{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T08:51:50Z","timestamp":1791967910704,"version":"4.3.4"},"update-to":[{"DOI":"10.3310\/nihropenres.14190.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T00:00:00Z","timestamp":1771545600000}}],"reference-count":45,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T00:00:00Z","timestamp":1771545600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/www.nationalarchives.gov.uk\/doc\/open-government-licence\/version\/3\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"National Institute for Health and Care Research","doi-asserted-by":"publisher","award":["NIHR301286"],"award-info":[{"award-number":["NIHR301286"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["openresearch.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["NIHR Open Res"],"abstract":"<ns3:p>\n                    Background Since the recent introduction of highly effective modulator therapies (HEMT), adults with cystic fibrosis (CF) have experienced significant health improvements. However, HEMTs can also lead to weight gain, and over 30% of adults living with CF, are now overweight or obese. The English National Health Service digital Weight Management Programme (NHS digital WMP) is offered to adults with obesity to support weight loss. This programme may not meet the complex health needs of people living with CF and may not address the established diet and physical activity behaviours that may contribute to weight gain in this population. Methods This paper outlines the steps to co-develop a CF-specific weight management programme (CF WMP), designed to be delivered alongside an NHS digital WMP. The CF-specific programme will be developed in collaboration with people with CF who have overweight or obesity (PwCF\n                    <ns3:sup>ow\/ob<\/ns3:sup>\n                    ) and professional stakeholders, using the three phases of the Person Based Approach (PBA); planning, co-designing and optimising. Planning Mixed-methods research with PwCF\n                    <ns3:sup>ow\/ob<\/ns3:sup>\n                    and CF health care professionals will identify the barriers and facilitators to healthy eating and physical activity experienced by PwCF\n                    <ns3:sup>ow\/ob<\/ns3:sup>\n                    . This will inform the guiding principles to underpin the co-design of the CF WMP and how it will address the dietary and physical activity behavioural needs of PwCF\n                    <ns3:sup>ow\/ob<\/ns3:sup>\n                    to ensure it is engaging, acceptable and motivating. Co-design: a series of participatory workshops with PwCF\n                    <ns3:sup>ow\/ob<\/ns3:sup>\n                    and key stakeholders will use guiding principles to specify design objectives and corresponding intervention features. Optimising: think aloud interviews with PwCF\n                    <ns3:sup>ow\/ob<\/ns3:sup>\n                    will gather feedback on the CF WMP, to iteratively refine the programme. Discussion The resulting CF WMP will extend the usability of an NHS digital WMP to adults with CF, to better ensure it meets their needs, which have changed since the introduction of HEMT.\n                  <\/ns3:p>","DOI":"10.3310\/nihropenres.14190.2","type":"journal-article","created":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T15:59:06Z","timestamp":1771603146000},"page":"7","update-policy":"https:\/\/doi.org\/10.3310\/nihropenres.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Development of a Cystic Fibrosis Weight Management Programme:\u00a0 protocol for a co-design study"],"prefix":"10.3310","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5601-4028","authenticated-orcid":false,"given":"Joanne","family":"Barrett","sequence":"first","affiliation":[{"name":"West Midlands Adult CF Centre Birmingham England B9 5SS University Hospitals Birmingham NHS Foundation Trust"},{"name":"School of Sport Exercise and Rehabilitation Sciences Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0111-2341","authenticated-orcid":false,"given":"Anne Elizabeth","family":"Topping","sequence":"additional","affiliation":[{"name":"College of Medicine and Health Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikos","family":"Ntoumanis","sequence":"additional","affiliation":[{"name":"Department of Sports Science and Clinical Biomechanics Odense M Island of Funen DK-5230 University of Southern Denmark"},{"name":"School of Sport Exercise and Rehabilitation Sciences Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5947-3254","authenticated-orcid":false,"given":"Alice Margaret","family":"Turner","sequence":"additional","affiliation":[{"name":"Institute of Applied Health 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Yardley"},{"key":"ref35","doi-asserted-by":"crossref","first-page":"S169-S170","DOI":"10.1016\/S1569-1993(24)00627-1","article-title":"P330 Navigating the unknown an international survey of current dietetic practices for overweight and obesity in people with Cystic Fibrosis.","volume":"23","author":"J Snowball","year":"2024","journal-title":"J Cyst Fibros."},{"key":"ref36","doi-asserted-by":"publisher","first-page":"63-72","DOI":"10.1080\/1091367X.2021.1948414","article-title":"Validation of the actigraph wGT3X-BT accelerometer for step counts at five different body locations in laboratory settings.","volume":"26","author":"A Karaca","year":"2022","journal-title":"Meas Phys Educ Exerc Sci."},{"key":"ref37","doi-asserted-by":"publisher","first-page":"136","DOI":"10.1186\/s12916-018-1113-8","article-title":"Validity of an online 24-h recall tool (myfood24) for dietary assessment in population studies: comparison with biomarkers and standard interviews.","volume":"16","author":"P 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status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.3310\/nihropenres.15447.r39224, Sarah Collins, CF Therapies, Royal Brompton and Harefield Hospitals (Ringgold ID: 4964), London, England, 27 Jan 2026, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-7\/v1#referee-response-39224","order":0,"name":"referee-response-39224","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Joanne Barrett<\/b>; \n<i>Posted: 04 Feb 2026<\/i>; \n<b>Response to Reviewer 1<\/b> Thank you for your thorough and constructive review of our manuscript. We appreciate your favourable assessment of the study rationale, methodological approach, and the contribution this work makes to an emerging area of clinical need. We have carefully considered your suggestions and have revised the manuscript accordingly. Please note that there may be a delay in uploading documents outlined below to the edata repository, but this has been request.  \n<b>1. Consideration of lifestyle and demographic factors<\/b> We agree that factors such as age, socioeconomic status, sex, and disease severity may influence weight management behaviours and engagement with digital interventions. To address this, we have expanded the introduction to acknowledge the potential influence of these demographic and lifestyle characteristics on overweight and obesity. \n<i>\u2018The aetiology of weight gain is unclear, although several factors such as a reduction in the frequency of respiratory infections and resting energy expenditure, decreased gut inflammation, and increased fat intake and absorption have been suggested (<\/i>\n<i>12, 13)<\/i>\n<i>. Lifestyle and demographic factors such as older age, pancreatic status, disease severity and sex&nbsp; are also likely to play a role, as well as&nbsp; diet and physical activity behaviours formed as a consequence of CF management strategies<\/i>\n<i>(11, 14, 15)<\/i>\n<i> Specifically, adults with CF may continue to adhere to a high energy diet when no longer necessary, leading to the development of overweight or obesity <\/i>\n<i>(16)<\/i>\n<i>&nbsp; <\/i>\n<i>In addition, levels of moderate-to-vigorous physical activity \u2013 which may contribute to maintaining a healthy weight - have been found to be lower in people with CF<\/i>\n<i>(17, 18)<\/i>\n<i>. \u2018<\/i> Digital exclusion as a potential limitation has been acknowledged also in the introduction. \n<i>\u2018Digital delivery may introduce potential limitations related to digital exclusion; however, an increasing proportion of CF care is now delivered remotely, and digital models align with the emerging model of CF care and NHS policy plans (28). However, this programme has not been trialled in the CF population, and may not meet their complex dietary, physical and psychological needs.\u2019 <\/i>  \n<b>2. Clarification of data management, organisation, and governance<\/b> Thank you for highlighting the need for greater clarity regarding data handling. We have now added a dedicated statement within the \u2018data availability\u2019 section outlining how datasets generated during the study will be organised and stored. To support the co-design process we have further outlined how a summary of the integrated qualitative and quantitative findings from the planning stage will be presented to the co-design team. &nbsp;We hope this will enhance transparency and support study reproducibility. \n<b><i>\u2018Data Availability<\/i><\/b> \n<i>No data are associated with this article. The protocols, interview guides, future co-design workshop documentation and future data sets for this study can be accessed at the University of Birmingham eData repository <\/i>\n<i>https:\/\/doi.org\/10.25500\/edata.bham.00001503<\/i>\n<i>\u2019<\/i>","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-7\/v2#referee-comment-3535","order":1,"name":"referee-comment-3535","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15510.r39675, Ammar Ahmed, University of Minnesota School of Medicine, Minneapolis, Minnesota, 26 Feb 2026, version 2, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-7\/v2#referee-response-39675","order":2,"name":"referee-response-39675","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15447.r39296, Kimberly McBennett, Case Western Reserve University Department of Medicine, Cleveland, Ohio, 16 Feb 2026, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-7\/v1#referee-response-39296","order":3,"name":"referee-response-39296","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The authors would like to thank the National Institute for Health and Care Research (NIHR) for funding this project (NIHR301286). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This open access work is licensed under the Open Government Licence v3.0.","order":0,"name":"copyright-info","label":"Copyright"}]}}