The Acceptability of Lifestyle Medicine Approaches for People in Midlife: A Rapid Review

The Acceptability of Lifestyle Medicine Approaches for People in Midlife: A Rapid Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Acceptability of Lifestyle Medicine Approaches for People in Midlife: A Rapid Review Jennifer Black, Sam Manger, Karen Carlisle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7504849/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: This rapid review examined the acceptability of Lifestyle Medicine (LM) interventions among midlife adults (40–65 years), exploring experiences and perceptions across health contexts. The review sought to identify factors influencing engagement with LM to inform future health promotion strategies. Methods: A rapid review of peer-reviewed studies published between 2013 and 2023 was conducted across five databases. Eligible studies were from Australia, Canada, New Zealand, or the United Kingdom, involved adults aged 40–65, and addressed at least two LM pillars. A thematic synthesis was applied across qualitative, quantitative, and mixed methods designs. Results: Twenty-eight studies met the inclusion criteria. Five themes were identified: (1) Timing and Teachable Moments – health events increased receptivity to change; (2) Positive Experience – enjoyment and perceived benefits enhanced engagement; (3) Support – professional and social support facilitated change; (4) Confidence and Self-Efficacy – belief in one’s ability enabled sustained practice; and (5) Non-Acceptance – barriers included time, motivation, and perceived relevance. These themes were mapped to Sekhon et al.’s [ 50 ] Theoretical Framework of Acceptability (TFA), which comprises seven constructs related to the acceptability of healthcare interventions; notably, support was absent from the original framework. LM was predominantly implemented post-diagnosis, with limited preventive application. Conclusions: LM is broadly acceptable to midlife adults, particularly when introduced during significant health events and reinforced through professional and social support. Preventive use, however, remains underutilised. Future strategies should harness routine health assessments and deliver personalised, multi-pillar LM interventions to maximise impact. Lifestyle Health Behaviour Chronic Disease Preventative Health Services Middle Aged Patient Acceptance of Health Care Figures Figure 1 Figure 2 Introduction The Acceptability of Lifestyle Medicine Approaches for People in Midlife: A Rapid Review The global population is ageing and by 2050, the number of people over the age of 60 will almost double from 12% to 22% [57]. With an ageing population comes an increase in the prevalence of non-communicable disease (NCD), such as diabetes, cancer and heart disease, putting pressure on healthcare systems [57]. By 2030, chronic diseases are projected to impose a global economic burden of approximately $47 trillion [20]. Globally, in 2021, the leading causes of death were cardiovascular disease (19.4 million) and cancers (9.89 million) [10]. People entering the 65 and over age bracket have a growing burden of lifestyle diseases, greater than in any previous generations [4, 24]. An opportune life stage to reduce the burden of NCDs in older age is midlife, a time when there is an increase in diagnosis of chronic disease [4, 30]. Addressing these health issues at this midlife stage can help with the transition into a healthier older age. Midlife is typically defined as the central period of a person’s life, between youth and old age and between 40 to 65 years old [29]. During this life stage, unhealthy behaviours and the increased prevalence of obesity can increase the risk of NCDs [38]. In addition to the increase of health issues, midlife is a time of important life transitions and balancing of multiple roles, for example with family (ageing parents, empty nesting, changing relationships etc.), career (work/life balance, financial issues etc.) and physical changes (changing body composition (fat/muscle), menopause/late-onset hypogonadism etc.). The intensity and magnitude of these concurrent changes can result in neglect of personal health and wellbeing [22]. LM can be used as a method of managing overall health and wellbeing as well as preventing chronic disease, with a potential of up to 80% reduced risk of NCDs such as cancer, diabetes, myocardial infarction and stroke [18]. LM is foundational to conventional medicine and considers environmental, proximal and distal determinants that have an influence on disease [15]. These determinants produce many drivers that could effect change, the top six commonly associated with LM, known as the six pillars, are diet/nutrition, physical activity, avoidance of risky substances, restorative sleep, stress management and social connection [34]. In the same way that all aspects of our lives are intertwined and complex, the six pillars can be used together as a powerful way to treat and prevent chronic disease, where acceptability in making lifestyle changes is the key to long term success. Sekhon et al. [50] defines acceptability as a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention. Sekhon et al. [50] identified a theoretical framework for acceptability (TFA), comprising of seven component constructs relating to the acceptance of healthcare interventions. These are: Affective Attitude, Burden, Ethicality, Intervention Coherence, Opportunity Costs, Perceived Effectiveness and Self-efficacy. Although the rising burden of chronic disease and the potential cost-effectiveness of LM are increasingly recognised, its integration into mainstream healthcare remains limited and warrants further exploration [15, 17]. Cited barriers for non-use of LM approaches in a medical setting are a lack of training/education, insufficient resources, limited awareness and limited appointment times [34, 56]. For individuals, the adoption of LM can be influenced by socioeconomic factors and the challenge of embracing behaviour modification [34]. The aim of this review was to examine what is already known regarding how people in midlife view and accept LM as a tool to improve their health and wellbeing and the contributing factors associated with the use of LM interventions in midlife. The research questions guiding the review of the literature were: What are the views of people in midlife on the acceptability of LM as a tool to improve health and wellbeing? And What are the contributing factors associated with the acceptability of LM interventions in midlife? Methods Rapid reviews employ a systematic and rigorous methodology to synthesise existing evidence on a defined practice or policy issue within a condensed timeframe and are increasingly used in health research due to constraints such as time, budgets and personnel [26]. This rapid review was directed by guidelines for rapid reviews [25]. Inclusion/exclusion criteria The following inclusion criteria were applied: 1) Population – adults in midlife (age range 40-65), 2) Concept – LM interventions which focus on any of the pillars, at least two (addressing at least two pillars reflects a more holistic approach to health, moving beyond a single-focus intervention) and exploration of patient acceptance of the intervention or exploration of factors associated with acceptance of the LM intervention, 3) Context – Any health setting/health intervention (if online/home based) and Studies conducted in Australia, Canada, New Zealand and United Kingdom (developed countries with comparable health systems, socio-economic conditions and cultural values), 4) Study design – Original research – quantitative, qualitative and mixed methods research, 5) Year of publication – 2014-2024 (Given that LM is an emerging field, a ten-year timeframe was considered appropriate to capture the most recent research while managing the volume of literature retrieved), 6) Language – English Language. The following exclusion criteria were applied: 1) Population – Children, Young adults (18-39), Older adults (65+ years), 2) Concept – Studies on LM interventions that focus only on one of the 6 pillars and studies that do not explore patient acceptability of the intervention or factors associated with acceptance of the interventions, 3) Context – Studies conducted outside health settings/not including a health intervention and countries outside of Australia, Canada, New Zealand and United Kingdom, 4) Study design – Secondary review studies, editorials, letters, conference proceedings, poster presentations, commentaries, protocols, 5) Year of publication – Prior to 2014, 6) Language – Not in the English Language. Search strategy Searches were conducted in Medline, CINAHL, Emcare, Scopus and PubMed databases on 11 September 2024 after consultation with an academic librarian. A combination of subject headings and keyword searches was used in Medline, CINAHL, Emcare and keyword searches used in Scopus and PubMed. The search terms related to midlife (middle aged, midlife, middle adulthood, middle life), acceptance (patient acceptance of health care, patient satisfaction, attitude to change, health literacy, health attitudes) and LM (lifestyle medicine, lifestyle intervention, lifestyle modification, lifestyle change, lifestyle education, non-drug interventions, non-drug therap*, non-drug treatment, non-pharmacological interventions, non-pharmacological therap*, non-pharmacological treatment). Results Search results The initial search yielded 5,125 records. After removing articles published outside the ten-year inclusion period ( n = 1,432), non-English articles ( n = 60), and those from countries outside the target regions ( n = 2,140), 1,493 articles remained. These were imported into EndNote (version 21.4), where 161 duplicates were removed, leaving 1,332 records for screening. Titles and abstracts were then screened for relevance based on the inclusion and exclusion criteria. If the population, context, or concept could not be determined from the abstract, the article was retained for full-text review. This process identified 140 articles for full-text screening. At the full-text stage, studies were excluded if they did not focus on the midlife population (i.e., included children, young adults, or older adults), or did not address the acceptability of LM interventions. Following this, 28 studies met the inclusion criteria and proceeded to data extraction. The screening process was conducted by the principal researcher (JB) and is summarised in the PRISMA flow chart (Figure 1). Data extraction, charting and synthesis Data extraction was conducted by the principal researcher (JB) using a custom Excel spreadsheet designed to capture key information relevant to the review question. Extracted data included author, year, participant characteristics, study aim, design, LM intervention, disease focus, main findings, and recommendations. Of the 28 studies, most originated from the UK ( n = 13), followed by Australia ( n = 8), Canada ( n = 6), and New Zealand ( n = 1). Study designs were primarily qualitative ( n = 14), with mixed methods ( n = 8) and quantitative ( n = 6) also represented. Quantitative data on acceptability were obtained through satisfaction questionnaires and pre–post outcome measures, while qualitative data were collected via interviews, group discussions, or open-ended survey questions. The most common disease areas were cancers (breast, bowel, colorectal, prostate; n = 9), obesity/weight ( n = 6), and heart disease ( n = 5). Most interventions focused on physical activity and diet ( n = 25), with less emphasis on other LM pillars such as substance use, sleep, stress, and social connection. A summary of study characteristics is presented in Table 1. Table 1. Characteristics of the included studies ordered by number of Pillars of LM, followed by Disease / Intervention Purpose. First author, date & country Design Disease/ Int Purpose Pillar of LM PA Diet SU Sleep Stress SC Driscoll, S., et al. (2021), Aus QUANT Obesity/weight ✓ ✓ ✓ ✓ ✓ McGarrol, S. (2020), UK QUAL Heart disease ✓ ✓ ✓ ✓ Riley, R., et al. (2016), UK QUAL Heart disease ✓ ✓ ✓ ✓ McGuire, A. M., et al. (2019), Aus QUANT LRF/ int ✓ ✓ ✓ ✓ Anderson, A. S., et al. (2018), UK MM Cancer ✓ ✓ ✓ Anderson, A. S., et al. (2014), UK QUANT Cancer ✓ ✓ ✓ Stead, M., et al. (2015), UK MM Cancer ✓ ✓ ✓ Tarr, G. P., et al. (2014), NZ QUANT Cancer ✓ ✓ ✓ Polley, M. J., et al. (2016), UK MM Cancer ✓ ✓ ✓ Throndson, K., et al. (2016), Can QUAL Heart disease ✓ ✓ ✓ Halcomb, E., et al. (2021), Aus QUAL LRF/ int ✓ ✓ ✓ Balneaves, L. G., et al. (2020), Can QUAL Cancer ✓ ✓ Poole, K., et al. (2019), UK QUAL Cancer ✓ ✓ Shingler, E., et al. (2017), UK QUAL Cancer ✓ ✓ Stevens, C., et al. (2019), UK QUANT Cancer ✓ ✓ Powter, H., et al. (2024), Aus QUAL Chronic medical conditions ✓ ✓ Banner, D., et al. (2015), Can MM Heart disease ✓ ✓ Dullaghan, L., et al. (2014), UK QUAL Heart disease ✓ ✓ Ashley, C., et al. (2020), Aus QUAL LRF/ int ✓ ✓ Egger, G., et al. (2015), Aus MM LRF/ int ✓ ✓ McGill, B., et al. (2018), Aus MM LRF/ int ✓ ✓ Kozica, S., et al. (2015), UK QUAL Obesity/ weight ✓ ✓ Lewis, E., et al. (2019), Aus QUANT Obesity/ weight ✓ ✓ Park, T., et al. (2017), Can QUAL Obesity/ weight ✓ ✓ Poltawski, L., et al. (2020), UK QUAL Obesity/ weight ✓ ✓ Baillot, A., et al. (2016), Can QUANT Obesity/weight ✓ ✓ Azzi, J. L., et al. (2020), Can MM Prediabetes/ diabetes ✓ ✓ Sebire, S. J., et al. (2018), UK QUAL Prediabetes/ diabetes ✓ ✓ Abbreviations: Can = Canada; NZ = New Zealand; Aus = Australia; MM = Mixed Methods; QUANT = Quantitative; QUAL = Qualitative; LRF = Lifestyle Risk Factors; Int = Intervention; PA= Physical Activity; SU= Substance Use; SC = Social Connection To summarise the data, the included studies were thematically analysed to explore factors influencing the acceptability of LM and readiness for change among midlife adults. Five core themes emerged: 1. Timing and/or the teachable moment – Lifestyle changes were often triggered by health scares, diagnoses, or screening events, emphasising the importance of timing and emotional readiness; 2. Positive experience – High satisfaction, enjoyment, and a sense of empowerment were associated with greater acceptance and sustained engagement; 3. Support – Ongoing support from facilitators, peers, and family was critical to initiating and maintaining lifestyle changes; 4. Confidence and self-efficacy – Increased confidence in managing one’s health enhanced the likelihood of adopting and maintaining LM behaviours and 5. Non-acceptance – Barriers such as competing demands, low motivation, or disbelief in risk reduced engagement and intervention acceptability. It should be noted that some lifestyle factors may have been included in these interventions but were not mentioned in the article. In addition, although social connection was not explicitly mentioned in many of the studies, several interventions included a group component, which fostered connections [5, 7, 15, 39, 44]. Care was taken, where possible, to only use qualitative data from participants within the midlife age range (40-65) where part of an age range in a study fell outside the parameters. Acceptability of LM The acceptability of LM to people in midlife were mapped to the five emerging themes. Timing/teachable moment The timing of lifestyle change varied across the studies. Eleven of the twenty-eight introduced a lifestyle change post-diagnosis often in response to the shock or implications of a medical condition [7, 9, 14, 35, 41, 43, 44, 49, 51, 52, 55]. Participants described motivation to avoid health deterioration: “(I) don’t want to go blind… I want to stay as healthy as I can for as long as I can…” [49]. Diagnosis often served as a ‘teachable moment’ to reframe illness positively: “ I was a breast cancer survivor… I actually embraced life and lived during my treatment. ” [7]. The concept of a teachable moment also extended to prevention [1, 53, 54]. Six studies focused on disease prevention before diagnosis [1, 3, 5, 21, 47, 54] and three studies examined preventive interventions based on genetic risk [2, 53, 54]. However, proactive use of LM was limited, often hindered by denial or low perceived risk: “I guess you think you're young and bullet proof… I've never once thought about it…” [21]. Cancer screening (e.g., cervical, breast, bowel) offered key opportunities to promote lifestyle change through direct healthcare interaction, with 79–82% of participants open to receiving advice [1,53]. Six studies addressed obesity as both a disease state and a risk factor, where lifestyle change was driven by the goal of preventing multimorbidity [6, 13, 27, 32, 39, 42]. Secondary prevention was also a strong motivator, particularly following a health scare or diagnosis. Positive experience Positive program experiences enhanced engagement, satisfaction, and empowerment [14]. Positive experiences were often attributed to well-designed programs, effective delivery, and the usefulness of tools and content provided. Four studies reported quantitative satisfaction and likelihood of recommending the intervention [1, 2, 5, 41], with an average satisfaction/recommendation rate of 83.35% across a total of 271 participants. Seven studies provided qualitative evidence highlighting the effectiveness of interventions and participants' self-reported success and acceptance of lifestyle change [5, 7, 9, 13, 15, 36, 44]. Across these studies, high satisfaction was consistently linked to a positive emotional and physical experience: “…I feel so good!… I love yoga and I can do things that I couldn’t do before.” [5]. Support Support emerged as a key factor influencing behaviour change and the overall acceptability of lifestyle interventions, as reported in nineteen studies. Support was provided through health professionals, peer groups, and personal networks of family and friends. A consistent finding across studies was the critical role of knowledgeable and encouraging health professionals or intervention facilitators in enabling positive behaviour change [1, 5, 7, 13, 27, 32, 36-38, 41, 44, 47, 49, 52]. Participants valued guidance and reinforcement from trusted professionals: “It was good to have an outline of the important stuff from someone who knows about it” and “It was good having someone reinforce eating the right way and supporting you not to return to the bad habits ” [39]. Peer support was also highly valued, providing motivation, accountability, and a sense of social belonging [5, 6, 16, 39, 44]. Group participation fostered a shared identity and functioned as a resource for maintaining lifestyle change: “One person, she said, ‘We go to tea on this day. Do you want to join us?’ and we developed a posse. We also started a book club, we try to hike once a month, we try to get together... for a dinner. And if one person has a question... she emailed her posse and you would not believe the fan-out of response...” [7]. Family and friends also played a significant role in supporting change [3, 5, 21, 43]. In particular, lifestyle changes made in partnership were noted to enhance commitment and mutual benefit: “… you need to try and find something that both of you can do and enjoy doing… my wife doesn't like or isn't a particularly good swimmer… but we do like walking and we have to walk the dogs… so we upped it to three times a day from two.” [43]. Confidence and self-efficacy Nine studies reported that increased confidence contributed to greater self-efficacy, facilitating sustained lifestyle change [1, 6, 13, 27, 32, 39, 42, 44, 52]. As confidence grew, participants described becoming more independent in their health behaviours: “Well, I suppose it just gave you the confidence to try and do some of these exercises on your own” [44], and self-efficacy with greater sense of control: “Instead of being a bit like a mindless eater and drinker I feel as though I’m in a more controlled situation about my own person.” [42]. Interventions that incorporated motivational interviewing and goal setting promoted internal motivation [32, 44]. Non-acceptance Barriers to accepting and sustaining lifestyle change were reported in fifteen studies and reflected common challenges in behaviour change. These included time constraints, employment (particularly sedentary work), cost, travel, competing responsibilities (e.g., childcare, family commitments), poor physical or mental health, stressful life events (e.g., bereavement, illness), low motivation, limited knowledge of risk factors, low health or digital literacy, inadequate support, and environmental factors such as weather [2, 5, 7, 9, 21, 35, 36, 39, 41, 44, 47, 49, 52, 55]. Participants shared frustrations: “ It’s too expensive for us ” [44], or lacked understanding: “ My cholesterol was 250… I don’t understand what that really means. ” [55]. Maintaining behaviour change beyond the initial period of high motivation was also challenging for some participants: “That [the program] was good to start off with, but I could sort of push [the program messages] by the wayside” [27]. Denial of risk or belief that change was unnecessary also limited engagement [44, 47, 55]. Discussion Overall, both quantitative and qualitative findings suggest high acceptability of LM interventions in midlife. Participant perspectives highlighted the factors shaping this acceptability. The five emerging themes from these findings were mapped against Sekhon et al.’s [50] seven constructs in the TFA to illustrate how the themes align with established constructs in healthcare intervention acceptability (Figure 2). Each of Sekhon et al.’s [50] seven TFA constructs corresponded with themes identified in this review, with one exception: the theme of support , which does not have a direct counterpart in the TFA. The construct Affective Attitude aligns with the theme Timing/Teachable Moment , reflecting participants’ emotional responses at the recruitment stage. Ethicality , Intervention Coherence , and Perceived Effectiveness correspond to Positive Experience , highlighting the importance of alignment with personal values, understanding of the intervention, and perceived outcomes. It is clear that tailoring interventions to individual lifestyles and providing support enhanced overall experience. While Support is not included in the TFA, it emerged as a key determinant of acceptability in 19 studies. Its role in promoting health and sustaining behaviour change is well established [46], underscoring its relevance in LM interventions. The theme Confidence/Self-Efficacy maps directly to the construct Self-Efficacy , which refers to confidence in one’s ability to perform intervention-related behaviours. The constructs Burden and Opportunity Costs align with Non-Acceptance , encompassing perceived effort, competing demands, and internal/external barriers [11]. Fourteen studies explicitly discussed these barriers, indicating their impact on engagement. These findings offer practical insights into enhancing LM interventions across three phases: recruitment, delivery, and sustained practice (Figure 2). Recruitment is influenced by timing and teachable moments; delivery benefits from well-designed programs that foster positive experiences, build confidence, and include strong support systems; and sustained practice requires addressing ongoing barriers to participation and change. These phases and their implications are examined further below. Phase 1 - Recruitment : Significance of timing and the teachable moment LM can serve both as a personalised approach to managing chronic conditions and as a preventive strategy [17]. In this review, the timing of LM engagement was classified into two phases: post-diagnosis and pre-disease prevention. “Teachable moments” – defined by Lawson and Flocke [31] as events that trigger positive behavioural change – were identified in both contexts, often coinciding with clinician–patient interactions that enhanced motivation and receptiveness. Post-diagnosis engagement was more commonly reported, with chronic disease serving as a strong catalyst for change [6, 7, 14, 41, 43, 51] For example, pharmacy-based interventions for men with prostate cancer were effectively delivered at critical decision points [43]. This phase was particularly effective for initiating LM due to heightened motivation [48]. Preventive interventions – through screening, genetic testing, or obesity management – also created teachable moments and were generally well received [1, 5, 13, 27, 32, 47, 53, 54]. However, preventive LM remains underused in practice [23]. Future efforts could include structured interventions during routine assessments (e.g., midlife health checks) or tailored resources (such as prostate cancer packs), which are currently available only in certain countries, accompanied by access to health coaching. Phase 2 - Delivery : Intervention delivery with support as key Three core themes – positive experience, support, and confidence/self-efficacy – were central to LM intervention delivery. These themes align sequentially with the LM acceptance process: starting with a teachable moment, progressing through implementation, and leading to sustained behaviour change. Support spans all stages, with facilitators, peers, and family contributing at different points. Conversely, non-acceptance can emerge at any phase and requires continuous attention. Positive experiences were associated with programs tailored to participant demographics, preferences, and delivery modes [13, 35, 37]. Techniques like motivational interviewing, goal-setting, and personalised feedback enhanced engagement – supporting person-based approaches to intervention design [58] and the role of positive affect in decision-making [19]. Among all themes, support was most influential. Facilitators played a key role early on, especially following a teachable moment, by offering knowledge, empathy, and encouragement. Peer groups fostered motivation and social connection throughout, while family and friends reinforced accountability and long-term lifestyle integration [12]. Embedding multi-source support in LM programs is essential, and future research should explore effective ways to incorporate it. Confidence and self-efficacy were also vital to sustaining change, particularly as participants moved toward independently maintaining LM behaviours. Defined as belief in one’s ability to control actions and environment [8], self-efficacy is consistently linked to successful behaviour change [40]. Phase 3 – Sustained practice: Addressing non-acceptance Understanding what hinders LM acceptance is critical to improving uptake and long-term adherence. This review identified three key barriers: practical and psychosocial obstacles, difficulty maintaining change, and negative attitudes or denial [27]. Common obstacles included time pressures, competing responsibilities, and insufficient support. These may be addressed through timely intervention and continued assistance from facilitators, peers, and family. Maintenance difficulties were often linked to declining motivation and failure to integrate changes into daily life – issues that long-term social support can help resolve. Negative perceptions, such as denial of health risk or the belief that change is unnecessary, also reduced engagement. Targeted education, motivational interviewing, and self-reflection during teachable moments may help counteract these attitudes. To strengthen acceptability and sustainability, facilitators should apply a health coaching approach that assesses readiness, identifies barriers, and personalises support. Integrating this model into LM programs may enhance both initial engagement and long-term behavioural maintenance. Gaps in the literature and opportunities for future research Although the evidence base supporting LM is expanding, few studies have specifically focused on midlife as a critical period of behavioural and health transition [29]. With increasing rates of chronic disease and an ageing population, research targeting the midlife age group (40–65 years) is urgently needed [4, 57]. Most LM studies to date have examined broad adult populations (18 and over), overlooking the unique challenges and opportunities presented during midlife [22]. Future research should prioritise the integration of LM earlier in midlife, with particular attention to how interventions are delivered and framed. This review identified five key elements associated with LM acceptability – timing/teachable moment, positive experience, support, confidence/self-efficacy, and addressing non-acceptance – which should inform future intervention design tailored to this life stage. Understanding the perceptions of those not yet exposed to LM is also essential. Exploring midlife adults’ awareness, attitudes, and readiness to engage with LM could offer valuable insights into how to promote preventive behaviour before chronic disease onset. In addition, equity must be a focus. LM interventions are often delivered individually or in small groups, which may limit accessibility for disadvantaged or culturally diverse populations. Future studies should consider inclusive, community-based approaches – such as those informed by the CELM framework [28] – to ensure broader applicability and reach. Limitations This review has some limitations. Firstly, it only includes publications from four countries, Australia, Canada, New Zealand and UK. The exclusion of other countries is likely to have led to missing publications which could have added value to this review. Secondly, grey literature was not included which may have provided useful information on LM health promotion interventions for people in midlife. Thirdly, as LM is a relatively new concept, a lack of publications referring to LM existed; lifestyle interventions typically included only a few of the six pillars of LM. Additionally, the term midlife can include differing age ranges, a selection of the studies included adults from a larger age range. In qualitative research, where age was specified, care was taken to only select quotes from participants in the 40-65 age range. Conclusion This review has revealed critical factors that enable LM interventions to be acceptable to participants. Coupled with the analysis of alignment with Sekhon’s TFA this research gives clues to how LM interventions can achieve greater acceptability for midlife participants. The five themes of timing and teachable moment, positive experience, support, confidence and self-efficacy and non-acceptance underpin the success of LM interventions, so future campaigns should consider these aspects in intervention delivery. Importantly, the inclusion of support, which is absent in Sekhon’s TFA should inform the design of future interventions, either through facilitator-led, community-based or family-supported mechanisms. Declarations Author Contribution J.B. conceptualised the study, conducted the literature review, performed data collection and analysis, and drafted and wrote the main manuscript text. S.M and K.C. provided guidance on study design, provided critical input on methodology, assisted and contributed to manuscript revisions including intellectual content. All authors reviewed and approved the manuscript. References Anderson AS, Macleod M, Mutrie N, et al. Breast cancer risk reduction - is it feasible to initiate a randomised controlled trial of a lifestyle intervention programme (ActWell) within a national breast screening programme? The international journal of behavioral nutrition and physical activity . 2014;11(1). Anderson AS, Dunlop J, Gallant S, et al. Feasibility study to assess the impact of a lifestyle intervention (‘LivingWELL’) in people having an assessment of their family history of colorectal or breast cancer. BMJ open . 2018;8(2):e019410. Ashley C, Halcomb E, McInnes S, et al. Middle-aged Australians’ perceptions of support to reduce lifestyle risk factors: a qualitative study. Australian journal of primary health . 2020;26(4):313. Australian Institute of Health and Welfare (AIHW). “Ageing and the health system: challenges, opportunities and adaptations.” Australian Government. https://www.aihw.gov.au/getmedia/19dbc591-b1ef-4485-80ce-029ff66d6930/6_9-health-ageing.pdf.aspx. Accessed September 5, 2024. Azzi JL, Azzi S, Lavigne-Robichaud M, et al. Participant Evaluation of a Prediabetes Intervention Program Designed for Rural Adults. Canadian journal of dietetic practice and research . 2020;81(2):80-85. Baillot A, Mampuya WM, Dionne IJ, Comeau E, Méziat-Burdin A, Langlois MF. Impacts of Supervised Exercise Training in Addition to Interdisciplinary Lifestyle Management in Subjects Awaiting Bariatric Surgery: a Randomized Controlled Study. Obesity surgery . 2016;26(11):2602-2610. Balneaves LG, Truant TLO, Van Patten C, Kirkham AA, Waters E, Campbell KL. Patient and Medical Oncologists’ Perspectives on Prescribed Lifestyle Intervention—Experiences of Women with Breast Cancer and Providers. Journal of clinical medicine . 2020;9(9):2815. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychological review . 1977;84(2):191-215. Banner D, Lear S, Kandola D, et al. The experiences of patients undertaking a “virtual” cardiac rehabilitation program. In: Studies in Health Technology and Informatics . Vol 209. ; 2015:9. Dattani S, Spooner F, Ritchie H, et al. “Causes of Death” OurWorldinData.org. https://ourworldindata.org/causes-of-death. Accessed September 5, 2024. Davis R, Campbell R, Hildon Z, Hobbs L, Michie S. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. Health psychology review . 2015;9(3):323-344. Dorn C, Phillips S, Nicol S, Russell H, Guenther E. Motivations Behind Lifestyle Changes. American journal of lifestyle medicine . 2023;17(3):443-447. Driscoll S, Meyerowitz-Katz G, Ahlenstiel G, Reynolds T, Reid K, Bishay RH. Efficacy of Telephone Health Coaching Integration with Standard Multidisciplinary Care for Adults with Obesity Attending a Weight Management Service: A Pilot Study. Nutrients . 2021;13(11):4078. Dullaghan L, Lusk L, McGeough M, Donnelly P, Herity N, Fitzsimons D. ‘I am still a bit unsure how much of a heart attack it really was!’ Patients presenting with non ST elevation myocardial infarction lack understanding about their illness and have less motivation for secondary prevention. European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology . 2014;13(3):270-276. Egger GJ, Binns AF, Rossner SR. The emergence of “lifestyle medicine” as a structured approach for management of chronic disease. Medical Journal of Australia . 2009;190(3):143-145. Egger G, Dixon J, Meldrum H, et al. Patients’ and providers’ satisfaction with shared medical appointments. Australian family physician . 2015;44(9):674-679. Fallows ES. Lifestyle medicine: a cultural shift in medicine that can drive integration of care. Future healthcare journal . 2023;10(3):226-231. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy Living Is the Best Revenge: Findings From the European Prospective Investigation Into Cancer and Nutrition–Potsdam Study. Archives of internal medicine (1960) . 2009;169(15):1355-1362. Fredrickson BL. The Role of Positive Emotions in Positive Psychology: The Broaden-and-Build Theory of Positive Emotions. The American psychologist . 2001;56(3):218-226. Hacker K. The Burden of Chronic Disease. Mayo Clinic proceedings Innovations, quality & outcomes . 2024;8(1):112-119. Halcomb E, Ashley C, Middleton R, et al. Understanding perceptions of health, lifestyle risks and chronic disease in middle age. Journal of clinical nursing . 2021;30(15-16):2279-2286. Infurna FJ, Gerstorf D, Lachman ME. Midlife in the 2020s: Opportunities and Challenges. The American psychologist . 2020;75(4):470-485. Institute for Advancing Health Value. “The Potential of Lifestyle Medicine as a High Value Approach to Address Health Equity”. https://lifestylemedicine.org/wp-content/uploads/2022/09/institute_ib_lifestyle-medicine-aclm-0922.pdf. Accessed September 20, 2024. Khan HTA, Addo KM, Findlay H. Public Health Challenges and Responses to the Growing Ageing Populations. Public health challenges . 2024;3(3):e213-n/a. Khangura S, Konnyu K, Cushman R, Grimshaw J, Moher D. Evidence summaries: the evolution of a rapid review approach. Systematic Reviews . 2012;1(1). King VJ, Stevens A, Nussbaumer-Streit B, Kamel C, Garritty C. Paper 2: Performing rapid reviews. Systematic Reviews . 2022;11(1). Kozica S, Lombard C, Teede H, Ilic D, Murphy K, Harrison C. Initiating and Continuing Behaviour Change within a Weight Gain Prevention Trial: A Qualitative Investigation. PloS one . 2015;10(4):e0119773. Krishnaswami J, Sardana J, Daxini A. Community-Engaged Lifestyle Medicine as a Framework for Health Equity: Principles for Lifestyle Medicine in Low-Resource Settings. American journal of lifestyle medicine . 2019;13(5):443-450. Lachman ME, Teshale S, Agrigoroaei S. Midlife as a pivotal period in the life course: Balancing growth and decline at the crossroads of youth and old age. International journal of behavioral development . 2015;39(1):20-31. Lange-Maia BS, Karavolos K, Avery EF, et al. Contribution of common chronic conditions to midlife physical function decline: The Study of Women’s Health Across the Nation. Women’s Midlife Health . 2020;6(1). Lawson PJ, Flocke SA. Teachable moments for health behavior change: A concept analysis. Patient education and counseling . 2009;76(1):25-30. Lewis E, Huang HCC, Hassmén P, Welvaert M, Pumpa KL. Adding Telephone and Text Support to an Obesity Management Program Improves Behavioral Adherence and Clinical Outcomes. A Randomized Controlled Crossover Trial. International journal of behavioral medicine . 2019;26(6):580-590. Liotta, M. “Where in Australia is chronic disease most prevalent?” The Royal Australian College of General Practitioners (RACGP). https://www1.racgp.org.au/newsgp/clinical/where-in-australia-is-chronic-disease-most-prevale. Accessed September 15, 2024. Lippman D, Stump M, Veazey E, et al. Foundations of Lifestyle Medicine and its Evolution. Mayo Clinic proceedings Innovations, quality & outcomes . 2024;8(1):97-111. McGarrol S. Contextualising lifestyles: how socially contrasting places in Fife, Scotland influence lay understandings of lifestyle and health behaviours in relation to coronary heart disease. Health & place . 2020;66. McGill B, O’Hara B, Phongsavan P. Participant perspectives of a 6-month telephone-based lifestyle coaching program. Public Health Research & Practice . 2018;28(2). McGuire AM, Seib C, Porter-Steele J, Anderson DJ. The Association Between Web-Based or Face-to-Face Lifestyle Interventions on the Perceived Benefits and Barriers to Exercise in Midlife Women: Three-Arm Equivalency Study. Journal of medical Internet research . 2019;21(8):e10963. McGuire AM, Porter-Steele J, McDonald N, Burgess SC, Anderson DJ, Seib C. Reducing noncommunicable disease risk in midlife adults using eHealth: The GroWell for Health Program feasibility study. Collegian (Royal College of Nursing, Australia) . 2022;29(3):328-336. Park T, Foster K, Usher K. Participants’ Voices From Within a Healthy Lifestyle Group. Issues in mental health nursing . 2017;38(2):107-112. Pekmezi D, Jennings E, Marcus BH. Evaluating And Enhancing Self-Efficacy For Physical Activity. ACSM’s health & fitness journal . 2009;13(2):16-21. Polley MJ, Jolliffe R, Boxell E, Zollman C, Jackson S, Seers H. Using a Whole Person Approach to Support People With Cancer: A Longitudinal, Mixed-Methods Service Evaluation. Integrative cancer therapies . 2016;15(4):435-445. Poltawski L, van Beurden SB, Morgan-Trimmer S, Greaves C. The dynamics of decision-making in weight loss and maintenance: a qualitative enquiry. BMC public health . 2020;20(1). Poole K, Ogden J, Gasson S, et al. Creating a teachable moment in community pharmacy for men with prostate cancer: A qualitative study of lifestyle changes. Psycho-oncology (Chichester, England) . 2019;28(3):593-599. Powter H, Lambert K, Nicholls N. Experiences and perspectives of integrating nutrition education into an exercise program for people with chronic medical conditions. Health promotion journal of Australia . 2024;35(4):1098-1115. PRISMAStatement. PRISMA Flow Diagram . https://www.prisma-statement.org/prisma-2020-flow-diagram. Accessed September 18, 2024. Reblin M, Uchino BN. Social and emotional support and its implication for health. Current opinion in psychiatry . 2008;21(2):201-205. Riley R, Coghill N, Montgomery A, Feder G, Horwood J. Experiences of patients and healthcare professionals of NHS cardiovascular health checks: a qualitative study. Journal of public health (Oxford, England) . 2016;38(3):543-551. Samuel PO, Edo GI, Emakpor OL, et al. Lifestyle modifications for preventing and managing cardiovascular diseases. Sport sciences for health . 2024;20(1):23-36. Sebire SJ, Toumpakari Z, Turner KM, et al. “I’ve made this my lifestyle now”: a prospective qualitative study of motivation for lifestyle change among people with newly diagnosed type two diabetes mellitus. BMC public health . 2018;18(1). Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC health services research . 2017;17(1). Shingler E, Hackshaw-McGeagh L, Robles L, et al. The feasibility of the Prostate cancer: Evidence of Exercise and Nutrition Trial (PrEvENT) dietary and physical activity modifications: a qualitative study. Current controlled trials in cardiovascular medicine . 2017;18(1). Stead M, Craigie AM, Macleod M, et al. Why are some people more successful at lifestyle change than others? Factors associated with successful weight loss in the BeWEL randomised controlled trial of adults at risk of colorectal cancer. The international journal of behavioral nutrition and physical activity . 2015;12(1). Stevens C, Vrinten C, Smith SG, Waller J, Beeken RJ. Acceptability of receiving lifestyle advice at cervical, breast and bowel cancer screening. Preventive medicine . 2019;120:19-25. Tarr GP, Crowley A, John R, et al. Do high risk patients alter their lifestyle to reduce risk of colorectal cancer? BMC gastroenterology . 2014;14(1). Throndson K, Sawatzky JAV, Schultz A. Exploring the Perceptions and Health Behaviours of Patients Following an Elective Ad-hoc Percutaneous Coronary Intervention: A Qualitative Study. Canadian journal of cardiovascular nursing . 2016;26(2):25-32. Vega MR, Nadeem S, Vaughan EM, Johnston CA. The Use of Reframing: Increasing the Importance of Lifestyle Medicine. American journal of lifestyle medicine . 2023;17(6):746-749. World Health Organisation (WHO). Ageing and health . https://www.who.int/news-room/fact-sheets/detail/ageing-and-health. Accessed September 5, 2024. Yardley L, Morrison L, Bradbury K, Muller I. The Person-Based Approach to Intervention Development: Application to Digital Health-Related Behavior Change Interventions. Journal of medical Internet research . 2015;17(1):e30. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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2","display":"","copyAsset":false,"role":"figure","size":70731,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eAlignment of the emerging themes with the framework of acceptability through recruitment, delivery and sustained practice\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7504849/v1/1bfbf9ca39d210699ade1acd.png"},{"id":94599036,"identity":"2fb55aff-e07f-46d0-981d-371dfe8f8c39","added_by":"auto","created_at":"2025-10-28 19:02:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1289926,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7504849/v1/ace42834-b35f-488b-8cb6-64d5c505cf73.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Acceptability of Lifestyle Medicine Approaches for People in Midlife: A Rapid Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eThe Acceptability of Lifestyle Medicine Approaches for People in Midlife: A Rapid Review\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe global population is ageing and by 2050, the number of people over the age of 60 will almost double from 12% to 22% [57]. With an ageing population comes an increase in the prevalence of non-communicable disease (NCD), such as diabetes, cancer and heart disease, putting pressure on healthcare systems [57]. By 2030, chronic diseases are projected to impose a global economic burden of approximately $47 trillion [20]. Globally, in 2021, the leading causes of death were cardiovascular disease (19.4 million) and cancers (9.89 million) [10]. \u0026nbsp;People entering the 65 and over age bracket have a growing burden of lifestyle diseases, greater than in any previous generations [4, 24]. An opportune life stage to reduce the burden of NCDs in older age is midlife, a time when there is an increase in diagnosis of chronic disease [4, 30]. Addressing these health issues at this midlife stage can help with the transition into a healthier older age.\u003c/p\u003e\n\u003cp\u003eMidlife is typically defined as the central period of a person\u0026rsquo;s life, between youth and old age and between 40 to 65 years old [29]. During this life stage, unhealthy behaviours and the increased prevalence of obesity can increase the risk of NCDs [38]. In addition to the increase of health issues, midlife is a time of important life transitions and balancing of multiple roles, for example with family (ageing parents, empty nesting, changing relationships etc.), career (work/life balance, financial issues etc.) and physical changes (changing body composition (fat/muscle), menopause/late-onset hypogonadism etc.). The intensity and magnitude of these concurrent changes can result in neglect of personal health and wellbeing [22].\u003c/p\u003e\n\u003cp\u003eLM can be used as a method of managing overall health and wellbeing as well as preventing chronic disease, with a potential of up to 80% reduced risk of NCDs such as cancer, diabetes, myocardial infarction and stroke [18]. LM is foundational to conventional medicine and considers environmental, proximal and distal determinants that have an influence on disease [15]. These determinants produce many drivers that could effect change, the top six commonly associated with LM, known as the six pillars, are diet/nutrition, physical activity, avoidance of risky substances, restorative sleep, stress management and social connection [34]. In the same way that all aspects of our lives are intertwined and complex, the six pillars can be used together as a powerful way to treat and prevent chronic disease, where acceptability in making lifestyle changes is the key to long term success.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSekhon et al. [50] defines acceptability as a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention. Sekhon et al. [50] identified a theoretical framework for acceptability (TFA), comprising of seven component constructs relating to the acceptance of healthcare interventions. These are: Affective Attitude, Burden, Ethicality, Intervention Coherence, Opportunity Costs, Perceived Effectiveness and Self-efficacy.\u003c/p\u003e\n\u003cp\u003eAlthough the rising burden of chronic disease and the potential cost-effectiveness of LM are increasingly recognised, its integration into mainstream healthcare remains limited and warrants further exploration [15, 17]. Cited barriers for non-use of LM approaches in a medical setting are a lack of training/education, insufficient resources, limited awareness and limited appointment times [34, 56]. For individuals, the adoption of LM can be influenced by socioeconomic factors and the challenge of embracing behaviour modification [34]. \u0026nbsp;The aim of this review was to examine what is already known regarding how people in midlife view and accept LM as a tool to improve their health and wellbeing and the contributing factors associated with the use of LM interventions in midlife.\u003c/p\u003e\n\u003cp\u003eThe research questions guiding the review of the literature were: \u003cem\u003eWhat are the views of people in midlife on the acceptability of LM as a tool to improve health and wellbeing? And What are the contributing factors associated with the acceptability of LM interventions in midlife?\u003c/em\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eRapid reviews employ a systematic and rigorous methodology to synthesise existing evidence on a defined practice or policy issue within a condensed timeframe and are increasingly used in health research due to constraints such as time, budgets and personnel [26]. This rapid review was directed by guidelines for rapid reviews [25].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInclusion/exclusion criteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following inclusion criteria were applied: 1) Population \u0026ndash; adults in midlife (age range 40-65), 2) Concept \u0026ndash; LM interventions which focus on any of the pillars, at least two (addressing at least two pillars reflects a more holistic approach to health, moving beyond a single-focus intervention) and exploration of patient acceptance of the intervention or exploration of factors associated with acceptance of the LM intervention, 3) Context \u0026ndash; Any health setting/health intervention (if online/home based) and Studies conducted in Australia, Canada, New Zealand and United Kingdom (developed countries with comparable \u0026nbsp;health systems, socio-economic conditions and cultural values), 4) Study design \u0026ndash; Original research \u0026ndash; quantitative, qualitative and mixed methods research, 5) Year of publication \u0026ndash; 2014-2024 (Given that LM is an emerging field, a ten-year timeframe was considered appropriate to capture the most recent research while managing the volume of literature retrieved), 6) Language \u0026ndash; English Language. The following exclusion criteria were applied: 1) Population \u0026ndash; Children, Young adults (18-39), Older adults (65+ years), 2) Concept \u0026ndash; Studies on LM interventions that focus only on one of the 6 pillars and studies that do not explore patient acceptability of the intervention or factors associated with acceptance of the interventions, 3) Context \u0026ndash; Studies conducted outside health settings/not including a health intervention and countries outside of Australia, Canada, New Zealand and United Kingdom, 4) Study design \u0026ndash; Secondary review studies, editorials, letters, conference proceedings, poster presentations, commentaries, protocols, 5) Year of publication \u0026ndash; Prior to 2014, 6) Language \u0026ndash; Not in the English Language.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSearch strategy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSearches were conducted in Medline, CINAHL, Emcare, Scopus and PubMed databases on 11 September 2024 after consultation with an academic librarian. A combination of subject headings and keyword searches was used in Medline, CINAHL, Emcare and keyword searches used in Scopus and PubMed. The search terms related to midlife (middle aged, midlife, middle adulthood, middle life), acceptance (patient acceptance of health care, patient satisfaction, attitude to change, health literacy, health attitudes) and LM (lifestyle medicine, lifestyle intervention, lifestyle modification, lifestyle change, lifestyle education, non-drug interventions, non-drug therap*, non-drug treatment, non-pharmacological interventions, non-pharmacological therap*, non-pharmacological treatment).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSearch results\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initial search yielded 5,125 records. After removing articles published outside the ten-year inclusion period (\u003cem\u003en\u003c/em\u003e = 1,432), non-English articles (\u003cem\u003en\u003c/em\u003e = 60), and those from countries outside the target regions (\u003cem\u003en\u003c/em\u003e = 2,140), 1,493 articles remained. These were imported into EndNote (version 21.4), where 161 duplicates were removed, leaving 1,332 records for screening. Titles and abstracts were then screened for relevance based on the inclusion and exclusion criteria. If the population, context, or concept could not be determined from the abstract, the article was retained for full-text review. This process identified 140 articles for full-text screening. At the full-text stage, studies were excluded if they did not focus on the midlife population (i.e., included children, young adults, or older adults), or did not address the acceptability of LM interventions. Following this, 28 studies met the inclusion criteria and proceeded to data extraction. The screening process was conducted by the principal researcher (JB) and is summarised in the PRISMA flow chart (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData extraction, charting and synthesis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData extraction was conducted by the principal researcher (JB) using a custom Excel spreadsheet designed to capture key information relevant to the review question. Extracted data included author, year, participant characteristics, study aim, design, LM intervention, disease focus, main findings, and recommendations.\u003c/p\u003e\n\u003cp\u003eOf the 28 studies, most originated from the UK (\u003cem\u003en\u003c/em\u003e = 13), followed by Australia (\u003cem\u003en\u003c/em\u003e = 8), Canada (\u003cem\u003en\u003c/em\u003e = 6), and New Zealand (\u003cem\u003en\u003c/em\u003e = 1). Study designs were primarily qualitative (\u003cem\u003en\u003c/em\u003e = 14), with mixed methods (\u003cem\u003en\u003c/em\u003e = 8) and quantitative (\u003cem\u003en\u003c/em\u003e = 6) also represented. Quantitative data on acceptability were obtained through satisfaction questionnaires and pre\u0026ndash;post outcome measures, while qualitative data were collected via interviews, group discussions, or open-ended survey questions. The most common disease areas were cancers (breast, bowel, colorectal, prostate; \u003cem\u003en\u003c/em\u003e = 9), obesity/weight (\u003cem\u003en\u003c/em\u003e = 6), and heart disease (\u003cem\u003en\u003c/em\u003e = 5). Most interventions focused on physical activity and diet (\u003cem\u003en\u003c/em\u003e = 25), with less emphasis on other LM pillars such as substance use, sleep, stress, and social connection. A summary of study characteristics is presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 1. Characteristics of the included studies ordered by number of Pillars of LM, followed by Disease / Intervention Purpose.\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"610\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst author, date \u0026amp; country\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease/\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInt Purpose\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePillar of LM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStress\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDriscoll, S., et al. (2021), Aus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUANT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eObesity/weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcGarrol, S. (2020), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRiley, R., et al. (2016), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcGuire, A. M., et al. (2019), Aus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUANT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eLRF/ int\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnderson, A. S., et al. (2018), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnderson, A. S., et al. (2014), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eQUANT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStead, M., et al. (2015), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eMM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTarr, G. P., et al. (2014), NZ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUANT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePolley, M. J., et al. (2016), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eMM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThrondson, K., et al. (2016), Can\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHalcomb, E., et al. (2021), Aus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eLRF/ int\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBalneaves, L. G., et al. (2020), Can\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePoole, K., et al. (2019), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eShingler, E., et al. (2017), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStevens, C., et al. (2019), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUANT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePowter, H., et al. (2024), Aus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eChronic medical conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBanner, D., et al. (2015), Can\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eMM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDullaghan, L., et al. (2014), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAshley, C., et al. (2020), Aus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eLRF/ int\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEgger, G., et al. (2015), Aus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eMM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eLRF/ int\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcGill, B., et al. (2018), Aus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eMM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eLRF/ int\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKozica, S., et al. (2015), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eObesity/ weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLewis, E., et al. (2019), Aus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUANT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eObesity/ weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePark, T., et al. (2017), Can\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eObesity/ weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePoltawski, L., et al. (2020), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eObesity/ weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaillot, A., et al. (2016), Can\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUANT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eObesity/weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAzzi, J. L., et al. (2020), Can\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eMM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003ePrediabetes/ diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSebire, S. J., et al. (2018), UK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eQUAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003ePrediabetes/ diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003eAbbreviations: Can = Canada; NZ = New Zealand; Aus = Australia; MM = Mixed Methods; QUANT = Quantitative; QUAL = Qualitative; LRF = Lifestyle Risk Factors; Int = Intervention; PA= Physical Activity; SU= Substance Use; SC = Social Connection\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eTo summarise the data, the included studies were thematically analysed to explore factors influencing the acceptability of LM and readiness for change among midlife adults. Five core themes emerged:\u003cem\u003e1. Timing and/or the teachable moment\u003c/em\u003e \u0026ndash; Lifestyle changes were often triggered by health scares, diagnoses, or screening events, emphasising the importance of timing and emotional readiness; \u003cem\u003e2. Positive experience\u003c/em\u003e \u0026ndash; High satisfaction, enjoyment, and a sense of empowerment were associated with greater acceptance and sustained engagement; \u003cem\u003e3. Support\u003c/em\u003e \u0026ndash; Ongoing support from facilitators, peers, and family was critical to initiating and maintaining lifestyle changes; \u003cem\u003e4. Confidence and self-efficacy\u003c/em\u003e \u0026ndash; Increased confidence in managing one\u0026rsquo;s health enhanced the likelihood of adopting and maintaining LM behaviours and \u003cem\u003e5. Non-acceptance\u003c/em\u003e \u0026ndash; Barriers such as competing demands, low motivation, or disbelief in risk reduced engagement and intervention acceptability.\u003c/p\u003e\n\u003cp\u003eIt should be noted that some lifestyle factors may have been included in these interventions but were not mentioned in the article. In addition, although social connection was not explicitly mentioned in many of the studies, several interventions included a group component, which fostered connections [5, 7, 15, 39, 44]. Care was taken, where possible, to only use qualitative data from participants within the midlife age range (40-65) where part of an age range in a study fell outside the parameters.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcceptability of LM\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe acceptability of LM to people in midlife were mapped to the five emerging themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTiming/teachable moment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe timing of lifestyle change varied across the studies. Eleven of the twenty-eight introduced a lifestyle change post-diagnosis often in response to the shock or implications of a medical condition [7, 9, 14, 35, 41, 43, 44, 49, 51, 52, 55]. Participants described motivation to avoid health deterioration: \u0026ldquo;(I) don\u0026rsquo;t want to go blind\u0026hellip; I want to stay as healthy as I can for as long as I can\u0026hellip;\u0026rdquo; [49]. Diagnosis often served as a \u0026lsquo;teachable moment\u0026rsquo; to reframe illness positively: \u0026ldquo;\u003cem\u003eI was a breast cancer survivor\u0026hellip; I actually embraced life and lived during my treatment.\u003c/em\u003e\u0026rdquo; [7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe concept of a teachable moment also extended to prevention [1, 53, 54]. Six studies focused on disease prevention before diagnosis [1, 3, 5, 21, 47, 54] and three studies examined preventive interventions based on genetic risk [2, 53, 54]. However, proactive use of LM was limited, often hindered by denial or low perceived risk: \u003cem\u003e\u0026ldquo;I guess you think you\u0026apos;re young and bullet proof\u0026hellip; I\u0026apos;ve never once thought about it\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e[21]. Cancer screening (e.g., cervical, breast, bowel) offered key opportunities to promote lifestyle change through direct healthcare interaction, with 79\u0026ndash;82% of participants open to receiving advice [1,53].\u003c/p\u003e\n\u003cp\u003eSix studies addressed obesity as both a disease state and a risk factor, where lifestyle change was driven by the goal of preventing multimorbidity [6, 13, 27, 32, 39, 42]. \u0026nbsp;Secondary prevention was also a strong motivator, particularly following a health scare or diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePositive experience\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePositive program experiences enhanced engagement, satisfaction, and empowerment [14]. Positive experiences were often attributed to well-designed programs, effective delivery, and the usefulness of tools and content provided. Four studies reported quantitative satisfaction and likelihood of recommending the intervention [1, 2, 5, 41], with an average satisfaction/recommendation rate of 83.35% across a total of 271 participants.\u003c/p\u003e\n\u003cp\u003eSeven studies provided qualitative evidence highlighting the effectiveness of interventions and participants\u0026apos; self-reported success and acceptance of lifestyle change [5, 7, 9, 13, 15, 36, 44]. Across these studies, high satisfaction was consistently linked to a positive emotional and physical experience: \u003cem\u003e\u0026ldquo;\u0026hellip;I feel so good!\u0026hellip; I love yoga and I can do things that I couldn\u0026rsquo;t do before.\u0026rdquo;\u003c/em\u003e [5].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSupport\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupport emerged as a key factor influencing behaviour change and the overall acceptability of lifestyle interventions, as reported in nineteen studies. Support was provided through health professionals, peer groups, and personal networks of family and friends.\u003c/p\u003e\n\u003cp\u003eA consistent finding across studies was the critical role of knowledgeable and encouraging health professionals or intervention facilitators in enabling positive behaviour change [1, 5, 7, 13, 27, 32, 36-38, 41, 44, 47, 49, 52]. Participants valued guidance and reinforcement from trusted professionals: \u003cem\u003e\u0026ldquo;It was good to have an outline of the important stuff from someone who knows about it\u0026rdquo; and \u0026ldquo;It was good having someone reinforce eating the right way and supporting you not to return to the bad habits\u003c/em\u003e\u0026rdquo; [39].\u003c/p\u003e\n\u003cp\u003ePeer support was also highly valued, providing motivation, accountability, and a sense of social belonging [5, 6, 16, 39, 44]. Group participation fostered a shared identity and functioned as a resource for maintaining lifestyle change: \u003cem\u003e\u0026ldquo;One person, she said, \u0026lsquo;We go to tea on this day. Do you want to join us?\u0026rsquo; and we developed a posse. We also started a book club, we try to hike once a month, we try to get together... for a dinner. And if one person has a question... she emailed her posse and you would not believe the fan-out of response...\u0026rdquo;\u003c/em\u003e [7].\u003c/p\u003e\n\u003cp\u003eFamily and friends also played a significant role in supporting change [3, 5, 21, 43]. In particular, lifestyle changes made in partnership were noted to enhance commitment and mutual benefit: \u003cem\u003e\u0026ldquo;\u0026hellip; you need to try and find something that both of you can do and enjoy doing\u0026hellip; my wife doesn\u0026apos;t like or isn\u0026apos;t a particularly good swimmer\u0026hellip; but we do like walking and we have to walk the dogs\u0026hellip; so we upped it to three times a day from two.\u0026rdquo;\u0026nbsp;\u003c/em\u003e[43].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConfidence and self-efficacy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNine studies reported that increased confidence contributed to greater self-efficacy, facilitating sustained lifestyle change [1, 6, 13, 27, 32, 39, 42, 44, 52]. As confidence grew, participants described becoming more independent in their health behaviours: \u003cem\u003e\u0026ldquo;Well, I suppose it just gave you the confidence to try and do some of these exercises on your own\u0026rdquo;\u0026nbsp;\u003c/em\u003e[44], and self-efficacy with greater sense of control: \u003cem\u003e\u0026ldquo;Instead of being a bit like a mindless eater and drinker I feel as though I\u0026rsquo;m in a more controlled situation about my own person.\u0026rdquo;\u0026nbsp;\u003c/em\u003e[42]. Interventions that incorporated motivational interviewing and goal setting promoted internal motivation [32, 44].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNon-acceptance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBarriers to accepting and sustaining lifestyle change were reported in fifteen studies and reflected common challenges in behaviour change. These included time constraints, employment (particularly sedentary work), cost, travel, competing responsibilities (e.g., childcare, family commitments), poor physical or mental health, stressful life events (e.g., bereavement, illness), low motivation, limited knowledge of risk factors, low health or digital literacy, inadequate support, and environmental factors such as weather [2, 5, 7, 9, 21, 35, 36, 39, 41, 44, 47, 49, 52, 55]. Participants shared frustrations: \u0026ldquo;\u003cem\u003eIt\u0026rsquo;s too expensive for us\u003c/em\u003e\u0026rdquo; [44], or lacked understanding: \u0026ldquo;\u003cem\u003eMy cholesterol was 250\u0026hellip; I don\u0026rsquo;t understand what that really means.\u003c/em\u003e\u0026rdquo; [55]. Maintaining behaviour change beyond the initial period of high motivation was also challenging for some participants: \u003cem\u003e\u0026ldquo;That [the program] was good to start off with, but I could sort of push [the program messages] by the wayside\u0026rdquo;\u0026nbsp;\u003c/em\u003e[27].\u003cem\u003e\u0026nbsp;\u003c/em\u003eDenial of risk or belief that change was unnecessary also limited engagement [44, 47, 55].\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOverall, both quantitative and qualitative findings suggest high acceptability of LM interventions in midlife. Participant perspectives highlighted the factors shaping this acceptability. The five emerging themes from these findings were mapped against Sekhon et al.\u0026rsquo;s [50] seven constructs in the TFA to illustrate how the themes align with established constructs in healthcare intervention acceptability (Figure 2).\u003c/p\u003e\n\u003cp\u003eEach of Sekhon et al.\u0026rsquo;s [50] seven TFA constructs corresponded with themes identified in this review, with one exception: the theme of \u003cem\u003esupport\u003c/em\u003e, which does not have a direct counterpart in the TFA. The construct \u003cem\u003eAffective Attitude\u003c/em\u003e aligns with the theme \u003cem\u003eTiming/Teachable Moment\u003c/em\u003e, reflecting participants\u0026rsquo; emotional responses at the recruitment stage. \u003cem\u003eEthicality\u003c/em\u003e, \u003cem\u003eIntervention Coherence\u003c/em\u003e, and \u003cem\u003ePerceived Effectiveness\u003c/em\u003e correspond to \u003cem\u003ePositive Experience\u003c/em\u003e, highlighting the importance of alignment with personal values, understanding of the intervention, and perceived outcomes. It is clear that tailoring interventions to individual lifestyles and providing support enhanced overall experience. While \u003cem\u003eSupport\u003c/em\u003e is not included in the TFA, it emerged as a key determinant of acceptability in 19 studies. Its role in promoting health and sustaining behaviour change is well established [46], underscoring its relevance in LM interventions. The theme \u003cem\u003eConfidence/Self-Efficacy\u003c/em\u003e maps directly to the construct \u003cem\u003eSelf-Efficacy\u003c/em\u003e, which refers to confidence in one\u0026rsquo;s ability to perform intervention-related behaviours. The constructs \u003cem\u003eBurden\u003c/em\u003e and \u003cem\u003eOpportunity Costs\u003c/em\u003e align with \u003cem\u003eNon-Acceptance\u003c/em\u003e, encompassing perceived effort, competing demands, and internal/external barriers [11]. Fourteen studies explicitly discussed these barriers, indicating their impact on engagement.\u003c/p\u003e\n\u003cp\u003eThese findings offer practical insights into enhancing LM interventions across three phases: recruitment, delivery, and sustained practice (Figure 2). \u003cem\u003eRecruitment\u003c/em\u003e is influenced by timing and teachable moments; \u003cem\u003edelivery\u003c/em\u003e benefits from well-designed programs that foster positive experiences, build confidence, and include strong support systems; and \u003cem\u003esustained practice\u003c/em\u003e requires addressing ongoing barriers to participation and change. These phases and their implications are examined further below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhase 1 - Recruitment\u003c/em\u003e\u003c/strong\u003e: \u003cstrong\u003e\u003cem\u003eSignificance of timing and the teachable moment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLM can serve both as a personalised approach to managing chronic conditions and as a preventive strategy [17]. In this review, the timing of LM engagement was classified into two phases: post-diagnosis and pre-disease prevention. \u0026ldquo;Teachable moments\u0026rdquo; \u0026ndash; defined by Lawson and Flocke [31] as events that trigger positive behavioural change \u0026ndash; were identified in both contexts, often coinciding with clinician\u0026ndash;patient interactions that enhanced motivation and receptiveness.\u003c/p\u003e\n\u003cp\u003ePost-diagnosis engagement was more commonly reported, with chronic disease serving as a strong catalyst for change [6, 7, 14, 41, 43, 51] For example, pharmacy-based interventions for men with prostate cancer were effectively delivered at critical decision points [43]. This phase was particularly effective for initiating LM due to heightened motivation [48].\u003c/p\u003e\n\u003cp\u003ePreventive interventions\u0026nbsp;\u0026ndash;\u0026nbsp;through screening, genetic testing, or obesity management\u0026nbsp;\u0026ndash;\u0026nbsp;also created teachable moments and were generally well received [1, 5, 13, 27, 32, 47, 53, 54]. However, preventive LM remains underused in practice [23]. Future efforts could include structured interventions during routine assessments (e.g., midlife health checks) or tailored resources (such as prostate cancer packs), which are currently available only in certain countries, accompanied by access to health coaching.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhase 2 - Delivery\u003c/em\u003e\u003c/strong\u003e: \u003cstrong\u003e\u003cem\u003eIntervention delivery with support as key\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree core themes\u0026nbsp;\u0026ndash;\u0026nbsp;positive experience, support, and confidence/self-efficacy\u0026nbsp;\u0026ndash;\u0026nbsp;were central to LM intervention delivery. These themes align sequentially with the LM acceptance process: starting with a teachable moment, progressing through implementation, and leading to sustained behaviour change. Support spans all stages, with facilitators, peers, and family contributing at different points. Conversely, non-acceptance can emerge at any phase and requires continuous attention.\u003c/p\u003e\n\u003cp\u003ePositive experiences were associated with programs tailored to participant demographics, preferences, and delivery modes [13, 35, 37]. Techniques like motivational interviewing, goal-setting, and personalised feedback enhanced engagement\u0026nbsp;\u0026ndash;\u0026nbsp;supporting person-based approaches to intervention design [58] and the role of positive affect in decision-making [19].\u003c/p\u003e\n\u003cp\u003eAmong all themes, support was most influential. Facilitators played a key role early on, especially following a teachable moment, by offering knowledge, empathy, and encouragement. Peer groups fostered motivation and social connection throughout, while family and friends reinforced accountability and long-term lifestyle integration [12]. Embedding multi-source support in LM programs is essential, and future research should explore effective ways to incorporate it.\u003c/p\u003e\n\u003cp\u003eConfidence and self-efficacy were also vital to sustaining change, particularly as participants moved toward independently maintaining LM behaviours. Defined as belief in one\u0026rsquo;s ability to control actions and environment [8], self-efficacy is consistently linked to successful behaviour change [40].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhase 3 \u0026ndash; Sustained practice: Addressing non-acceptance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnderstanding what hinders LM acceptance is critical to improving uptake and long-term adherence. This review identified three key barriers: practical and psychosocial obstacles, difficulty maintaining change, and negative attitudes or denial [27].\u003c/p\u003e\n\u003cp\u003eCommon obstacles included time pressures, competing responsibilities, and insufficient support. These may be addressed through timely intervention and continued assistance from facilitators, peers, and family. Maintenance difficulties were often linked to declining motivation and failure to integrate changes into daily life\u0026nbsp;\u0026ndash;\u0026nbsp;issues that long-term social support can help resolve.\u003c/p\u003e\n\u003cp\u003eNegative perceptions, such as denial of health risk or the belief that change is unnecessary, also reduced engagement. Targeted education, motivational interviewing, and self-reflection during teachable moments may help counteract these attitudes.\u003c/p\u003e\n\u003cp\u003eTo strengthen acceptability and sustainability, facilitators should apply a health coaching approach that assesses readiness, identifies barriers, and personalises support. Integrating this model into LM programs may enhance both initial engagement and long-term behavioural maintenance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGaps in the literature and opportunities for future research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough the evidence base supporting LM is expanding, few studies have specifically focused on midlife as a critical period of behavioural and health transition [29]. With increasing rates of chronic disease and an ageing population, research targeting the midlife age group (40\u0026ndash;65 years) is urgently needed [4, 57]. Most LM studies to date have examined broad adult populations (18 and over), overlooking the unique challenges and opportunities presented during midlife [22].\u003c/p\u003e\n\u003cp\u003eFuture research should prioritise the integration of LM earlier in midlife, with particular attention to how interventions are delivered and framed. This review identified five key elements associated with LM acceptability\u0026nbsp;\u0026ndash;\u0026nbsp;timing/teachable moment, positive experience, support, confidence/self-efficacy, and addressing non-acceptance\u0026nbsp;\u0026ndash;\u0026nbsp;which should inform future intervention design tailored to this life stage.\u003c/p\u003e\n\u003cp\u003eUnderstanding the perceptions of those not yet exposed to LM is also essential. Exploring midlife adults\u0026rsquo; awareness, attitudes, and readiness to engage with LM could offer valuable insights into how to promote preventive behaviour before chronic disease onset.\u003c/p\u003e\n\u003cp\u003eIn addition, equity must be a focus. LM interventions are often delivered individually or in small groups, which may limit accessibility for disadvantaged or culturally diverse populations. Future studies should consider inclusive, community-based approaches\u0026nbsp;\u0026ndash;\u0026nbsp;such as those informed by the CELM framework [28]\u0026nbsp;\u0026ndash;\u0026nbsp;to ensure broader applicability and reach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review has some limitations. Firstly, it only includes publications from four countries, Australia, Canada, New Zealand and UK. The exclusion of other countries is likely to have led to missing publications which could have added value to this review. Secondly, grey literature was not included which may have provided useful information on LM health promotion interventions for people in midlife. Thirdly, as LM is a relatively new concept, a lack of publications referring to LM existed; lifestyle interventions typically included only a few of the six pillars of LM. Additionally, the term midlife can include differing age ranges, a selection of the studies included adults from a larger age range. In qualitative research, where age was specified, care was taken to only select quotes from participants in the 40-65 age range.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis review has revealed critical factors that enable LM interventions to be acceptable to participants. Coupled with the analysis of alignment with Sekhon\u0026rsquo;s TFA this research gives clues to how LM interventions can achieve greater acceptability for midlife participants. The five themes of timing and teachable moment, positive experience, support, confidence and self-efficacy and non-acceptance underpin the success of LM interventions, so future campaigns should consider these aspects in intervention delivery. Importantly, the inclusion of support, which is absent in Sekhon\u0026rsquo;s TFA should inform the design of future interventions, either through facilitator-led, community-based or family-supported mechanisms.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eJ.B. conceptualised the study, conducted the literature review, performed data collection and analysis, and drafted and wrote the main manuscript text. S.M and K.C. provided guidance on study design, provided critical input on methodology, assisted and contributed to manuscript revisions including intellectual content. All authors reviewed and approved the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAnderson AS, Macleod M, Mutrie N, et al. Breast cancer risk reduction - is it feasible to initiate a randomised controlled trial of a lifestyle intervention programme (ActWell) within a national breast screening programme? \u003cem\u003eThe international journal of behavioral nutrition and physical activity\u003c/em\u003e. 2014;11(1).\u003c/li\u003e\n\u003cli\u003eAnderson AS, Dunlop J, Gallant S, et al. Feasibility study to assess the impact of a lifestyle intervention (\u0026lsquo;LivingWELL\u0026rsquo;) in people having an assessment of their family history of colorectal or breast cancer. \u003cem\u003eBMJ open\u003c/em\u003e. 2018;8(2):e019410. \u003c/li\u003e\n\u003cli\u003eAshley C, Halcomb E, McInnes S, et al. Middle-aged Australians\u0026rsquo; perceptions of support to reduce lifestyle risk factors: a qualitative study. \u003cem\u003eAustralian journal of primary health\u003c/em\u003e. 2020;26(4):313. \u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare (AIHW). \u0026ldquo;Ageing and the health system: challenges, opportunities and adaptations.\u0026rdquo; Australian Government. https://www.aihw.gov.au/getmedia/19dbc591-b1ef-4485-80ce-029ff66d6930/6_9-health-ageing.pdf.aspx. Accessed September 5, 2024.\u003c/li\u003e\n\u003cli\u003eAzzi JL, Azzi S, Lavigne-Robichaud M, et al. Participant Evaluation of a Prediabetes Intervention Program Designed for Rural Adults. \u003cem\u003eCanadian journal of dietetic practice and research\u003c/em\u003e. 2020;81(2):80-85.\u003c/li\u003e\n\u003cli\u003eBaillot A, Mampuya WM, Dionne IJ, Comeau E, M\u0026eacute;ziat-Burdin A, Langlois MF. Impacts of Supervised Exercise Training in Addition to Interdisciplinary Lifestyle Management in Subjects Awaiting Bariatric Surgery: a Randomized Controlled Study. \u003cem\u003eObesity surgery\u003c/em\u003e. 2016;26(11):2602-2610.\u003c/li\u003e\n\u003cli\u003eBalneaves LG, Truant TLO, Van Patten C, Kirkham AA, Waters E, Campbell KL. Patient and Medical Oncologists\u0026rsquo; Perspectives on Prescribed Lifestyle Intervention\u0026mdash;Experiences of Women with Breast Cancer and Providers. \u003cem\u003eJournal of clinical medicine\u003c/em\u003e. 2020;9(9):2815.\u003c/li\u003e\n\u003cli\u003eBandura A. Self-efficacy: Toward a unifying theory of behavioral change. \u003cem\u003ePsychological review\u003c/em\u003e. 1977;84(2):191-215.\u003c/li\u003e\n\u003cli\u003eBanner D, Lear S, Kandola D, et al. The experiences of patients undertaking a \u0026ldquo;virtual\u0026rdquo; cardiac rehabilitation program. In: \u003cem\u003eStudies in Health Technology and Informatics\u003c/em\u003e. Vol 209. ; 2015:9.\u003c/li\u003e\n\u003cli\u003eDattani S, Spooner F, Ritchie H, et al. \u0026ldquo;Causes of Death\u0026rdquo; OurWorldinData.org. https://ourworldindata.org/causes-of-death. Accessed September 5, 2024.\u003c/li\u003e\n\u003cli\u003eDavis R, Campbell R, Hildon Z, Hobbs L, Michie S. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. \u003cem\u003eHealth psychology review\u003c/em\u003e. 2015;9(3):323-344.\u003c/li\u003e\n\u003cli\u003eDorn C, Phillips S, Nicol S, Russell H, Guenther E. Motivations Behind Lifestyle Changes. \u003cem\u003eAmerican journal of lifestyle medicine\u003c/em\u003e. 2023;17(3):443-447. \u003c/li\u003e\n\u003cli\u003eDriscoll S, Meyerowitz-Katz G, Ahlenstiel G, Reynolds T, Reid K, Bishay RH. Efficacy of Telephone Health Coaching Integration with Standard Multidisciplinary Care for Adults with Obesity Attending a Weight Management Service: A Pilot Study. \u003cem\u003eNutrients\u003c/em\u003e. 2021;13(11):4078.\u003c/li\u003e\n\u003cli\u003eDullaghan L, Lusk L, McGeough M, Donnelly P, Herity N, Fitzsimons D. \u0026lsquo;I am still a bit unsure how much of a heart attack it really was!\u0026rsquo; Patients presenting with non ST elevation myocardial infarction lack understanding about their illness and have less motivation for secondary prevention. \u003cem\u003eEuropean journal of cardiovascular nursing\u003c/em\u003e\u003cem\u003e : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology\u003c/em\u003e. 2014;13(3):270-276.\u003c/li\u003e\n\u003cli\u003eEgger GJ, Binns AF, Rossner SR. The emergence of \u0026ldquo;lifestyle medicine\u0026rdquo; as a structured approach for management of chronic disease. \u003cem\u003eMedical Journal of Australia\u003c/em\u003e. 2009;190(3):143-145.\u003c/li\u003e\n\u003cli\u003eEgger G, Dixon J, Meldrum H, et al. Patients\u0026rsquo; and providers\u0026rsquo; satisfaction with shared medical appointments. \u003cem\u003eAustralian family physician\u003c/em\u003e. 2015;44(9):674-679.\u003c/li\u003e\n\u003cli\u003eFallows ES. Lifestyle medicine: a cultural shift in medicine that can drive integration of care. \u003cem\u003eFuture healthcare journal\u003c/em\u003e. 2023;10(3):226-231.\u003c/li\u003e\n\u003cli\u003eFord ES, Bergmann MM, Kr\u0026ouml;ger J, Schienkiewitz A, Weikert C, Boeing H. Healthy Living Is the Best Revenge: Findings From the European Prospective Investigation Into Cancer and Nutrition\u0026ndash;Potsdam Study. \u003cem\u003eArchives of internal medicine (1960)\u003c/em\u003e. 2009;169(15):1355-1362.\u003c/li\u003e\n\u003cli\u003eFredrickson BL. The Role of Positive Emotions in Positive Psychology: The Broaden-and-Build Theory of Positive Emotions. \u003cem\u003eThe American psychologist\u003c/em\u003e. 2001;56(3):218-226.\u003c/li\u003e\n\u003cli\u003eHacker K. The Burden of Chronic Disease. \u003cem\u003eMayo Clinic proceedings Innovations, quality \u0026amp; outcomes\u003c/em\u003e. 2024;8(1):112-119.\u003c/li\u003e\n\u003cli\u003eHalcomb E, Ashley C, Middleton R, et al. Understanding perceptions of health, lifestyle risks and chronic disease in middle age. \u003cem\u003eJournal of clinical nursing\u003c/em\u003e. 2021;30(15-16):2279-2286. \u003c/li\u003e\n\u003cli\u003eInfurna FJ, Gerstorf D, Lachman ME. Midlife in the 2020s: Opportunities and Challenges. \u003cem\u003eThe American psychologist\u003c/em\u003e. 2020;75(4):470-485.\u003c/li\u003e\n\u003cli\u003eInstitute for Advancing Health Value. \u0026ldquo;The Potential of Lifestyle Medicine as a High Value Approach to Address Health Equity\u0026rdquo;. https://lifestylemedicine.org/wp-content/uploads/2022/09/institute_ib_lifestyle-medicine-aclm-0922.pdf. Accessed September 20, 2024.\u003c/li\u003e\n\u003cli\u003eKhan HTA, Addo KM, Findlay H. Public Health Challenges and Responses to the Growing Ageing Populations. \u003cem\u003ePublic health challenges\u003c/em\u003e. 2024;3(3):e213-n/a.\u003c/li\u003e\n\u003cli\u003eKhangura S, Konnyu K, Cushman R, Grimshaw J, Moher D. Evidence summaries: the evolution of a rapid review approach. \u003cem\u003eSystematic Reviews\u003c/em\u003e. 2012;1(1).\u003c/li\u003e\n\u003cli\u003eKing VJ, Stevens A, Nussbaumer-Streit B, Kamel C, Garritty C. Paper 2: Performing rapid reviews. \u003cem\u003eSystematic Reviews\u003c/em\u003e. 2022;11(1).\u003c/li\u003e\n\u003cli\u003eKozica S, Lombard C, Teede H, Ilic D, Murphy K, Harrison C. Initiating and Continuing Behaviour Change within a Weight Gain Prevention Trial: A Qualitative Investigation. \u003cem\u003ePloS one\u003c/em\u003e. 2015;10(4):e0119773.\u003c/li\u003e\n\u003cli\u003eKrishnaswami J, Sardana J, Daxini A. Community-Engaged Lifestyle Medicine as a Framework for Health Equity: Principles for Lifestyle Medicine in Low-Resource Settings. \u003cem\u003eAmerican journal of lifestyle medicine\u003c/em\u003e. 2019;13(5):443-450. \u003c/li\u003e\n\u003cli\u003eLachman ME, Teshale S, Agrigoroaei S. Midlife as a pivotal period in the life course: Balancing growth and decline at the crossroads of youth and old age. \u003cem\u003eInternational journal of behavioral development\u003c/em\u003e. 2015;39(1):20-31.\u003c/li\u003e\n\u003cli\u003eLange-Maia BS, Karavolos K, Avery EF, et al. Contribution of common chronic conditions to midlife physical function decline: The Study of Women\u0026rsquo;s Health Across the Nation. \u003cem\u003eWomen\u0026rsquo;s Midlife Health\u003c/em\u003e. 2020;6(1).\u003c/li\u003e\n\u003cli\u003eLawson PJ, Flocke SA. Teachable moments for health behavior change: A concept analysis. \u003cem\u003ePatient education and counseling\u003c/em\u003e. 2009;76(1):25-30.\u003c/li\u003e\n\u003cli\u003eLewis E, Huang HCC, Hassm\u0026eacute;n P, Welvaert M, Pumpa KL. Adding Telephone and Text Support to an Obesity Management Program Improves Behavioral Adherence and Clinical Outcomes. A Randomized Controlled Crossover Trial. \u003cem\u003eInternational journal of behavioral medicine\u003c/em\u003e. 2019;26(6):580-590.\u003c/li\u003e\n\u003cli\u003eLiotta, M. \u0026ldquo;Where in Australia is chronic disease most prevalent?\u0026rdquo; The Royal Australian College of General Practitioners (RACGP). https://www1.racgp.org.au/newsgp/clinical/where-in-australia-is-chronic-disease-most-prevale. Accessed September 15, 2024.\u003c/li\u003e\n\u003cli\u003eLippman D, Stump M, Veazey E, et al. Foundations of Lifestyle Medicine and its Evolution. \u003cem\u003eMayo Clinic proceedings Innovations, quality \u0026amp; outcomes\u003c/em\u003e. 2024;8(1):97-111.\u003c/li\u003e\n\u003cli\u003eMcGarrol S. Contextualising lifestyles: how socially contrasting places in Fife, Scotland influence lay understandings of lifestyle and health behaviours in relation to coronary heart disease. \u003cem\u003eHealth \u0026amp; place\u003c/em\u003e. 2020;66.\u003c/li\u003e\n\u003cli\u003eMcGill B, O\u0026rsquo;Hara B, Phongsavan P. Participant perspectives of a 6-month telephone-based lifestyle coaching program. \u003cem\u003ePublic Health Research \u0026amp; Practice\u003c/em\u003e. 2018;28(2).\u003c/li\u003e\n\u003cli\u003eMcGuire AM, Seib C, Porter-Steele J, Anderson DJ. The Association Between Web-Based or Face-to-Face Lifestyle Interventions on the Perceived Benefits and Barriers to Exercise in Midlife Women: Three-Arm Equivalency Study. \u003cem\u003eJournal of medical Internet research\u003c/em\u003e. 2019;21(8):e10963.\u003c/li\u003e\n\u003cli\u003eMcGuire AM, Porter-Steele J, McDonald N, Burgess SC, Anderson DJ, Seib C. Reducing noncommunicable disease risk in midlife adults using eHealth: The GroWell for Health Program feasibility study. \u003cem\u003eCollegian (Royal College of Nursing, Australia)\u003c/em\u003e. 2022;29(3):328-336. \u003c/li\u003e\n\u003cli\u003ePark T, Foster K, Usher K. Participants\u0026rsquo; Voices From Within a Healthy Lifestyle Group. \u003cem\u003eIssues in mental health nursing\u003c/em\u003e. 2017;38(2):107-112.\u003c/li\u003e\n\u003cli\u003ePekmezi D, Jennings E, Marcus BH. Evaluating And Enhancing Self-Efficacy For Physical Activity. \u003cem\u003eACSM\u0026rsquo;s health \u0026amp; fitness journal\u003c/em\u003e. 2009;13(2):16-21. \u003c/li\u003e\n\u003cli\u003ePolley MJ, Jolliffe R, Boxell E, Zollman C, Jackson S, Seers H. Using a Whole Person Approach to Support People With Cancer: A Longitudinal, Mixed-Methods Service Evaluation. \u003cem\u003eIntegrative cancer therapies\u003c/em\u003e. 2016;15(4):435-445.\u003c/li\u003e\n\u003cli\u003ePoltawski L, van Beurden SB, Morgan-Trimmer S, Greaves C. The dynamics of decision-making in weight loss and maintenance: a qualitative enquiry. \u003cem\u003eBMC public health\u003c/em\u003e. 2020;20(1).\u003c/li\u003e\n\u003cli\u003ePoole K, Ogden J, Gasson S, et al. Creating a teachable moment in community pharmacy for men with prostate cancer: A qualitative study of lifestyle changes. \u003cem\u003ePsycho-oncology (Chichester, England)\u003c/em\u003e. 2019;28(3):593-599.\u003c/li\u003e\n\u003cli\u003ePowter H, Lambert K, Nicholls N. Experiences and perspectives of integrating nutrition education into an exercise program for people with chronic medical conditions. \u003cem\u003eHealth promotion journal of Australia\u003c/em\u003e. 2024;35(4):1098-1115. \u003c/li\u003e\n\u003cli\u003ePRISMAStatement. \u003cem\u003ePRISMA Flow Diagram\u003c/em\u003e. https://www.prisma-statement.org/prisma-2020-flow-diagram. Accessed September 18, 2024.\u003c/li\u003e\n\u003cli\u003eReblin M, Uchino BN. Social and emotional support and its implication for health. \u003cem\u003eCurrent opinion in psychiatry\u003c/em\u003e. 2008;21(2):201-205.\u003c/li\u003e\n\u003cli\u003eRiley R, Coghill N, Montgomery A, Feder G, Horwood J. Experiences of patients and healthcare professionals of NHS cardiovascular health checks: a qualitative study. \u003cem\u003eJournal of public health (Oxford, England)\u003c/em\u003e. 2016;38(3):543-551.\u003c/li\u003e\n\u003cli\u003eSamuel PO, Edo GI, Emakpor OL, et al. Lifestyle modifications for preventing and managing cardiovascular diseases. \u003cem\u003eSport sciences for health\u003c/em\u003e. 2024;20(1):23-36.\u003c/li\u003e\n\u003cli\u003eSebire SJ, Toumpakari Z, Turner KM, et al. \u0026ldquo;I\u0026rsquo;ve made this my lifestyle now\u0026rdquo;: a prospective qualitative study of motivation for lifestyle change among people with newly diagnosed type two diabetes mellitus. \u003cem\u003eBMC public health\u003c/em\u003e. 2018;18(1).\u003c/li\u003e\n\u003cli\u003eSekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. \u003cem\u003eBMC health services research\u003c/em\u003e. 2017;17(1).\u003c/li\u003e\n\u003cli\u003eShingler E, Hackshaw-McGeagh L, Robles L, et al. The feasibility of the Prostate cancer: Evidence of Exercise and Nutrition Trial (PrEvENT) dietary and physical activity modifications: a qualitative study. \u003cem\u003eCurrent controlled trials in cardiovascular medicine\u003c/em\u003e. 2017;18(1).\u003c/li\u003e\n\u003cli\u003eStead M, Craigie AM, Macleod M, et al. Why are some people more successful at lifestyle change than others? Factors associated with successful weight loss in the BeWEL randomised controlled trial of adults at risk of colorectal cancer. \u003cem\u003eThe international journal of behavioral nutrition and physical activity\u003c/em\u003e. 2015;12(1).\u003c/li\u003e\n\u003cli\u003eStevens C, Vrinten C, Smith SG, Waller J, Beeken RJ. Acceptability of receiving lifestyle advice at cervical, breast and bowel cancer screening. \u003cem\u003ePreventive medicine\u003c/em\u003e. 2019;120:19-25. \u003c/li\u003e\n\u003cli\u003eTarr GP, Crowley A, John R, et al. Do high risk patients alter their lifestyle to reduce risk of colorectal cancer? \u003cem\u003eBMC gastroenterology\u003c/em\u003e. 2014;14(1).\u003c/li\u003e\n\u003cli\u003eThrondson K, Sawatzky JAV, Schultz A. Exploring the Perceptions and Health Behaviours of Patients Following an Elective Ad-hoc Percutaneous Coronary Intervention: A Qualitative Study. \u003cem\u003eCanadian journal of cardiovascular nursing\u003c/em\u003e. 2016;26(2):25-32. \u003c/li\u003e\n\u003cli\u003eVega MR, Nadeem S, Vaughan EM, Johnston CA. The Use of Reframing: Increasing the Importance of Lifestyle Medicine. \u003cem\u003eAmerican journal of lifestyle medicine\u003c/em\u003e. 2023;17(6):746-749.\u003c/li\u003e\n\u003cli\u003eWorld Health Organisation (WHO). \u003cem\u003eAgeing and health\u003c/em\u003e. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health. Accessed September 5, 2024.\u003c/li\u003e\n\u003cli\u003eYardley L, Morrison L, Bradbury K, Muller I. The Person-Based Approach to Intervention Development: Application to Digital Health-Related Behavior Change Interventions. \u003cem\u003eJournal of medical Internet research\u003c/em\u003e. 2015;17(1):e30.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lifestyle, Health Behaviour, Chronic Disease, Preventative Health Services, Middle Aged, Patient Acceptance of Health Care","lastPublishedDoi":"10.21203/rs.3.rs-7504849/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7504849/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis rapid review examined the acceptability of Lifestyle Medicine (LM) interventions among midlife adults (40\u0026ndash;65 years), exploring experiences and perceptions across health contexts. The review sought to identify factors influencing engagement with LM to inform future health promotion strategies.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA rapid review of peer-reviewed studies published between 2013 and 2023 was conducted across five databases. Eligible studies were from Australia, Canada, New Zealand, or the United Kingdom, involved adults aged 40\u0026ndash;65, and addressed at least two LM pillars. A thematic synthesis was applied across qualitative, quantitative, and mixed methods designs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTwenty-eight studies met the inclusion criteria. Five themes were identified: (1) \u003cem\u003eTiming and Teachable Moments\u003c/em\u003e \u0026ndash; health events increased receptivity to change; (2) \u003cem\u003ePositive Experience\u003c/em\u003e \u0026ndash; enjoyment and perceived benefits enhanced engagement; (3) \u003cem\u003eSupport\u003c/em\u003e \u0026ndash; professional and social support facilitated change; (4) \u003cem\u003eConfidence and Self-Efficacy\u003c/em\u003e \u0026ndash; belief in one\u0026rsquo;s ability enabled sustained practice; and (5) \u003cem\u003eNon-Acceptance\u003c/em\u003e \u0026ndash; barriers included time, motivation, and perceived relevance. These themes were mapped to Sekhon et al.\u0026rsquo;s [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] Theoretical Framework of Acceptability (TFA), which comprises seven constructs related to the acceptability of healthcare interventions; notably, support was absent from the original framework. LM was predominantly implemented post-diagnosis, with limited preventive application.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eLM is broadly acceptable to midlife adults, particularly when introduced during significant health events and reinforced through professional and social support. Preventive use, however, remains underutilised. Future strategies should harness routine health assessments and deliver personalised, multi-pillar LM interventions to maximise impact.\u003c/p\u003e","manuscriptTitle":"The Acceptability of Lifestyle Medicine Approaches for People in Midlife: A Rapid Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-28 16:40:58","doi":"10.21203/rs.3.rs-7504849/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73496289-7aee-457a-98a6-6f5e325bc2c6","owner":[],"postedDate":"October 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-28T16:40:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-28 16:40:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7504849","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7504849","identity":"rs-7504849","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}