Anthony Kessel

Exploring the evidence base for national and regional policy interventions to combat resistance

The effectiveness of existing policies to control antimicrobial resistance is not yet fully understood. A strengthened evidence base is needed to inform effective policy interventions across countries with different income levels and the human health and animal sectors. We examine three policy domains-responsible use, surveillance, and infection prevention and control-and consider which will be the most effective at national and regional levels. Many complexities exist in the implementation of such policies across sectors and in varying political and regulatory environments. Therefore, we make recommendations for policy action, calling for comprehensive policy assessments, using standardised frameworks, of cost-effectiveness and generalisability. Such assessments are especially important in low-income and middle-income countries, and in the animal and environmental sectors. We also advocate a One Health approach that will enable the development of sensitive policies, accommodating the needs of each sector involved, and addressing concerns of specific countries and regions.

A pragmatic randomised controlled trial in primary care of the Camden Weight Loss (CAMWEL) programme

Objectives To evaluate effectiveness of a structured one-to-one behaviour change programme on weight loss in obese and overweight individuals. Design Randomised controlled trial. Setting 23 general practices in Camden, London. Participants 381 adults with body mass index ≥25 kg/m2 randomly assigned to intervention (n=191) or control (n=190) group. Interventions A structured one-to-one programme, delivered over 14 visits during 12 months by trained advisors in three primary care centres compared with usual care in general practice. Outcome measures Changes in weight, per cent body fat, waist circumference, blood pressure and heart rate between baseline and 12 months. Results 217/381 (57.0%) participants were assessed at 12 months: missing values were imputed. The difference in mean weight change between the intervention and control groups was not statistically significant (0.70 kg (0.67 to 2.17, p=0.35)), although a higher proportion of the intervention group (32.7%) than the control group (20.4%) lost 5% or more of their baseline weight (OR: 1.80 (1.02 to 3.18, p=0.04)). The intervention group achieved a lower mean heart rate (mean difference 3.68 beats per minute (0.31 to 7.04, p=0.03)) than the control group. Participants in the intervention group reported higher satisfaction and more positive experiences of their care compared with the control group. Conclusions Although there is no significant difference in mean weight loss between the intervention and control groups, trained non-specialist advisors can deliver a structured programme and achieve clinically beneficial weight loss in some patients in primary care. The intervention group also reported a higher level of satisfaction with the support received. Primary care interventions are unlikely to be sufficient to tackle the obesity epidemic and effective population-wide measures are also necessary. Clinical trial registration number Trial registrationClincaltrials.gov NCT00891943.

Child obesity cut-offs as derived from parental perceptions: cross-sectional questionnaire

BACKGROUND Overweight children are at an increased risk of premature mortality and disease in adulthood. Parental perceptions and clinical definitions of child obesity differ, which may lessen the effectiveness of interventions to address obesity in the home setting. The extent to which parental and objective weight status cut-offs diverge has not been documented. AIM To compare parental perceived and objectively derived assessment of underweight, healthy weight, and overweight in English children, and to identify sociodemographic characteristics that predict parental under- or overestimation of a childs weight status. DESIGN AND SETTING Cross-sectional questionnaire completed by parents linked with objective measurement of height and weight by school nurses, in English children from five regions aged 4-5 and 10-11 years old. METHOD Parental derived cut-offs for under- and overweight were derived from a multinomial model of parental classification of their own childs weight status against school nurse measured body mass index (BMI) centile. RESULTS Measured BMI centile was matched with parent classification of weight status in 2976 children. Parents become more likely to classify their children as underweight when they are at the 0.8th centile or below, and overweight at the 99.7th centile or above. Parents were more likely to underestimate a childs weight if the child was black or South Asian, male, more deprived, or the child was older. These values differ greatly from the BMI centile cut-offs for underweight (2nd centile) and overweight (85th). CONCLUSION Clinical and parental classifications of obesity are divergent at extremes of the weight spectrum.

Antimicrobial stewardship: English Surveillance Programme for Antimicrobial Utilization and Resistance (ESPAUR)

The clinical, public health and economic implications of antimicrobial resistance present a major threat to future healthcare. Antimicrobial use is a major driver of resistance, and antimicrobial stewardship programmes are increasingly being advocated as a means of improving the quality of prescribing. However, to increase their impact and assess their success, a better understanding of antimicrobial usage, both in primary and secondary care, and linkage with antimicrobial resistance data are required. In England, national summaries of primary care dispensing data are issued annually by the Health and Social Care Information Centre. However, there is currently no routine public reporting of antimicrobial usage in hospitals. In response to the threat posed by antimicrobial resistance, as highlighted in the Report of the Chief Medical Officer and on the request of the Department of Health, Public Health England has developed a new national programme, the English Surveillance Programme for Antimicrobial Utilization and Resistance (ESPAUR). The programme will bring together the elements of antimicrobial utilization and resistance surveillance in both primary and secondary care settings, alongside the development of quality measures and methods to monitor unintended outcomes of antimicrobial stewardship and both public and professional behaviour interventions. This article reports on the background to the programme development, the current oversight group membership and the public reporting structure.

Public health ethics: teaching survey and critical review

The last decade has witnessed development of the new field of public health ethics, as well as growing emphasis on the importance of ethics education to both students and graduates of the health care professions. Using a topic-based interpretation of public health ethics this paper presents a questionnaire survey of the nature and content of teaching of public health ethics to medical undergraduates and public health postgraduate students in the United Kingdom. Completed questionnaires were returned by 76.9% (20/26) of medical schools and 76.7% (23/30) of institutions teaching postgraduate public health courses. Public health ethics was described as being taught in 75% of medical schools and 52% of institutions providing postgraduate education. However, in both types of location the content and nature of teaching was patchy and often minimal. If medical schools and postgraduate institutions are serious about improving the discussion and teaching of ethical issues in public health, there will need to be considerable investment and commitment, accompanied by creativity and imagination. In parallel, the debate about the meaning of, and approaches to, public health ethics needs to be broadened and enriched. The topic-based interpretation of public health ethics has limitations. Alternatives are explored and critically reviewed.

The benefits and harms of providing parents with weight feedback as part of the national child measurement programme: a prospective cohort study

BackgroundSmall-scale evaluations suggest that the provision of feedback to parents about their child’s weight status may improve recognition of overweight, but the effects on lifestyle behaviour are unclear and there are concerns that informing parents that their child is overweight may have harmful effects. The aims of this study were to describe the benefits and harms of providing weight feedback to parents as part of a national school-based weight-screening programme in England.MethodsWe conducted a pre-post survey of 1,844 parents of children aged 4–5 and 10–11 years who received weight feedback as part of the 2010–2011 National Child Measurement Programme. Questionnaires assessed general knowledge about the health risks associated with child overweight, parental recognition of overweight and the associated health risks in their child, child lifestyle behaviour, child self-esteem and weight-related teasing, parental experience of the feedback, and parental help-seeking behaviour. Differences in the pre-post proportions of parents reporting each outcome were assessed using a McNemar’s test.ResultsGeneral knowledge about child overweight as a health issue was high at baseline and increased further after weight feedback. After feedback, the proportion of parents that correctly recognised their child was overweight increased from 21.9% to 37.7%, and more than a third of parents of overweight children sought further information regarding their child’s weight. However, parent-reported changes in lifestyle behaviours among children were minimal, and limited to increases in physical activity in the obese children only. There was some suggestion that weight feedback had a greater impact upon changing parental recognition of the health risks associated with child overweight in non-white ethnic groups.ConclusionsIn this population-based sample of parents of children participating in the National Child Measurement Programme, provision of weight feedback increased recognition of child overweight and encouraged some parents to seek help, without causing obvious unfavourable effects. The impact of weight feedback on behaviour change was limited; suggesting that further work is needed to identify ways to more effectively communicate health information to parents and to identify what information and support may encourage parents in making and maintaining lifestyle changes for their child.

Assessing the efficacy of the Healthy Eating and Lifestyle Programme (HELP) compared with enhanced standard care of the obese adolescent in the community: study protocol for a randomized controlled trial

BackgroundThe childhood obesity epidemic is one of the foremost UK health priorities. Childhood obesity tracks into adult life and places individuals at considerable risk for diabetes, cardiovascular disease, liver disease and other morbidities. There is widespread need for paediatric lifestyle programmes as change may be easier to accomplish in childhood than later in life.Study Design/MethodThe study will evaluate the management of adolescent obesity by conducting a Medical Research Council complex intervention phase III efficacy randomised clinical trial of the Healthy Eating Lifestyle Programme within primary care. The study tests a community delivered multi-component intervention designed for adolescents developed from best practice as identified by National Institute for Health and Clinical Excellence. The hospital based pilot reduced body mass index and improved health-related quality of life.Subjects will be individually randomised to receiving either the Healthy Eating Lifestyle Programme (12 fortnightly family sessions) or enhanced standard care. Baseline and follow up assessments will be undertaken blind to allocation status. A health economic evaluation is also being conducted.200 obese young people (13-17 years, body mass index > 98th centile for age and sex) will be recruited from primary care within the greater London area.The primary hypothesis is that a motivational and solution-focused family-based weight management programme delivered over 6 months is more efficacious in reducing body mass index in obese adolescents identified in the community than enhanced standard care.The primary outcome will be body mass index at the end of the intervention, adjusted for baseline body mass index, age and sex.The secondary hypothesis is that the Healthy Eating Lifestyle Programme is more efficacious in improving quality of life and psychological function and reducing waist circumference and cardiovascular risk factors in obese adolescents than enhanced standard care assessed at 6 and 12 months post baseline assessment.Improvement in quality of life predicts on-going lifestyle change and maximises the chances of long-term weight reduction. We will explore whether improvement in QOL may be intermediate on the pathway between the intervention and body mass index change.Trial registrationISRCTN: ISRCTN99840111

Data Mashups: Potential Contribution to Decision Support on Climate Change and Health

Linking environmental, socioeconomic and health datasets provides new insights into the potential associations between climate change and human health and wellbeing, and underpins the development of decision support tools that will promote resilience to climate change, and thus enable more effective adaptation. This paper outlines the challenges and opportunities presented by advances in data collection, storage, analysis, and access, particularly focusing on “data mashups”. These data mashups are integrations of different types and sources of data, frequently using open application programming interfaces and data sources, to produce enriched results that were not necessarily the original reason for assembling the raw source data. As an illustration of this potential, this paper describes a recently funded initiative to create such a facility in the UK for use in decision support around climate change and health, and provides examples of suitable sources of data and the purposes to which they can be directed, particularly for policy makers and public health decision makers.

Perceptions of health risk among parents of overweight children: A cross-sectional study within a cohort☆

OBJECTIVE To identify the socio-demographic and behavioural characteristics associated with perceptions of weight-related health risk among the parents of overweight children. METHODS Baseline data from a cohort of parents of children aged 4-11 years in five areas in England in 2010-2011 were analysed; the sample was restricted to parents of overweight children (body mass index ≥ 91(st) centile of UK 1990 reference; n=579). Associations between respondent characteristics and parental perception of health risk associated with their childs weight were examined using logistic regression analyses. RESULTS Most parents (79%) did not perceive their childs weight to be a health risk. Perception of a health risk was associated with recognition of the childs overweight status (OR 10.59, 95% CI 5.51 to 20.34), having an obese child (OR 4.21, 95% CI 2.28 to 7.77), and having an older child (OR 2.67, 95% CI 1.32 to 5.41). However, 41% of parents who considered their child to be overweight did not perceive a health risk. CONCLUSIONS Parents that recognise their childs overweight status, and the parents of obese and older children, are more likely to perceive a risk. However, many parents that acknowledge their child is overweight do not perceive a related health risk.

The new UK antimicrobial resistance strategy and action plan

A major societal, political, clinical, and research challenge