Kay Gibbons

Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomised controlled trial

Objective To determine whether ascertainment of childhood obesity by surveillance followed by structured secondary prevention in primary care improved outcomes in overweight or mildly obese children. Design Randomised controlled trial nested within a baseline cross sectional survey of body mass index (BMI). Randomisation and outcomes measurement, but not participants, were blinded to group assignment. Setting 45 family practices (66 general practitioners) in Melbourne, Australia. Participants 3958 children visiting their general practitioner in May 2005-July 2006 were surveyed for BMI. Of these, 258 children aged 5 years 0 months up to their 10th birthday who were overweight or obese by International Obesity Taskforce criteria were randomised to intervention (n=139) or control (n=119) groups. Children who were very obese (UK BMI z score ≥3.0) were excluded. Intervention Four standard consultations over 12 weeks targeting change in nutrition, physical activity, and sedentary behaviour, supported by purpose designed family materials. Main outcomes measures Primary measure was BMI at 6 and 12 months after randomisation. Secondary measures were mean activity count/min by 7-day accelerometry, nutrition score from 4-day abbreviated food frequency diary, and child health related quality of life. Differences were adjusted for socioeconomic status, age, sex, and baseline BMI. Results Of 781 eligible children, 258 (33%) entered the trial; attrition was 3.1% at 6 months and 6.2% at 12 months. Adjusted mean differences (intervention − control) at 6 and 12 months were, for BMI, −0.12 (95% CI −0.40 to 0.15, P=0.4) and −0.11 (−0.45 to 0.22, P=0.5); for physical activity in counts/min, 24 (−4 to 52, P=0.09) and 11 (−26 to 49, P=0.6); and, for nutrition score, 0.2 (−0.03 to 0.4, P=0.1) and 0.1 (−0.1 to 0.4, P=0.2). There was no evidence of harm to the child. Costs to the healthcare system were significantly higher in the intervention arm. Conclusions Primary care screening followed by brief counselling did not improve BMI, physical activity, or nutrition in overweight or mildly obese 5-10 year olds, and it would be very costly if universally implemented. These findings are at odds with national policies in countries including the US, UK, and Australia. Trial registration ISRCTN 52511065 (www.isrctn.org)

Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight/mild obesity

Objectives:To reduce gain in body mass index (BMI) in overweight/mildly obese children in the primary care setting.Design:Randomized controlled trial (RCT) nested within a baseline cross-sectional BMI survey.Setting:Twenty nine general practices, Melbourne, Australia.Participants:(1) BMI survey: 2112 children visiting their general practitioner (GP) April–December 2002; (2) RCT: individually randomized overweight/mildly obese (BMI z-score <3.0) children aged 5 years 0 months–9 years 11 months (82 intervention, 81 control).Intervention:Four standard GP consultations over 12 weeks, targeting change in nutrition, physical activity and sedentary behaviour, supported by purpose-designed family materials.Main outcome measures:Primary: BMI at 9 and 15 months post-randomization. Secondary: Parent-reported child nutrition, physical activity and health status; child-reported health status, body satisfaction and appearance/self-worth.Results:Attrition was 10%. The adjusted mean difference (intervention–control) in BMI was −0.2 kg/m2 (95% CI: −0.6 to 0.1; P=0.25) at 9 months and −0.0 kg/m2 (95% CI: −0.5 to 0.5; P=1.00) at 15 months. There was a relative improvement in nutrition scores in the intervention arm at both 9 and 15 months. There was weak evidence of an increase in daily physical activity in the intervention arm. Health status and body image were similar in the trial arms.Conclusions:This intervention did not result in a sustained BMI reduction, despite the improvement in parent-reported nutrition. Brief individualized solution-focused approaches may not be an effective approach to childhood overweight. Alternatively, this intervention may not have been intensive enough or the GP training may have been insufficient; however, increasing either would have significant cost and resource implications at a population level.

Regional specificity of exercise and calcium during skeletal growth in girls: a randomized controlled trial.

Combining exercise with calcium supplementation may produce additive or multiplicative effects at loaded sites; thus, we conducted a single blind, prospective, randomized controlled study in pre‐ and early‐pubertal girls to test the following hypotheses. (1) At the loaded sites, exercise and calcium will produce greater benefits than exercise or calcium alone. (2) At non‐loaded sites, exercise will have no benefit, whereas calcium with or without exercise will increase bone mass over that in exercise alone or no intervention. Sixty‐six girls aged 8.8 ± 0.1 years were randomly assigned to one of four study groups: moderate‐impact exercise with or without calcium or low‐impact exercise with or without calcium. All participants exercised for 20 minutes, three times a week and received Ca‐fortified (434 ± 19 mg/day) or non‐fortified foods for 8.5 months. Analysis of covariance (ANCOVA) was used to determine interaction and main effects for exercise and calcium on bone mass after adjusting for baseline bone mineral content and growth in limb lengths. An exercise‐calcium interaction was detected at the femur (7.1%, p < 0.05). In contrast, there was no exercise‐calcium interaction detected at the tibia‐fibula; however, there was a main effect of exercise: bone mineral content increased 3% more in the exercise than non‐exercise groups (p < 0.05). Bone mineral content increased 2–4% more in the calcium‐supplemented groups than the non‐supplemented groups at the humerus (12.0% vs. 9.8%, respectively, p < 0.09) and radius‐ulna (12.6% vs. 8.6%, respectively, p < 0.01). In conclusion, greater gains in bone mass at loaded sites may be achieved when short bouts of moderate exercise are combined with increased dietary calcium, the former conferring region‐specific effects and the latter producing generalized effects.

Maternal feeding practices predict weight gain and obesogenic eating behaviors in young children: a prospective study

BackgroundMaternal feeding practices have been proposed to play an important role in early child weight gain and obesogenic eating behaviors. However, to date longitudinal investigations in young children exploring these relationships have been lacking. The aim of the present study was to explore prospective relationships between maternal feeding practices, child weight gain and obesogenic eating behaviors in 2-year-old children. The competing hypothesis that child eating behaviors predict changes in maternal feeding practices was also examined.MethodsA sample of 323 mother (mean age = 35 years, ± 0.37) and child dyads (mean age = 2.03 years, ± 0.37 at recruitment) were participants. Mothers completed a questionnaire assessing parental feeding practices and child eating behaviors at baseline and again one year later. Child BMI (predominantly objectively measured) was obtained at both time points.ResultsIncreases in child BMI z-scores over the follow-up period were predicted by maternal instrumental feeding practices. Furthermore, restriction, emotional feeding, encouragement to eat, weight-based restriction and fat restriction were associated prospectively with the development of obesogenic eating behaviors in children including emotional eating, tendency to overeat and food approach behaviors (such as enjoyment of food and good appetite). Maternal monitoring, however, predicted decreases in food approach eating behaviors. Partial support was also observed for child eating behaviors predicting maternal feeding practices.ConclusionsMaternal feeding practices play an important role in the development of weight gain and obesogenic eating behaviors in young children and are potential targets for effective prevention interventions aiming to decrease child obesity.

Double disadvantage : the influence of ethnicity over socioeconomic position on childhood overweight and obesity: findings from an inner urban population of primary school children

OBJECTIVE To examine the relationship between overweight/obesity in children, socioeconomic status and ethnicity/cultural background. DESIGN Cross-sectional survey of children aged 4-13 years. SETTING A total of 23 primary (elementary) schools in an inner urban municipality of Melbourne, Australia. Participants. A total of 2685 children aged 4-13 years and their parents. MAIN EXPOSURE MEASURES Ethnicity/cultural background - maternal region of birth; socioeconomic position (SEP) indicators - maternal and paternal educational attainment, family employment status, possession of a healthcare card, ability to buy food, indicator of disadvantage (Socioeconomic Index for Areas, SEIFA) score for school; parental weight status. Main outcome measure. Prevalence of overweight/obesity. RESULTS Prevalence of overweight/obesity approached 1 in 3 (31%) in this sample. Prevalence of overweight/obesity was greater for children of both North Africa and Middle Eastern background and children of Southern, South Eastern and Eastern European background compared with children of Australian background. This difference remained after adjusting for age, sex, height, clustering by school, SEP indicators and parental weight status; odds ratio, OR=1.57 (95% confidence interval, CI 1.12-2.19) and 1.88 (95%CI 1.24-2.85), respectively. CONCLUSIONS There is a clear independent effect of ethnicity above and beyond the effect of socioeconomic status on overweight and obesity in children. Further research is required to explore the mediators of this gradient.

Can Australian general practitioners tackle childhood overweight/obesity? Methods and processes from the LEAP (Live, Eat and Play) randomized controlled trial

Background:  General practitioners (GPs) could make an important contribution to management of childhood overweight. However, there are no efficacy data to support this, and the feasibility of this approach is unknown.

Shared care obesity management in 3-10 year old children: 12 month outcomes of HopSCOTCH randomised trial

Objective To determine whether general practice surveillance for childhood obesity, followed by obesity management across primary and tertiary care settings using a shared care model, improves body mass index and related outcomes in obese children aged 3-10 years. Design Randomised controlled trial. Setting 22 family practices (35 participating general practitioners) and a tertiary weight management service (three paediatricians, two dietitians) in Melbourne, Australia. Participants Children aged 3-10 years with body mass index above the 95th centile recruited through their general practice between July 2009 and April 2010. Intervention Children were randomly allocated to one tertiary appointment followed by up to 11 general practice consultations over one year, supported by shared care, web based software (intervention) or “usual care” (control). Researchers collecting outcome measurements, but not participants, were blinded to group assignment. Main outcome measures Children’s body mass index z score (primary outcome), body fat percentage, waist circumference, physical activity, quality of diet, health related quality of life, self esteem, and body dissatisfaction and parents’ body mass index (all 15 months post-enrolment). Results 118 (60 intervention, 56 control) children were recruited and 107 (91%) were retained and analysed (56 intervention, 51 control). All retained intervention children attended the tertiary appointment and their general practitioner for at least one (mean 3.5 (SD 2.5, range 1-11)) weight management consultation. At outcome, children in the two trial arms had similar body mass index (adjusted mean difference −0.1 (95% confidence interval −0.7 to 0.5; P=0.7)) and body mass index z score (−0.05 (−0.14 to 0.03); P=0.2). Similarly, no evidence was found of benefit or harm on any secondary outcome. Outcomes varied widely in the combined cohort (mean change in body mass index z score −0.20 (SD 0.25, range −0.97-0.47); 26% of children resolved from obese to overweight and 2% to normal weight. Conclusions Although feasible, not harmful, and highly rated by both families and general practitioners, the shared care model of primary and tertiary care management did not lead to better body mass index or other outcomes for the intervention group compared with the control group. Improvements in body mass index in both groups highlight the value of untreated controls when determining efficacy. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12608000055303.

Body Dissatisfaction, Weight Loss Behaviours, and Bulimic Tendencies in Australian Adolescents With an Estimate of Female Data Representativeness

Body image, weight loss behaviours, and bulimic tendencies were assessed using questionnaires on 606 female and 315 male Victorian high-school students. In addition the representativeness of the sample was investigated. Nearly half the girls, and 28% of boys reported using an extreme weight loss method at least occasionally. Females indicated greater body dissatisfaction and drive for thinness, but not bulimic tendencies, than males. Weight loss behaviours and eating attitudes in this Australian sample appeared similar to comparable North American samples. Females refusing to be weighed rated their current figure as larger and indicated more body dissatisfaction than the weighed females, and teacher ratings of a sub-sample of females (n = 334) suggested that female nonparticipants were heavier than those who completed the study. Implications of these findings are discussed.

A shared-care model of obesity treatment for 3–10 year old children: Protocol for the HopSCOTCH randomised controlled trial

BackgroundDespite record rates of childhood obesity, effective evidence-based treatments remain elusive. While prolonged tertiary specialist clinical input has some individual impact, these services are only available to very few children. Effective treatments that are easily accessible for all overweight and obese children in the community are urgently required. General practitioners are logical care providers for obese children but high-quality trials indicate that, even with substantial training and support, general practitioner care alone will not suffice to improve body mass index (BMI) trajectories. HopSCOTCH (the Shared Care Obesity Trial in Children) will determine whether a shared-care model, in which paediatric obesity specialists co-manage obesity with general practitioners, can improve adiposity in obese children.DesignRandomised controlled trial nested within a cross-sectional BMI survey conducted across 22 general practices in Melbourne, Australia.ParticipantsChildren aged 3–10 years identified as obese by Centers for Disease Control criteria at their family practice, and randomised to either a shared-care intervention or usual care.InterventionA single multidisciplinary obesity clinic appointment at Melbourne’s Royal Children’s Hospital, followed by regular appointments with the child’s general practitioner over a 12 month period. To support both specialist and general practice consultations, web-based shared-care software was developed to record assessment, set goals and actions, provide information to caregivers, facilitate communication between the two professional groups, and jointly track progress.OutcomesPrimary - change in BMI z-score. Secondary - change in percentage fat and waist circumference; health status, body satisfaction and global self-worth.DiscussionThis will be the first efficacy trial of a general-practitioner based, shared-care model of childhood obesity management. If effective, it could greatly improve access to care for obese children.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12608000055303

Why families choose not to participate in research: Feedback from non-responders

Subjects who did not respond to an invitation to participate in a community‐based randomised controlled trial for childhood obesity in Melbourne, Australia were approached to investigate reasons for non‐participation.