09; 95% CI 0.15 to 0.48; p<0.001) for that sustained increase in physical activity.

SUMMARY

Behaviour change interventions targeting men's physical activity can be effective. Moderator analyses are preliminary and suggest research directions.

Scale-Up and Scale-Out of a Gender-Sensitized Weight Management and Healthy Living Program Delivered to Overweight Men via Professional Sports Clubs: The Wider Implementation of Football Fans in Training (FFIT)

Increasing prevalence of obesity poses challenges for public health. Men have been under-served by weight management programs, highlighting a need for gender-sensitized programs that can be embedded into routine practice or adapted for new settings/populations, to accelerate the process of implementing programs that are successful and cost-effective under research conditions. To address gaps in examples of how to bridge the research to practice gap, we describe the scale-up and scale-out of Football Fans in Training (FFIT), a weight management and healthy living program in relation to two implementation frameworks. The paper presents: the development, evaluation and scale-up of FFIT, mapped onto the PRACTIS guide; outcomes in scale-up deliveries; and the scale-out of FFIT through programs delivered in other contexts (other countries, professional sports, target groups, public health focus). FFIT has been scaled-up through a single-license franchise model in over 40 UK professional football clubs to 2019 (and 30 more from 2020) and scaled-out into football and other sporting contexts in Australia, Canada, New Zealand, England and other European countries. The successful scale-up and scale-out of FFIT demonstrates that, with attention to cultural constructions of masculinity, public health interventions can appeal to men and support them in sustainable lifestyle change.

Short term effects of a weight loss and healthy lifestyle programme for overweight and obese men delivered by German football clubs

Numbers of obese and overweight people continue to grow in Germany as they do worldwide. Men are affected more often but do less about it and few weight loss services attract men in particular. To evaluate the effectiveness of a men-only weight loss programme, Football Fans in Training (FFIT), delivered by football clubs in the German Bundesliga, we did a non-randomized trial with a waiting list control group. Participants' data were collected between January 2017 and July 2018. FFIT is a 12-week, group-based, weight loss programme and was delivered in stadia and facilities of 15 professional German Bundesliga clubs. Inclusion criteria were age 35-65 years, BMI ≥ 28 and waist circumference ≥100 cm. Clubs recruited participants through Social Media, E-Mail and match day advertisement. 477 German male football fans were allocated to the intervention group by order of registration date at their respective clubs. 84 participants on the waiting list were allocated to the control group. Primary outcome was mean difference in weight loss with treatment condition over time as independent variable. We performed a multilevel mixed-effects linear regression analysis. Results were based on Intention-to-treat (ITT) analysis with Multiple Imputation. After 12 weeks, the mean weight loss of the intervention group adjusted for club, course and participants' age was 6.24 kg (95% CI 5.82-6.66) against 0.50 kg (-0.47-1.49) in the comparison group (p < 0.001). The results indicate that Football Fans in Training effectively helped German men to reduce their weight and waist circumference.

Acceptability of HIV testing for men attending televised football venues in Uganda

BACKGROUND

Worldwide, HIV remains a major public health challenge, especially in Sub-Saharan Africa. Literature indicates that men's involvement in HIV testing, care, and treatment services is lower compared to women, therefore novel approaches are required to engage men in the cascade of HIV care. This study aimed to explore men's perception on the provision of HIV testing services in venues where English Premier League football games are televised.

METHODS

An exploratory qualitative study was conducted between February and May 2018. Six focus group discussions were conducted with 50 conveniently selected men aged 18 years and older using a pre-tested discussion guide. All focus group discussions were audio recorded, transcribed verbatim, and analyzed thematically.

RESULTS

Overall, HIV testing at venues telecasting English Premier League football games was acceptable to men. There was a very strong preference for health workers providing testing and counseling services be external or unknown in the local community. Possible motivators for testing services provided in these settings include subsidizing or eliminating entrance fee to venues telecasting games, integrating testing and counseling with health promotion or screening for other diseases, use of local football games as mobilization tools and use of expert clients as role models.

CONCLUSIONS

This study suggests that HIV testing services at venues where EPL football games are televised is generally acceptable to men. In implementing such services, consideration should be given to preferences for external or unknown health workers and the motivating factors contributing to the use of these services. Given that HIV testing is currently not conducted in these settings, further research should be conducted to evaluate the feasibility of this approach as a means of enhancing HIV testing among Ugandan men.