CATHERINE HOMER,1 KARINA KINSELLA,2 TAMARA BROWN,2 JORDAN MARWOOD,2 KEVIN JAMES DREW,2 DUNCAN RADLEY,3 CHARLOTTE FREEMAN,2* ABIMBOLA OJO,4 JENNIFER TEKE,4 KEN CLARE,2 CHIRAG BAKHAI,5 LOUISA ELLS2
1 Sport and Physical Activity Research Centre, Sheffield Hallam University, Olympic Legacy Park, Sheffield
2 Obesity Institute, School of Health, Leeds Beckett University, City Campus, Leeds
3 Obesity Institute, School of Sport, Leeds Beckett University, Headingley Campus, Leeds
4 Re:Mission Patient and Public Involvement Group, Obesity Institute, School of Health, Leeds Beckett University, Leeds
5 Larkside Practice, Churchfield Medical Centre, Luton, Bedfordshire
* Current address of author CF is Calderdale Metropolitan Borough Council, Halifax, UK
Address for correspondence: Dr Catherine Homer
Sport and Physical Activity Research Centre, Sheffield Hallam University, Olympic Legacy Park, 2 Old Hall Road, Sheffield, S9 3TU
E-mail: c.homer@shu.ac.uk
https://orcid.org/0000-0003-2571-6008
Background: The food reintroduction phase of the NHS Low Calorie Diet (LCD) programme aims to support service users to reintroduce food gradually back into their diet. Understanding experiences of food reintroduction from a broad and diverse range of service users is critical in helping to improve service delivery and commissioning and equity in care.
Methods: This was a co-produced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=43) of the NHS LCD Programme were recruited from three delivery models across 21 pilot sites in England. Data were analysed using a thematic approach.
Results: The food introduction phase required control and planning that challenged the behaviours of participants. Around a third of participants continued use of Total Diet Replacement products, or considered doing so, for convenience and to maintain calorie control. The coach–service user relationship was important to understanding of session content and translation into behaviour change. Physical activity increased during this phase, which contributed to positive health outcomes.
Conclusions: The paper reports insights from the food reintroduction phase of the LCD programme. Key messages include the need for increased frequency of support and the need for tailored and culturally representative education.
Br J Diabetes 2024;24:ONLINE AHEAD OF PUBLICATION
https://doi.org/10.15277/bjd.2024.436
Key words: food reintroduction, type 2 diabetes, obesity, Low Calorie Diet, qualitative, longitudinal, Re:Mission study
This is the second of three linked papers that follow the journey of service users through the NHS Low Calorie Diet (LCD) Programme.1 This paper focuses on service users’ experiences reported at 18 weeks, which is the end of Food Reintroduction (FR), the second phase of the programme. Full programme details are reported in Homer et al.2
The FR phase of the LCD programme aims to support service users to gradually re-introduce food back into their diet using a stepped approach.1 During this phase, service users reduce the number of daily Total Diet Replacement (TDR) products from four to zero over the course of four to six weeks, whilst introducing healthy meals into their diet and attending fortnightly behaviour change support sessions. The NHS England LCD programme service specification3 states that by the end of FR, service users should no longer be using TDR products, and should be consuming a nutritionally balanced diet that is appropriate for their individual nutrition needs, preferences and traditions. In contrast to the TDR phase, in which additional physical activity is not actively encouraged, service users in the FR phase are supported through goal- setting and educational resources to be physically active to achieve their weight maintenance goals, as recommended by NICE guidance. Understanding service user experiences helps to understand what works (and what doesn’t), for whom and why. These insights are critical in informing the development of equitable service delivery and commissioning.
This article details the methodological approach undertaken using the COREQ guidelines, see supplementary file 1.
Longitudinal interviews and photo elicitation were conducted with a sample of 28 participants from the original 30 interviewed at 12 weeks.1 The two participants not interviewed withdrew from the study for personal reasons. The experiences of service users who withdrew from the programme are reported elsewhere.4 Eighteen people also participated in photovoice data collection methods as described by Homer et al.2 Interviews were conducted and recorded online using Microsoft Teams and lasted between 38 and 90 minutes. Two researchers (KD, CH) conducted the interviews, with six interviews also supported by members of the Re:Mission patient and public involvement team. Interviews were transcribed verbatim and analysed thematically.5 KK led the initial coding of the 18-week interviews deductively and inductively using the 12-week thematic analysis framework. Additional codes from the 18-week data were added to the framework. CH cross-checked a sample of transcripts and, following discussion between KK and CH, a final thematic framework was developed and used to undertake the final coding. Data were stored and organised using NVivo Software (QS International Play Ltd. Version 12.6).
Data from cross-sectional interviews (n=15) interviews conducted with participants at six months into the LCD programme (see references 1 and 2 for more information) relating to participant experience of the FR phase were also included in this analysis. These interviews aimed to expand the diversity of experiences by collecting data from population groups or delivery models that were not well represented in the longitudinal interviews.
Ethical approval was received from the Health Research Authority (REF 21/WM/0126) and Leeds Beckett University (REF 107887 and 79441).
Participant demographics across the longitudinal and cross- sectional interviews were representative of the overall LCD programme, according to interim data presented to the advisory group in summer of 2023. Participant characteristics are shown in Table 1 and supplementary file 2.
Five core themes were derived from the findings: 1) navigating challenges and embracing enablers in the FR stage; 2) continued use of TDR; 3) the importance of clear person-centred session content; 4) the need for provider support; and 5) the benefits of physical activity.
Navigating challenges and embracing enablers in the FR stage (Table 2)
Participants reported the practical, physical, social and emotional aspects of FR. Practical challenges included changes in food shopping routines and responsibilities for home cooking and meal planning. Physical changes include changes to bowel habits, including reliance on medications to manage constipation. Whilst participants were looking forward to going out to socialise and eat with others (as this was restricted during the TDR phase), they discussed the challenges of making healthy food choices from limited menus or having to influence the choice of place based on finding something they could eat. They also reported how the TDR phase gave structure to their energy intake and provided a sense of control from not having to make food choices. This control was later challenged by needing to reintroduce food, with some participants feeling that TDR was easier to manage than healthy eating. Many participants reported feeling empowered and more mindful regarding healthy food choices, although some described anxiety about the possibility of returning to previous unhealthy habits and difficulties with portion control.
Participants were encouraged to reach and sustain weight loss targets during the programme. However, some had not met these targets by the end of the TDR phase and were seeking further weight loss, while others were aiming to sustain a particular weight goal as they transitioned during this FR phase. Apprehension regarding weight regain was commonly discussed.
Continued use of TDR (Table 3)
By the end of the FR phase, 15 (35%) of the 43 participants (nine females and six males aged 40-65) were either actively using TDR products or expressed an intention to continue doing so. The reasons for participants’ continued use of TDR included convenience and its effectiveness in helping them stick to their dietary routines. It also served as a compensatory measure in instances where they had eaten foods perceived as unhealthy. Some participants had identified other LCD brands they could purchase privately; this was not always discussed with their coach. Several participants articulated their intention to use TDR products as a fallback mechanism in instances where they experienced sensations of hunger. Additionally, some participants reported using TDR products as a mechanism to aid future weight loss if they hadn’t hit their intended target, or to manage any future weight regain. This has been implicitly reinforced by the programme including the offer of four weeks of ‘rescue’ TDR (termed by some providers as ‘reset’) if there was weight regain of more than 2kg during the weight maintenance phase.
The importance of clear person-centred session content (Table 4)
Across all delivery models, the sessions included a structured programme of content, intended to be delivered using a person-centred approach and to provide relevant information and behaviour change support at key points. During the FR interviews, participants reflected on the information they had received to support them with the FR phase and what was missing. Some, but not all, providers offered tailored dietary information for cultural food practices and support for managing FR during religious festivals (such as Ramadan). The interview data also suggested varying support to address emotional eating.
Participant understanding of session content varied. For some people the level of explanation regarding food types and macronutrients was sufficient, whereas others reported that they didn’t understand the content delivered during sessions or provided in the additional resources, and therefore struggled to implement this knowledge into their life. Participants who were in the group delivery model reported that they had insufficient opportunity to ask questions and were sometimes unable to speak to their coach to check understanding outside of the allocated group session. The one-to-one delivery model was more conducive to answering service user questions and responding to individual need. It was evident that some participants wanted more guidance and support with meal preparation and structured meal plans.
The need for provider support (Table 5)
Service users emphasised that the FR phase required the highest level of support from providers, and some perceived fortnightly sessions to be insufficiently frequent. Many stated that more frequent sessions would have helped them to feel more prepared to reintroduce food and provide more regular touchpoints to ask questions and receive support.
Participants noted that having the same coach delivering the sessions was integral to developing the coach-service user relationship, and sessions tended to be less effective when conducted by a replacement coach. The person-centredness demonstrated by some coaches was welcomed and participants talked about the relationship they had built with their coach. This appeared to be down to the individual coach rather than provider or delivery model.
Across all delivery models, out of session support was highlighted as an area for improvement. Participants talked about a lack of person-centredness, digital Apps not working, inadequate responses to emails or messages from the call centre, and helplines not consistently staffed by individuals with adequate training. This resulted in communication breakdown or delays in responding in a timely manner, resulting in some participants feeling abandoned outside the sessions.
The benefits of physical activity (Table 6)
During FR, service users were encouraged to set physical activity goals as part of their behaviour changes to support ongoing weight and blood glucose management. This was a new element of the programme, as additional physical activity (above routine activities) was not actively encouraged during the TDR phase. During FR some providers required service users to set challenges of steps per day, which was reported back as part of the routine monitoring. Most participants reported a notable increase in the amount and type of exercise they were doing. Many reported incorporating additional physical activity into their routines, ranging from regular family activities, commuting, using home-based gym equipment or taking up exercise on referral gym or swim passes (where available). The self-reported benefits of increased physical activity included feelings of increased energy, improved mobility, functional fitness and improved mental wellbeing. Several participants noted that weight loss boosted their confidence in taking up new activities such as dance or Zumba. This in turn led to positive experiences in day-to-day life, such as being able to manage self-care, visiting new places or fulfilling hobbies such as going to football matches. Participants who had not yet increased their activity levels still expressed intention to be more active in the future. Some participants highlighted barriers to increased physical activity such as sedentary jobs, cold weather deterring outdoor activities or a lack of awareness of local opportunities.
This is the first paper outlining the experience of service users as they completed the FR phase of the 52-week NHS LCD programme, delivered across broad and diverse populations. The interviews highlighted the practical, social and emotional aspects of FR, including excitement about eating real foods, as well as anxiety around choice and portion control. The control of energy intake and the limited choice experienced during TDR was often found easier to manage than making healthy food choices, a finding also reported in the DiRECT study,6 although some participants reported feeling newly empowered and mindful regarding eating habits. The interviews also highlighted a need for support with emotional eating behaviours, as identified in the interviews at 12 weeks,1 and other reports showing high prevalence of emotional eating in participants.7
Not all participants had met their weight loss goals by the time of FR and some were therefore seeking additional weight loss, with a proportion continuing to use TDR products or planning to do so to manage weight and offset unhealthy dietary choices. This is consistent with the findings of interviews at the end of the TDR phase of the programme. The DiRECT study, upon which the NHS LCD programme is largely based, permitted those in the intervention group to extend the use of TDR to beyond 12 weeks. Rehackova and colleagues reported that this allowed users to reach their own weight loss goals,6 increased self-satisfaction and the likelihood of longer-term weight loss maintenance.8,9
The availability of person-centred support outside session times was highlighted as a particular area for improvement by some participants. Additionally, participants reported a need for more guidance and support with meal preparation and structured meal plans,10 as well as a desire for more frequent support sessions during FR. Session content and delivery should be adapted according to health literacy,11 and should consistently be tailored to cultural needs.12 The attributes of the coach and their relationship with service users is important in supporting this process.13 Group sessions impacted on the time and opportunity to develop these relationships, a finding that was also seen in the observations of session delivery.14 This was also reflected in the new programme specification (now called the NHS Type 2 Diabetes Path to Remission Programme) which provides only one-to-one in-person or digital delivery,12 thus enhancing the opportunity for person-centred and tailored support.
Physical activity increased during the FR phase, as service users were motivated, more physically able following weight loss, and encouraged to be more active.15 If maintained, this activity increase has been shown to support longer-term weight loss,16,17 and to improve physical and psychological health.17-19 Barriers to participating in physical activity included limited awareness of local opportunities, which has been previously reported and can be further heightened in underserved populations.20,21 This could be addressed by service providers working more collaboratively with local organisations to enhance awareness of opportunities.22
Strengths and limitations
This paper presents participant experiences from the FR phase of the NHS LCD programme pilot and highlights areas for service improvements. Representation was strengthened by the addition of reflections from the cross-sectional data. As this paper presents outcomes at 18 weeks into a 52-week programme, the outcomes experienced at this point may not be reflective of outcomes reported at the end of the programme. A limitation of the data reported in this paper was the low number of participants from diverse ethnic groups and as such an understanding of the impact of ethnicity on dietary choices in the FR stage. The experience of 12 South Asian participants from the LCD programme is reported by Dhir et al.12
Recommendations for policy and practice
Commissioners and providers should consider increasing the regularity of the support available during the FR phase.
Consideration should be given to strengthening person-centred support available outside session times.
Coaches should be further trained regarding cultural competency and appropriately tailored resources and materials should be developed.
Providers should avoid assuming health literacy and should tailor content according to need. One-to-one delivery may allow for better coach understanding of service users’ individual requirements.
Providers should ensure awareness of local physical activity opportunities.
The paper provides unique insights into service user experiences during food reintroduction. It highlights common feelings about departing from the structure and control provided by TDR and having to manage new food choices. It also demonstrates the importance of person-centred support to support long-term behaviour changes.
© 2024. This work is openly licensed via CC BY 4.0.
This license enables reusers to distribute, remix, adapt, and build upon the material in any medium or format, so long as attribution is given to the creator. The license allows for commercial use. CC BY includes the following elements: BY – credit must be given to the creator.
Copyright ownership The author(s) retain copyright.
Conflict of interest The authors declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: LE has received funding from NIHR, MRC, Leeds City Council and OHID/PHE in the last three years and has had an honorary contract with OHID. CB is a primary care adviser to the national diabetes programme for NHS England. KC is the Chair of Trustees Patient Charity WLSinfo, Chair of Trustees ECPO, Membership Patient Advisory Board Boehringer Ingelheim and sits on the Advisory Board for Eli Lilly.
Funding This work was supported by the National Institute for Health Research, Health Services and Delivery Research [NIHR 132075]. The NHS LCD programme is funded by NHS England. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any author accepted manuscript version arising. The views expressed in this publication are those of the author(s) and not necessarily those of the MRC, NIHR or the Department of Health and Social Care.
Acknowledgements The authors would like to acknowledge Clare Helm from NHS England, who has worked on the coproduction of this study, identification of study aims and who provided feedback on an earlier draft of this manuscript.
The authors would also like to acknowledge the Patient and Public Involvement team that have worked on the coproduction of the Re:Mission study, including Mike Willis, Gulsoom Akhtar, Beth Clegg and Clair Goddard. Members of the steering and oversight groups are also acknowledged by the authors for their input and involvement in the Re:Mission study, including the clinical lead Dr Mark Ashton.
The Re:Mission study includes a multidisciplinary team of academics from across the North of England. The authors would like to acknowledge the team, including Dr Jamie Matu, Prof Jim McKenna, Dr Maria Maynard, Pat Watson, Dr Susan Jones, Dr Simon Rowlands, Dr Tanefa Apekey, Dr Stuart Flint, Prof Janet Cade, Dr Adam Martin, Dr Maria Bryant, Dr Wendy Burton, Mick Martson, Pooja Dhir and Tamla Evans.
Ethical approval Ethical approval was received from the Health Research Authority (REF 21/WM/0126) and Leeds Beckett University (REF 107887 and 79441). Participants provided informed consent to participate in the Re:Mission study, including consent for publication. All participant data were anonymised and where photos have been used in publications or presentations, permission was sought from each participant.
Developed from:
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349 – 357
Personal characteristics of researchers:
Dr Catherine Homer PhD (Female). Associate Professor of Obesity and Public Health with experience working in academia and extensive experience working in public health.
Karina Kinsella MRes (Female). Research Officer for the Re:Mission Study with extensive experience of evaluating interventions.
Dr Tamara Brown PhD (Female). Reader in Obesity, with 5 years’ experience of focus groups and research in weight management.
Dr Jordan Marwood PhD (Female). Research Fellow with extensive experience conducting obesity research, with particular focus on disordered and emotional eating.
Dr Kevin J Drew PhD (Male). Post-doctoral Research Fellow with 7 years’ experience of conducting qualitative evaluations of health-based interventions.
Dr Duncan Radley PhD (Male). Reader with 25 years’ experience conducting obesity research, and previously research manager in weight management service providers.
Charlotte Freeman (Female). Project research officer with experience of evaluating interventions in academia and primary care services as well as experience of working in public health.
Dr Abimbola Ojo PhD (Female). Member of the Patient and Public Engagement team for Re:Mission and Local Authority Public Health Specialist.
Dr Jennifer Teke (PhD) (Female). Member of the Patient and Public Engagement team for Re:Mission and Hospital Trust Research Manager.
Ken Clare (Male). Patient and Public Engagement Lead. Director of Bariatric and Metabolic Surgery Support at a national patient advocacy charity.
Dr Chirag Bakhai (Male). General Practitioner, Clinical Lead on the Re:Mission Study Oversight group and Primary Care Advisor to the NHS Diabetes Programme.
Dr Louisa Ells (Female). Professor of Obesity with a specialist interest in multi- disciplinary, cross-sector applied obesity research, with extensive experience of leading programme evaluations.