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Regular physical activity reduces the risk of many chronic diseases. Consequently, the promotion of it and particular types (e.g. walking and cycling for travel), have become a priority for governments seeking to improve health and constrain rising demand on health services. Despite this many uncertainties persist. The aim of this thesis is to address two particular areas of uncertainty: a) the association of walking and cycling for travel with indices of health and well-being; b) and the extent to which increases in physical activity will reduce need for health and social care. The first part of my thesis consists of three studies that describe the health benefits associated with walking and cycling to work among working age adults. The first is a longitudinal study of the associations between maintenance of active commuting with sickness absence and well-being using the Commuting and Health in Cambridge dataset. The second, using the same dataset, describes the longitudinal associations between maintenance of active commuting and self-reported body mass index. Building on this, the third study using a large cohort study (the Fenland Study) with detailed characterisation of diet and physical activity (including objective measurement) describes the baseline associations between active commuting and objective measures of adiposity. The second part of my thesis describes the development of a combined microsimulation multi-state life table model that is used to characterise the effects of a population 'shift' in physical activity on the burden of six major diseases at the population-level. Specifically, it seeks to better describe the effect of increases in physical activity on healthcare need considering not just the effect of physical activity on disease incidence but also the effect on healthcare need arising from consequent survival to an older age (at which disease incidence is higher), and contrasts this with a method that does not make allowance for increased survival. The findings of this thesis provide evidence of the importance of walking or cycling to work in maintaining or improving the health and well-being of working age adults. It suggests that increases in physical activity, even after allowance for increased survival, are likely to reduce need for healthcare, although the reductions in need are less than might be assumed when allowance is not made for increased survival. Taken together this work provides a stronger empirical basis to inform public health practice. A stronger 'health case' for active travel can be made. The benefits of which should be communicated to individuals choosing how to travel as well as policy makers and others who can influence the determinants of active travel. It also provides a more realistic and nuanced understanding of how increases in physical activity may affect future healthcare need. ; Wellcome Trust clinical doctoral fellowship (WT103394)

BACKGROUND: Systems thinking is integral to working effectively within complex systems, such as those which drive the current population levels of overweight and obesity. It is increasingly recognised that a systems approach - which corrals public, private, voluntary and community sector organisations to make their actions and efforts coherent - is necessary to address the complex drivers of obesity. Identifying, implementing and evaluating actions within complex adaptive systems is challenging, and may differ from previous approaches used in public health. METHODS: Within this conceptual article, we present the Action Scales Model (ASM). The ASM is a simple tool to help policymakers, practitioners and evaluators to conceptualise, identify and appraise actions within complex adaptive systems. We developed this model using our collective expertise and experience in working with local government authority stakeholders on the Public Health England Whole Systems Obesity programme. It aligns with, and expands upon, previous models such as the Intervention Level Framework, the Iceberg Model and Donella Meadows' 12 places to intervene within a system. RESULTS: The ASM describes four levels (synonymous with leverage points) to intervene within a system, with deeper levels providing greater potential for changing how the system functions. Levels include events, structures, goals and beliefs. We also present how the ASM can be used to support practice and policy, and finish by highlighting its utility as an evaluative aid. DISCUSSION: This practical tool was designed to support those working at the front line of systems change efforts, and while we use the population prevalence of obesity as an outcome of a complex adaptive system, the ASM and the associated principles can be applied to other issues. We hope that the ASM encourages people to think differently about the systems that they work within and to identify new and potentially more impactful opportunities to leverage change.

Abstract Background Some governments have recently shown a willingness to introduce taxes on unhealthy foods and drinks. In 2011, the Irish Minister for Health proposed a 10% tax on sugar sweetened beverages (SSBs) as a measure to combat childhood obesity. Whilst this proposed tax received considerable support, the Irish Department of Finance requested a Health Impact Assessment of this measure. As part of this assessment we set out to model the impact on obesity. Methods We used price elasticity estimates to calculate the effect of a 10% SSB tax on SSB consumption. SSBs were assumed to have an own-price elasticity of −0.9 and we assumed a tax pass-on rate to consumers of 90%. Baseline SSB consumption and obesity prevalence, by age, sex and income-group, for Ireland were taken from the 2007 Survey on Lifestyle and Attitude to Nutrition. A comparative risk assessment model was used to estimate the effect on obesity arising from the predicted change in calorie consumption, both for the whole population and for sub-groups (age, sex, income). Sensitivity analyses were conducted on price-elasticity estimates and tax pass-on rates. Results We estimate that a 10% tax on SSBs will result in a mean reduction in energy intake of 2.1 kcal/person/day. After adjustment for self-reported data, the 10% tax is predicted to reduce the percentage of the obese adult population (body mass index [BMI] ≥30 kg/m 2 ) by 1.3%, equating to 9,900 adults (95% credible intervals: 7,750 to 12,940), and the overweight or obese population (BMI ≥ 25 kg/m 2 ) by 0.7%, or 14,380 adults (9,790 to 17,820). Reductions in obesity are similar for men (1.2%) and women (1.3%), and similar for each income group (between 1.1% and 1.4% across income groups). Reductions in obesity are greater in young adults than older adults (e.g. 2.9% in adults aged 18–24 years vs 0.6% in adults aged 65 years and over). Conclusions This study suggests that a tax on SSBs in Ireland would have a small but meaningful effect on obesity. While such a tax would be perceived as affecting the whole population, from a health prospective the tax will predominantly affect younger adults who are the main consumers of SSBs.

Background In March, 2016, the UK government proposed a tiered levy on sugar-sweetened beverages (SSBs; high, moderate, and no tax for drinks with >8g, 5g to 8g, and <5g sugar per 100ml). We estimate the effect of possible industry responses to the levy on obesity, diabetes, and dental caries. Methods We modelled three possible industry responses: (1) reformulation to reduce sugar concentration, (2) increasing product price, and (3) changing the market share of high-, mid-, and low-sugar drinks. For each response, we defined a better and worse case health scenario. We developed a comparative risk assessment model to estimate the UK health impact of each scenario. Findings The best modelled scenario for health is SSB reformulation, resulting in 144,000 (95% uncertainty interval: 5,100 to 306,700) fewer adults and children with obesity in the UK, 19,000 (6,900 to 32,700) fewer incident cases of diabetes per year, and 269,000 (82,200 to 470,900) fewer decayed, missing, or filled teeth annually. Increasing the price of SSBs and changes to market share to increase the proportion of low-sugar drinks sold would also result in population health benefits, but to a lesser extent. The greatest benefit for obesity and oral health would be among individuals under 18 years, with people over 65 years experiencing the largest absolute decreases in diabetes incidence. Interpretation The health impact of the soft drink levy is dependent on its implementation by industry. There is uncertainty as to how industry will react and in the estimation of health outcomes. Health gains could be maximised by significant product reformulation with additional benefits possible if the levy is passed onto purchasers through raising the price of high- and mid-sugar drinks, and through activities to increase the market share of low-sugar products. ; RT and AK have previously done work on sugar-sweetened beverage taxes funded by the Union of European Soft Drinks Associations. MR is chair of Sustain and the Children's Food Campaign, which have campaigned for sugar drink taxes in the UK. MR is funded by the British Heart Foundation, grant number 006/PSS/CORE/2016/OXFORD. ADMB and OTM are members of the Faculty of Public Health, which has a position statement supporting sugary drink taxes. ADMB is funded by the Wellcome Trust, grant number 102730/Z/13/Z. OTM is a member of the UK Health Forum, which has also supported a UK sugar drinks tax. OTM is supported by a Wellcome Trust Clinical Doctoral Fellowship. SAJ was the independent Chair of the Department of Health Public Health Responsibility Deal Food Network from 2010 to 2015. SAJ is funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Oxford. The views expressed are those of the authors and not necessarily those of the National Health Service, National Institute for Health Research, or the Department of Health. PS is funded by the British Heart Foundation, grant number FS/15/34/31656. TB is funded the Health Research Council of New Zealand (16/443). AE declares no competing interests.

In 2018, the UK Government's Secretary of State for Health and Social Care articulated an ambition to increase healthy life expectancy by five years by 2035 for England, while also reducing the gap in this between the rich and the poor1. While we doubt that England – or indeed any high-income country – could achieve this ambition, we describe a set of policies with the potential to make a significant contribution.

Introduction One in five UK children aged 10-11 years live with obesity. They are more likely to continue living with obesity into adulthood and to develop obesity-related chronic health conditions at a younger age. Regulating the marketing of high fat, salt and sugar (HFSS) foods and beverages has been highlighted as a promising approach to obesity prevention. In 2019, Transport for London implemented restrictions on the advertisement of HFSS products across its network. This paper reports on a process evaluation of the design and implementation of this intervention. Methods In 2019-2020, we conducted semi-structured interviews with 23 stakeholders. Interviews with those responsible for implementation (n=13) explored stakeholder roles, barriers and facilitators to policy development/implementation and unintended consequences. Interviews with food industry stakeholders (n=10) explored perceptions and acceptability of the policy, changes to business practice and impact on business. Data were analysed using a General Inductive Approach. Results Practical challenges included limited time between policy announcement and implementation, translating the concept of 'junk food' into operational policy, the legal landscape and reported uneven impacts across industry stakeholders. Political challenges included designing a policy the public views as appropriate, balancing health and financial impacts, and the perceived influence of political motivations. Consultation during policy development and close communication with industry reportedly facilitated implementation, as did the development of an exceptions process that provided a review pathway for HFSS products that might not contribute to children's HFSS consumption. Conclusions Findings suggest that restricting the outdoor advertisement of HFSS foods and beverages at scale is feasible within a complex policy and business landscape. We outline practical steps that may further facilitate the development and implementation of similar policies and we report on the importance of ensuring such policies are applied in a way that is perceived as reasonable by industry and the public.

INTRODUCTION: One in five UK children aged 10-11 years live with obesity. They are more likely to continue living with obesity into adulthood and to develop obesity-related chronic health conditions at a younger age. Regulating the marketing of high fat, salt and sugar (HFSS) foods and beverages has been highlighted as a promising approach to obesity prevention. In 2019, Transport for London implemented restrictions on the advertisement of HFSS products across its network. This paper reports on a process evaluation of the design and implementation of this intervention. METHODS: In 2019-2020, we conducted semi-structured interviews with 23 stakeholders. Interviews with those responsible for implementation (n = 13) explored stakeholder roles, barriers and facilitators to policy development/implementation and unintended consequences. Interviews with food industry stakeholders (n = 10) explored perceptions and acceptability of the policy, changes to business practice and impact on business. Data were analysed using a general inductive approach. RESULTS: Practical challenges included limited time between policy announcement and implementation, translating the concept of 'junk food' into operational policy, the legal landscape, and reported uneven impacts across industry stakeholders. Political challenges included designing a policy the public views as appropriate, balancing health and financial impacts, and the perceived influence of political motivations. Consultation during policy development and close communication with industry reportedly facilitated implementation, as did the development of an exceptions process that provided a review pathway for HFSS products that might not contribute to children's HFSS consumption. CONCLUSIONS: Findings suggest that restricting the outdoor advertisement of HFSS foods and beverages at scale is feasible within a complex policy and business landscape. We outline practical steps that may further facilitate the development and implementation of similar policies and we report on the importance of ensuring such policies are applied in a way that is perceived as reasonable by industry and the public.

The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline ...

Introduction One in five UK children aged 10–11 years live with obesity. They are more likely to continue living with obesity into adulthood and to develop obesity-related chronic health conditions at a younger age. Regulating the marketing of high fat, salt and sugar (HFSS) foods and beverages has been highlighted as a promising approach to obesity prevention. In 2019, Transport for London implemented restrictions on the advertisement of HFSS products across its network. This paper reports on a process evaluation of the design and implementation of this intervention. Methods In 2019–2020, we conducted semi-structured interviews with 23 stakeholders. Interviews with those responsible for implementation (n = 13) explored stakeholder roles, barriers and facilitators to policy development/implementation and unintended consequences. Interviews with food industry stakeholders (n = 10) explored perceptions and acceptability of the policy, changes to business practice and impact on business. Data were analysed using a general inductive approach. Results Practical challenges included limited time between policy announcement and implementation, translating the concept of 'junk food' into operational policy, the legal landscape, and reported uneven impacts across industry stakeholders. Political challenges included designing a policy the public views as appropriate, balancing health and financial impacts, and the perceived influence of political motivations. Consultation during policy development and close communication with industry reportedly facilitated implementation, as did the development of an exceptions process that provided a review pathway for HFSS products that might not contribute to children's HFSS consumption. Conclusions Findings suggest that restricting the outdoor advertisement of HFSS foods and beverages at scale is feasible within a complex policy and business landscape. We outline practical steps that may further facilitate the development and implementation of similar policies and we report on the importance of ensuring such policies are applied in a way that is perceived as reasonable by industry and the public.