Dilip Nathan

Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood

Abstract The risk factors for childhood overweight and obesity are known and can be identified antenatally or during infancy, however, the majority of effective interventions are designed for older children. This review identified interventions designed to reduce the risk of overweight/obesity that were delivered antenatally or during the first 2 years of life, with outcomes reported from birth to 7 years of age. Six electronic databases were searched for papers reporting randomised controlled trials of interventions published from January 1990 to September 2013. A total of 35 eligible studies were identified, describing 27 unique trials of which 24 were behavioural and three were non‐behavioural. The 24 behavioural trials were categorised by type of intervention: (1) nutritional and/or responsive feeding interventions targeted at parents of infants, which improved feeding practices and had some impact on child weight (n = 12); (2) breastfeeding promotion and lactation support for mothers, which had a positive effect on breastfeeding but not child weight (n = 5); (3) parenting and family lifestyle (n = 4); and (4) maternal health (n = 3) interventions that had some impact on feeding practices but not child weight. The non‐behavioural trials comprised interventions manipulating formula milk composition (n = 3). Of these, lower/hydrolysed protein formula milk had a positive effect on weight outcomes. Interventions that aim to improve diet and parental responsiveness to infant cues showed most promise in terms of self‐reported behavioural change. Despite the known risk factors, there were very few intervention studies for pregnant women that continue during infancy which should be a priority for future research.

Estimating Overweight Risk in Childhood From Predictors During Infancy

OBJECTIVE: The aim of this study was to develop and validate a risk score algorithm for childhood overweight based on a prediction model in infants. METHODS: Analysis was conducted by using the UK Millennium Cohort Study. The cohort was divided randomly by using 80% of the sample for derivation of the risk algorithm and 20% of the sample for validation. Stepwise logistic regression determined a prediction model for childhood overweight at 3 years defined by the International Obesity Task Force criteria. Predictive metrics R2, area under the receiver operating curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Seven predictors were found to be significantly associated with overweight at 3 years in a mutually adjusted predictor model: gender, birth weight, weight gain, maternal prepregnancy BMI, paternal BMI, maternal smoking in pregnancy, and breastfeeding status. Risk scores ranged from 0 to 59 corresponding to a predicted risk from 4.1% to 73.8%. The model revealed moderately good predictive ability in both the derivation cohort (R2 = 0.92, AUROC = 0.721, sensitivity = 0.699, specificity = 0.679, PPV = 38%, NPV = 87%) and validation cohort (R2 = 0.84, AUROC = 0.755, sensitivity = 0.769, specificity = 0.665, PPV = 37%, NPV = 89%). CONCLUSIONS: Using a prediction algorithm to identify at-risk infants could reduce levels of child overweight and obesity by enabling health professionals to target prevention more effectively. Further research needs to evaluate the clinical validity, feasibility, and acceptability of communicating this risk.

UK health visitors' role in identifying and intervening with infants at risk of developing obesity

Childhood obesity is associated with a number of modifiable risk factors that can be identified during infancy or earlier. In the UK, health visitors advise parents about infant feeding, but little is known about their role in obesity prevention. The aim of this study was to investigate the beliefs and current practices of UK health visitors in relation to recognising and intervening with infants at risk of developing obesity. Thirty members of the health visiting team were interviewed. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was applied using an interpretative, inductive approach. Health visitors were aware of some of the modifiable risk factors for childhood obesity such as infant feeding practices. They felt they had a role in advising parents about diet but did not formally identify and/or intervene with larger infants. Infant overweight was considered a sensitive issue that was difficult to raise with parents. They believed some parents preferred larger infants and were unaware that their feeding practices might be contributing to obesity risk. A need for training and guidance was identified together with strategies to overcome system barriers. Health visitors do not currently target parents of infants at risk of obesity largely because they do not perceive they have appropriate guidance and skills to enable them to do so. There is an urgent need for tools and training to enable all health care professionals to recognise and manage infants at risk of developing obesity without creating a sense of blame.

Validation, Optimal Threshold Determination, and Clinical Utility of the Infant Risk of Overweight Checklist for Early Prevention of Child Overweight

BACKGROUND Previous research has demonstrated the predictive validity of the Infant Risk of Overweight Checklist (IROC). This study further establishes the predictive accuracy of the IROC using data from the Avon Longitudinal Study of Parents and Children (ALSPAC) and examines the optimal threshold for determining high risk of childhood overweight. METHODS Using the IROC algorithm, we calculated the risk of being overweight, based on International Obesity Task Force criteria, in the first year of life for 980 children in the ALSPAC cohort at 5 years. Discrimination was assessed by the area under the receiver operating curve (AUC c-statistic). Net reclassification index (NRI) was calculated for risk thresholds ranging from 2.5% to 30%, which determine cutoffs for identifying infants at risk of becoming overweight. RESULTS At 5 years of age, 12.3% of boys and 19.6% of girls were categorized overweight. Discrimination (AUC c-statistic) ranged from 0.67 (95% confidence interval [CI], 0.62-0.72) when risk scores were calculated directly to 0.93 (95% CI, 0.88-0.98) when the algorithm was recalibrated and missing values of the risk factor algorithm were imputed. The NRI showed that there were positive gains in reclassification using risk thresholds from 5% to 20%, with the maximum NRI being at 10%. CONCLUSIONS This study confirms that the IROC has moderately good validity for assessing overweight risk in infants and offers an optimal threshold for determining high risk. The IROC algorithm has been imbedded into a computer program for Proactive Assessment of Obesity Risk during Infancy, which facilitates early overweight prevention through communication of risk to parents.

Evaluating the effectiveness of a schools-based programme to promote exercise self-efficacy in children and young people with risk factors for obesity: steps to active kids (STAK).

BackgroundLow levels of physical activity in children have been linked to an increased risk of obesity, but many children lack confidence in relation to exercise (exercise self-efficacy). Factors which can impact on confidence include a chronic health condition such as asthma, poor motor skills and being overweight. Increasing levels of physical activity have obvious benefits for children with asthma and children who are overweight, but few activity interventions with children specifically target children with low exercise self-efficacy (ESE). This study aims to evaluate the efficacy and feasibility of a schools-based activity programme suitable for children with risk factors for adult obesity, including asthma, overweight and low exercise self-efficacy.Methods/DesignA clustered (at the level of school) RCT will be used to compare a targeted, 10 week, stepped activity programme (activity diary, dance DVD, circuit-training and motivational interviewing) designed to promote ESE. We will recruit 20 primary schools to participate in the intervention and 9-11 year old children will be screened for low levels of ESE, asthma and overweight. In order to provide sufficient power to detect a difference in primary outcomes (Body Mass Index-BMI & ESE at 12 month follow-up) between children in the intervention schools and control schools, the target sample size is 396. Assessments of BMI, ESE, waist circumference, peak flow, activity levels and emotional and behavioural difficulties will be made at baseline, 4 months and 12 month follow-up.DiscussionWe aim to increase ESE and levels of physical activity in children with risk factors for adult obesity. The outcomes of this study will inform policy makers about the feasibility, acceptability and effectiveness of delivering targeted health interventions within a school setting.Trial RegistrationISRCTN Register no. ISRCTN12650001

Childhood developmental examination: a novel approach to teaching.

Childhood developmental assessment is an essential skill that medical students must attain during their education. The authors describe a new technique which is neither laborious nor time‐consuming for both staff and students. Groups of 40 students were taught normal developmental examinations using a novel interactive approach during a lecture. The method proved successful in terms of student evaluation, cost effectiveness of medical teaching time and acceptability to the children used for the demonstration. Audio‐visual equipment, available in most teaching centres, was used that was easily and cheaply installed for the purpose of the session.

Digital technology to facilitate Proactive Assessment of Obesity Risk during Infancy (ProAsk): a feasibility study

Objective To assess the feasibility and acceptability of using digital technology for Proactive Assessment of Obesity Risk during Infancy (ProAsk) with the UK health visitors (HVs) and parents. Design Multicentre, pre- and post-intervention feasibility study with process evaluation. Setting Rural and urban deprived settings, UK community care. Participants 66 parents of infants and 22 HVs. Intervention ProAsk was delivered on a tablet device. It comprises a validated risk prediction tool to quantify overweight risk status and a therapeutic wheel detailing motivational strategies for preventive parental behaviour. Parents were encouraged to agree goals for behaviour change with HVs who received motivational interviewing training. Outcome measures We assessed recruitment, response and attrition rates. Demographic details were collected, and overweight risk status. The proposed primary outcome measure was weight-for-age z-score. The proposed secondary outcomes were parenting self-efficacy, maternal feeding style, infant diet and exposure to physical activity/sedentary behaviour. Qualitative interviews ascertained the acceptability of study processes and intervention fidelity. Results HVs screened 324/589 infants for inclusion in the study and 66/226 (29%) eligible infants were recruited. Assessment of overweight risk was completed on 53 infants and 40% of these were identified as above population risk. Weight-for-age z-score (SD) between the infants at population risk and those above population risk differed significantly at baseline (−0.67 SD vs 0.32 SD). HVs were able to collect data and calculate overweight risk for the infants. Protocol adherence and intervention fidelity was a challenge. HVs and parents found the information provided in the therapeutic wheel appropriate and acceptable. Conclusion Study recruitment and protocol adherence were problematic. ProAsk was acceptable to most parents and HVs, but intervention fidelity was low. There was limited evidence to support the feasibility of implementing ProAsk without significant additional resources. A future study could evaluate ProAsk as a HV-supported, parent-led intervention. Trial registration number NCT02314494 (Feasibility Study Results)

Development of an evidence-based practice guideline for UK public health nurses (health visitors) to use with parents of infants at risk of obesity.

Evidence about effective interventions that reduce obesity risk during infancy is needed. A systematic review of Randomised Controlled Trials (RCTs) of behavioural and non-behavioural interventions which address potential risk factors for childhood overweight and obesity was undertaken to inform a guideline for UK health visitors. The National Institute for Health and Clinical Excellence (NICE) guidelines were followed. The findings were used to develop a guideline which was reviewed internally by a multi-professional Guideline Development Group (GDG) and externally by national experts and practitioners. We identified 35 RCTs reporting behavioural and non-behavioural interventions delivered antenatally and/or during infancy that included infant weight outcomes (e.g. weight-for-length, weight-for-age, weight-for-BMI) or outcomes related to obesity risk (breastfeeding, physical activity, timing of weaning). A number of on-going trials were identified. Good evidence exists for breastfeeding promotion and support interventions. Evidence exists for parental education around responsive feeding, aspects of infant diet and soothing/sleep expectations. These behavioural components informed the guideline, which is freely available on the UK Institute for Health Visiting website. There was equivocal evidence that infants fed lower protein (compared to higher protein) formula milk gained less weight, and this was not incorporated into the guideline. Further research is needed to establish clinically effective interventions for obesity prevention during infancy. Continuous dialogue between commissioners, policy makers, health visitors and parents is essential to inform obesity prevention strategies in the first year of life.

48 Cluster-Randomised Trial of a Targeted Intervention to Promote Exercise Self-Efficacy and Reduce Bmi in Children at Risk of Obesity

Background and aims Being physically active can help to reduce the risk of obesity in later life. This study aimed to evaluate the effectiveness of a targeted, school-based intervention (Steps to Active Kids - STAK) in improving exercise self-efficacy and reducing BMI in children. Method STAK is a 12 week, activity programme including activity diary, street dance DVD, circuit training and, for children at or above the 91st centile weight for height, motivational interviewing and goal setting. STAK was evaluated in a cluster-randomised trial in 24 schools. Children aged 9 to 11 were screened for overweight, low exercise self-efficacy or asthma. Twelve schools were randomised to receive the STAK intervention and 12 to control. BMI, waist circumference and exercise self-efficacy were assessed at baseline and post intervention (4 months). Results Of the 2479 children screened, 1065 children (43%) met the study inclusion criteria. Parents of 424 (40%) children consented to their child’s participation with 4 months follow-up data available for 392 (92%). The groups were well matched at baseline. After controlling for baseline values and time between testing, children in the intervention group had higher total self-efficacy at 4 month follow-up. In the group of children who were overweight at baseline (=>91st centile), those in the STAK intervention group had smaller waist circumference and lower BMI at 4 month follow-up. Conclusion Preliminary analysis suggests that a targeted activity intervention has benefits for children at risk of obesity. Future analyses will explore if benefits are sustained at 12 months follow-up.

G04 An Interactive Online Package – a Flexible Way to Train Examiners

Aims Reducing inter examiner variability is crucial for exams. Training of examiners is seen as essential in ensuring validity and reliability of clinical examinations. We aimed to develop an interactive online package to aid training of examiners assessing undergraduate paediatric students and to evaluate inter examiner variability. Methods Using publicly available Google Sites, we created an online tool to train examiners for their role in paediatric undergraduate clinical skills assessments. It comprised a sequence of five videos of students, each presenting a clinical case(history and examination of a child). These case presentations were scored (scale 0–15 for the total score) by examiners online using an interactive mark sheet that automatically recorded the scores. Subsequently, examiners could compare their scores against an average given by a panel of senior expert examiners. In addition, recorded data were analysed for overall mean scores and standard deviation (SD). The students were ranked according to performance (1 excellent, 1 clear fail and three in between) using predetermined criteria Results Total of 31 participants, 18 of them fully completed the online package. Abstract G04 Table 1 Student Number of examiners Trainee examiners Average score (+/- SD) Expert examiners Average score (+/- SD) 1(excellent) 31 12.7 (+/- 2.1) 13.2 (+/- 1.8) 2 22 8.4 (+/- 2.1) 9.0 (+/- 2.7) 3 18 8.2 (+/- 2.6) 9 (+/- 0.8) 4 18 12.5 (+/- 2.2) 11.1 (+/- 1.9) 5(clear fail) 18 1.4 (+/- 2.0) 2.0 (+/- 1.7) Conclusions Trainee examiners considered the tool helpful, especially if they were to perform the clinical skills assessments for the first time. Results demonstrate variation of scores is higher among trainee examiners, apart from student number 2. Overall scores given by trainee examiners tend to be lower compared to experienced expert examiners.