Background: Dietary acculturation occurs when people, including students, move to a new host country and their habitual diet changes. Several factors impact international students’ dietary acculturation, including the diversity of the area. Students’ eating habits are reported to be poorer in less ethnically diverse areas where access to their cultural foods may be limited. However, these settings provide a unique opportunity to study the processes (influencers, challenges, and enablers) for eating a culturally acceptable healthy diet in the host country. This study explores the immediate and longitudinal experiences of dietary acculturation for international students in a university and city with low ethnic diversity. Methods: Using an interpretivist design, data were collected longitudinally, at baseline (0-2 months), at six months and one year of sojournment from a purposive sample of international students studying at a university location in the northwest of England, United Kingdom. Focus groups, one-to-one interviews and diet diaries were utilised respectively across the year, progressively focussing the discussion on the lived experience of accessing a healthy and culturally acceptable diet and dietary acculturation. The data were transcribed verbatim and analysed using an inductive thematic approach with the guide of hermeneutic phenomenology. Analysis at baseline, six months, and one year was undertaken, followed by a trajectory analysis to understand the impact of studying and living in a city with little ethnic diversity on international students’ food and health experiences. Results: The analysis shows that international students at the University struggled with adjusting to British cuisine and culture, leading to irregular eating habits that impacted mental health and well-being. The study found that inadequate assistance from the University with regard to diet played a significant role. Over the course of the three phases of the study, participants had limited opportunities to access a broad assortment of foods due to the constrained availability, accessibility, and affordability of familiar options in both the University cafeteria and the city of Chester. Trajectory analysis findings highlight four central issues in accessing culturally acceptable healthy diets at a university located in a less ethnically diverse area: i) the capability and capacity to cook for one’s self; ii) orientation, catering menus, and lack of support from the institution; iii) accessing community support networks; iv) the need to improve cultural awareness, acceptance, and inclusion. The lack of social support, inclusion, and the feeling of no sense of belonging were critical determinants of the student’s experiences. Perceived discriminatory experiences contributed to poorer mental health among participants and performance in their studies. This study suggests that it is imperative to fully grasp the importance of on-campus catering to the dietary requirements of international students for food offerings and menus in this setting. Such inclusion can go a long way towards creating a sense of belonging and promoting integration within universities that have low levels of ethnic diversity. Furthermore, the study sheds light on the development of segregation apparent in classroom settings and academic progress, which begins to perpetuate in higher education and may continue into everyday life. Conclusion: The availability of familiar food is crucial for maintaining a healthy diet, directly affecting one’s well-being. Through promoting inclusivity and a sense of belonging, we can address the negative impact on mental health that comes with feeling disconnected. The lack of availability of culturally acceptable ethnic foods was key, and students reported feelings of exclusion linked to being unable to obtain what they would like to eat easily. Wider community support from friends, family, and local organisations was crucial in developing healthier dietary habits and, crucially, a sense of community and settling. By supporting students in this way, we help them have a positive journey of acculturation, leading to overall success. Therefore, the University in this study needs to create activities and programmes that could bring balance to the entire student population’s dietary experiences. This would promote belongingness within the student group, according to the findings of this study. In addition, this thesis emphasises the importance of university leaders acknowledging the presence of perceived discrimination and implementing an actionable plan with measurable objectives that fosters inclusivity. This research has shown the importance of inclusivity, belonging, and integration for the dietary acculturation experiences of international students who live in a less diverse city. Whilst the research is undertaken in one such city, their findings are applicable to similar settings.

Introduction Although the efficacious pharmacotherapy advancements in the treatment of Heart Failure (HF) have been widely documented, mortality rates and hospitalisation rates among patients with HF remain high. An important reason for recurrent hospitalisation is patients’ nonadherence to self-care recommendations. Globally, medication nonadherence is a public health concern and a common phenomenon amongst patients with HF. This represents a continuous burden for patients, their relatives and the health-care system. The overall aim of this research is to develop an in-depth understanding of the issue of medication adherence among patients with HF in Nigeria by integrating the perspectives of both the patients and the healthcare providers. Methods Firstly, a review of empirical literature/qualitative meta-synthesis was conducted to explore the facilitators and barriers to adherence in heart failure. Secondly, a qualitative method by the means of in-depth, semi-structured interviews was utilised in exploring the perspectives of the patients, alongside their caregivers and their healthcare professionals regarding the factors they perceive are barriers and facilitators of medication adherence. The lived experience of patients living with HF was also explored. The results of which are discussed in two chapters. By the means of purposive sampling, a total of 65 participants (45 patients alongside their caregivers and 20 healthcare professionals) who met the inclusion criteria participated in this study. The interviews were recorded, transcribed verbatim and analysed by thematic content analysis. Results The rate of medication adherence was suboptimal (33%). The main barriers identified by the patients and their healthcare professionals include financial constraints, influence of religious beliefs, and culture, patients’ attitude and behaviour towards their medications, knowledge deficit, forgetfulness, interaction with the healthcare system among others. Experiencing side effects was a barrier identified by the patients but not the healthcare professionals. The key facilitators of medication adherence identified were forming a routine, support from family and friends, health education and counselling, and insight about the condition, medications prescribed and the repercussion of medication nonadherence. The strategies to improve medication adherence were also identified. Conclusion This study provides clear evidence that the factors influencing medication adherence are multiple and interrelated. As the barriers of medication adherence are multiple, solutions/ interventions to improve adherence should be holistic, multifaceted, and patient-centered in order to be effective.

Background: In Lebanon, the population is experiencing nutrition transition and a high prevalence of obesity. Studies have shown that the Lebanese people are shifting their dietary behaviours from the traditional Lebanese diet, a variation of the Mediterranean diet, towards a westernised diet and are being physically inactive. To achieve a population behaviour change and address the obesity epidemic, the root causes of these behaviours and food choices should be explored and addressed. This approach requires joint efforts from different sectors such as the government, healthcare, and civil society to develop action plans and enact policies. In Lebanon, the factors that influence eating behaviours and physical activity are still not explored, national level policies are still lacking, and researchers have called for an urgent need to implement policies to halt the rise of obesity prevalence. Aims and objectives: The general aim of this thesis is to explore the perceived factors that influence adults’ eating behaviours and physical activity using the socio-ecological model as the conceptual framework. In addition, this PhD research explores the relevant contribution and the position of different stakeholders towards obesity prevention in Lebanon. Finally, this thesis draws on lessons learned from countries worldwide that help in developing guidelines for obesity prevention in Lebanon. Methods: Two studies were conducted for this PhD research. In the first study, the Photovoice method was used to engage Lebanese adults from the North Governorate to explore different factors that influence their eating behaviours and physical activity and to identify their perceptions towards the actions needed to address obesity. The second study involved a series of one-to-one face-to-face semi-structured interviews which were conducted with key stakeholders from different public and private sectors (government, civil society, education, and healthcare). These interviews aimed to explore the key stakeholders’ perceptions towards obesity and its causes, their relevant contribution towards obesity prevention, their priority of action to address obesity, and finally the barriers to effective action to reduce obesity in Lebanon. Results: The findings of the two qualitative studies show that obesity is commonly perceived as a body image issue rather than a health issue. Some of the main factors that were perceived to influence Lebanese adults’ eating behaviours and physical activity were: females’ (wives’ and mothers’) employment, social gatherings, and social norms (e.g. food and meal sharing), safety concerns, the availability of countless unhealthy food options that are relatively cheaper than healthy food, the lack of a physical environment that encourages physical activity, and food marketing and advertisements. The results of the stakeholder’s interviews show that the key stakeholders are aware of the nutrition transition and some of the underlying environmental factors that caused these behaviour changes. Yet, most of the key stakeholders framed obesity in an “individualistic approach” by focusing on unhealthy dietary behaviours, the physical inactivity and placed the responsibility on individuals for their lifestyle. Due to their approach, most of them focused their actions on raising awareness such as the role of education. Some of the barriers to effective policy action to address obesity in Lebanon are the political instability, lack of public demand for action, and lack of coordinated multi-sectoral actions. Implications: The recognition of obesity as a disease as well as strengthening the public, stakeholders’, and policymakers’ support towards obesity prevention strategies are essential to overcome the “policy inertia” in Lebanon. The key areas that need to be addressed for obesity prevention are raising awareness on obesity health consequences, increasing access to healthy food in public and private settings, limiting unhealthy food advertisements, and fiscal measures such as taxing unhealthy food and subsidising healthy food. To facilitate the implementation of policies that aim to prevent obesity, a systematic plan of action should be developed. To engage stakeholders from different sectors and establish a national multi-sectoral collaboration, national strategies and policies that follow a Health in all Policies Approach (HiPA) are recommended. This requires strong leadership from the government. Conclusions: There is an urgent need to shift the actions beyond targeting the individual by implementing public policies to address the obesogenic environment in Lebanon. Recommendations for research, policy actions, and practice are provided to guide the action towards establishing an appropriate public policy that recognises the need to adopt a socioecological model of implementation.

The objective of this review is to provide a broad outline of the research surrounding the validity and reliability of the 15-metre multi-stage fitness test (MSFT) for measuring the aerobic fitness of police officers. Maintenance of optimal cardiorespiratory fitness (CRF) in the emergency services is vital for health maintenance, injury prevention, and physical preparation for on-duty tasks. Police officers in England and Wales are required to attend annual fitness testing with minimal standards in place for entry into police safety training (PST). The current minimal standard is level 5:4, an estimated V̇O2max of 35ml·kg-1 ·min-1 , with the requirements increasing for specialist roles. This is assessed using the 15-metre MSFT previously developed and validated against laboratory obtained measures. Previous validation studies have compared the physiological responses between the 15-metre MSFT and training protocols for varying police roles. For example, Brewer, Buckle & Castle (2013) validated the level 5:4 standard by assessing the heart rate responses between the PST and level 5:4 of the 15-metre MSFT. Despite greater peak heart rate responses reported in the 15-metre MSFT (Peak heart rate: 175±13 b·min-1 vs. 152±12 b·min-1 ), the standard was maintained with concerns the aerobic fitness of police officers would be suboptimal for the role and below that of the general population. Using a similar methodology, the minimal entry requirements for 13 additional roles were developed and validated. However to date, the validity and reliability of the 15-metre MSFT has not been assessed using direct measures of gas analysis, previously relying on indirect measures to assess demands.

The long chain omega-3 polyunsaturated fatty acids (LC3PUFA) in human diets are mainly derived from oily fish and fish oil based supplements. Currently, the consumption of oily fish in the UK is far below the recommended level. LC3PUFA's non-fish sources such as algal oil with DHA (docosahexaenoic acid) are particularly important for vegetarians, non-fish eaters, and pregnant women. In previous work, high DHA vegetative algal oil load 50% w/w was successfully used to develop an oil-in-water nanoemulsion system suitable for functional food enrichment. The aims of this study included to investigate the effect of selected emulsifiers on oil-in-water nanoemulsions of algal oil prepared using ultrasonic technology. To improve the stability and digestibility of nanoemulsions within an In vitro digestion model. To examine the oxidation stability of nanoemulsions of algal oil and bulk algal oil with composition and droplet size changes during a 5 weeks storage trial at a temperature of 4 °C, 20 °C and 40 °C respectively. To evaluate sensory properties and consumer acceptability of food products with the incorporation of resulted nanoemulsion and find out possible relationship between the sensory profile of foods and the characteristics of added nanoemulsion. Nanoemulsion of LC3PUFA algal oil was developed with selected 6% w/w emulsifiers, including Lecithin (LN), Tween 40 (TN), Tween 60, equal ratio of Tween 40 and lecithin (LTN), 50% w/w Algal oil and 44%w/w water using a homogenizer and ultrasound processor. The results show that the nanoemulsion has been stabilised with selected emulsifiers (LN, TN & LTN) and the smallest droplet size of nanoemulsion was obtained using the combination of lecithin and Tween 40 at ratio 50:50. The In vitro digestion experiments were conducted with a model of fed state gastric and duodenal digestion using method of Lin et al (2014). The results show that the omega-3 oil nanoemulsion (LE/TW 50:50) were stable over 60 min in the gastric phase, in contrast omega-3 nanoemulsion (LE 100%) was destabilised at the gastric phase in 60 min, in which the droplet size diameter was significantly larger than at the beginning of gastric phase (P ≤ 0.05). The droplet size, fatty composition and oxidised compounds were measured to compare bulk algal oil and nanoemulsions stabilised with lecithin (LN) and Tween 40 (TN) solely and in combination (LTN) over a storage period of 5 weeks at temperatures of 4, 20 and 40°C. The results show the droplet size of nanoemulsions had no significant changes for samples stored at tested temperatures over 5 weeks storage. There were no significant differences in DHA composition within the weeks and temperatures used. For the GCHS analysed results, the increase in temperature to 40 ºC and storage time had a significant effect on the development of propanal for all samples (P≤0.05). Nanoemulsions prepared with lecithin alone had significantly higher development of propanal in week 1 at both 40 ºC and 20 ºC (P≤0.05). Lecithin (sole and combination with Tween 40) had more significant increases in oxidised volatiles at 40°C, which may be due to the instability of linoleic acid found in lecithin molecules which located in the outer layer of the oil droplets. There were no significant increase in oxidised compounds from the beginning to the end of storage for all tested samples stored at 4 °C. The sensory testing was also conducted on white sauce incorporated with omega-3 nanoemulsions with selected emulsifiers and bulk algal oil. The results show that the sensory attributes and overall acceptability of foods enriched with omega-3 nanoemulsion were statistically significantly lower than that of control sample (P≤ 0.05). Overall, the smallest droplet size of nanoemulsion was achieved with combination of lecithin and Tween 40 at a ratio of 50:50 by using ultrasonic processor. The stability and digestibility of nanoemulsion with the combination of lecithin and Tween 40 was improved in an In vitro digestion approach. A storage period of 5 weeks and temperature have no significant effect on the droplet size of tested nanoemulsion samples. However, there is a significant increase of the oxidised volatiles at 40 °C for all samples. Sensory testing show the white sauce with nanoemulsion has a stronger fishy taste and less overall liking than with bulk oil, indicating the smaller drop size is more ready to spread and reach the sensors of the mouth.

Gum arabic is a natural gummy exudate from acacia trees and exhibits natural built-in variations commonly associated with hydrocolloids. This study is concerned with the determination of factors which could influence its properties and functionality. These factors include origin (location, soil type, rainfall), different collections, age of the trees and storage condition. Previous studies acknowledged the influence of some of these factors but somehow lack providing definitive answers to questions being asked by the end user and required for the development of Gum arabic industry in Sudan. Local knowledge as well as the various stages of gum collection and processing were reviewed in order to provide a clear background and the justification for the experimental design. In this study samples were collected from six plantations located in the west and east regions in Sudan. Samples were collected from trees of different age (5, 10, 15 and 20 years old) and also from different picking interval (1-4). Each sample was divided into three portions (UK, Khartoum and Port Sudan) and stored for 5 years in order to determine the effect of the respective location. Various analytical parameters (% loss on drying, Optical rotation, % protein, intrinsic viscosity, molecular weight and molecular weight distribution) were measured to fully characterise the gum samples and to determine their functionality (emulsification). The results obtained for all samples were consistent with those previously reported in the literature (see Chapter 4). The only exception, identified in a number of samples from the western region, is the high proportion (~30%) of high molecular weight fraction termed arabinogalactan-protein complex (AGP). The results clearly demonstrated significant variations between plantations located in western region compared with the eastern region. However, the variations between the plantations within the same region are statistically not significant. High values of % protein, viscosity, Mw and % AGP were obtained from the 1st pick, from both regions, and then significantly decreased thereafter to the fourth pick. Samples from west region in Sudan, from 1st and 2nd pick and from tree age (15) years gave the highest viscosity, molecular weight, % AGP and superior emulsification performance compared to other samples from different tree ages. The regression statistical analysis for the physiochemical properties correlation with emulsification performance demonstrated the role of % AGP to be the most influential factor followed by viscosity. The major finding of this study is the effect of storage condition on the properties and functionality of Acacia senegal. An increase in the molecular weight for all stored samples (for 5 years) irrespective of region was evident and statically significant. However, this increase was more prominent for samples from the western region compared to the eastern region. The AGP fraction was increased by the storage treatment up to 40% in Port-Sudan, 20% in Khartoum-Sudan and 15% in UK. The result clearly demonstrated that the temperature and humidity are the crucial factors to induce the natural maturation process in acacia gums. Statistical analysis (linear regression) suggested statistically significant models and equations to predict and explain the variations in the physiochemical and functional properties based on the environmental factors, picking set and age of the tree.

Given the strong evidence for a beneficial role of vitamin D in diabetes and CVD pathogenesis, and the prevalence of vitamin D deficiency, vitamin D supplementation has been advocated for the prevention of cardiometabolic disease. To provide information on the effects of 5,000IU (125µg) vitamin D3 on cardiometabolic risk, a double blind, RCT in a cohort of overweight and obese UK adult males with plasma 25(OH)D concentration < 75nmol/L for a duration of 8 weeks was conducted. To the best of my knowledge, this is the first RCT to investigate the effect of 5,000IU (125µg) vitamin D3 on cardiometabolic markers in vitamin D insufficient, non-hypertensive and non-diabetic overweight and obese adult males.

Prevalence of overweight and obesity has increased in adult and child populations during the last two to three decades in both developed and developing countries. Childhood obesity is common in the United Kingdom and has become a major public health issue. There is a growing body of evidence to suggest that the development of overweight and obesity in children has its roots in early life, with evidence of increasing weight over time in pre-school children. The study explored the early development of overweight in infants in Halton, an area of Northwest England. It was a mixed methods study comprising a quantitative analysis of routinely collected infant weight data and a longitudinal qualitative study of the process of weaning. Phase one - patterns of weight in Halton infants: The retrospective quantitative study utilised birthweight, and weight and length/height at eight weeks, eight months and 40 months of age from Halton infants born between 1994 and 2006 (16,328 singleton births). Analysis of these data provided further evidence of the early development of overweight, and highlighted patterns of infant overweight at eight months of age not previously reported. Phase two - longitudinal qualitative study of the process of weaning: Given the findings of phase one, factors that may influence early weight gain were considered. Therefore, the second phase focussed upon weaning, which has been little researched in terms of the way in which mothers manage the process. The aim was to explore weaning as a social process, focussing on the experience, knowledge, perceptions and actions of mothers as they weaned, in order to consider whether this could shed light on infant growth and development in general and the early development of overweight in particular. A grounded theory approach was utilised. Twenty one women were recruited and interviewed antenatally and then up to three times after their babies were born. A total of 67 interviews took place. A grounded theory, or ‘plausible account’, of the weaning process was developed. The centrality of the baby, and the way in which mothers talk about following the lead of the baby as they wean was highlighted, along with the ways in which this focus may falter or shift because of the complexity of influences on mothers’ lives. The primacy of embodied knowledge, that is the knowledge that mothers built up through the experience of feeding and weaning their infant, and the significance of being a mother in terms of being an ‘authority’ on feeding and weaning, were evident. In addition, the limitations of providing information, such as the feeding and weaning guidelines, without taking account of the individual mother, infant and their context was indicated. This is how some mistrust of the advice of health professionals, and possibly other ‘health messages’ emerged, as mothers did not see the advice as appropriate to them, their infant, or circumstances. Mothers did recognise babies as ‘bigger’ or ‘smaller’, but through valuing weight and weight gain were particularly aware of having small babies, which may have limited their capacity for recognising the significance of early signs of overweight in their infants. Final conclusions: Using mixed methods in this study allowed a broad picture of patterns of weight and overweight in Halton infants, and what some of the contributory factors to those patterns might be, to emerge, than if a single research method had been used. A number of implications for policy and practice: at an individual level in terms of the way in which women are supported to feed and wean their babies; and at a population level in terms of the monitoring of weight, were identified.