Miranda Pallan

Body image, body dissatisfaction and weight status in south asian children: a cross-sectional study

BackgroundChildhood obesity is a continuing problem in the UK and South Asian children represent a group that are particularly vulnerable to its health consequences. The relationship between body dissatisfaction and obesity is well documented in older children and adults, but is less clear in young children, particularly South Asians. A better understanding of this relationship in young South Asian children will inform the design and delivery of obesity intervention programmes. The aim of this study is to describe body image size perception and dissatisfaction, and their relationship to weight status in primary school aged UK South Asian children.MethodsObjective measures of height and weight were undertaken on 574 predominantly South Asian children aged 5-7 (296 boys and 278 girls). BMI z-scores, and weight status (underweight, healthy weight, overweight or obese) were calculated based on the UK 1990 BMI reference charts. Figure rating scales were used to assess perceived body image size (asking children to identify their perceived body size) and dissatisfaction (difference between perceived current and ideal body size). The relationship between these and weight status were examined using multivariate analyses.ResultsPerceived body image size was positively associated with weight status (partial regression coefficient for overweight/obese vs. non-overweight/obese was 0.63 (95% CI 0.26-0.99) and for BMI z-score was 0.21 (95% CI 0.10-0.31), adjusted for sex, age and ethnicity). Body dissatisfaction was also associated with weight status, with overweight and obese children more likely to select thinner ideal body size than healthy weight children (adjusted partial regression coefficient for overweight/obese vs. non-overweight/obese was 1.47 (95% CI 0.99-1.96) and for BMI z-score was 0.54 (95% CI 0.40-0.67)).ConclusionsAwareness of body image size and increasing body dissatisfaction with higher weight status is established at a young age in this population. This needs to be considered when designing interventions to reduce obesity in young children, in terms of both benefits and harms.

The views of stakeholders on the role of the primary school in preventing childhood obesity: a qualitative systematic review

Schools are increasingly recognized as an ideal setting for interventions to tackle childhood obesity. A better understanding of the views of key stakeholders would help to engage schools and inform the feasibility of such interventions in practice. This meta‐synthesis of 18 qualitative studies explores the views of parents, school staff, school governors, school nurses and students on the role of the primary school in preventing childhood obesity. Six categories emerged: ‘School as a key setting’; ‘What schools should be doing to promote healthy eating (HE)’; ‘What schools should be doing to promote physical activity (PA)’; ‘General barriers’; ‘Barriers to promoting HE at school’; and ‘Barriers to promoting PA at school’. Thirty‐seven finer‐level themes emerged within these categories. Stakeholders agreed on the key role of the primary school as a setting for obesity prevention, the importance of schools providing and promoting opportunities for HE and PA, and the need for schools to work with parents. Some perceived barriers could be overcome at school level, e.g. using unhealthy foods as rewards/fundraisers or withholding PA for bad behaviour. Leadership and guidance from government were considered to be needed to counteract other observed barriers, particularly regarding school canteens, support for parents and time for PA.

Contextual influences on the development of obesity in children: A case study of UK South Asian communities

Objective An advocated approach to childhood obesity prevention research is the use of local community knowledge to inform intervention development. This paper demonstrates the value of accessing such local knowledge, and discusses how this information fits with existing conceptual models of childhood obesity. Methods A series of 9 focus groups were run in 2007 with 68 local community stakeholders (including parents, school staff, community leaders and health and local government representatives) from 8 South Asian communities in Birmingham, UK to explore perceptions of factors contributing to the development of childhood obesity. Results Perceptions of causal influences were grouped into several contexts, from the individual to the macro-level, that influence diet and physical activity. Specific cultural contextual data emerged that may explain decisions around physical activity and food intake of children within these communities. Assumptions made about South Asian communities were frequently contested. Conclusions In order to truly understand the contextual influences on childhood obesity in target communities, it is necessary to access knowledge from local community members. Existing conceptual models of childhood obesity do not bring the role of cultural factors to the fore, but this context needs to be explicitly considered in the development of childhood obesity interventions.

Preventing childhood obesity, phase II feasibility study focusing on South Asians: BEACHeS

Objective To assess feasibility and acceptability of a multifaceted, culturally appropriate intervention for preventing obesity in South Asian children, and to obtain data to inform sample size for a definitive trial. Design Phase II feasibility study of a complex intervention. Setting 8 primary schools in inner city Birmingham, UK, within populations that are predominantly South Asian. Participants 1090 children aged 6–8 years took part in the intervention. 571 (85.9% from South Asian background) underwent baseline measures. 85.5% (n=488) were followed up 2 years later. Interventions The 1-year intervention consisted of school-based and family-based activities, targeting dietary and physical activity behaviours. The intervention was modified and refined throughout the period of delivery. Main outcome measures Acceptability and feasibility of the intervention and of measurements required to assess outcomes in a definitive trial. The difference in body mass index (BMI) z-score between arms was used to inform sample size calculations for a definitive trial. Results Some intervention components (increasing school physical activity opportunities, family cooking skills workshops, signposting of local leisure facilities and attending day event at a football club) were feasible and acceptable. Other components were acceptable, but not feasible. Promoting walking groups was neither acceptable nor feasible. At follow-up, children in the intervention compared with the control group were less likely to be obese (OR 0.41; 0.19 to 0.89), and had lower adjusted BMI z-score (−0.15 kg/m2; 95% CI −0.27 to −0.03). Conclusions The feasibility study informed components for an intervention programme. The favourable direction of outcome for weight status in the intervention group supports the need for a definitive trial. A cluster randomised controlled trial is now underway to assess the clinical and cost-effectiveness of the intervention. Trial registration number ISRCTN51016370.

Process evaluation design in a cluster randomised controlled childhood obesity prevention trial: the WAVES study

BackgroundThe implementation of a complex intervention is heavily influenced by individual context. Variation in implementation and tailoring of the intervention to the particular context will occur, even in a trial setting. It is recognised that in trials, evaluating the process of implementation of a complex intervention is important, yet process evaluation methods are rarely reported. The WAVES study is a cluster randomised controlled trial to evaluate the effectiveness of an obesity prevention intervention programme targeting children aged 6-7 years, delivered by teachers in primary schools across the West Midlands, UK. The intervention promoted activities encouraging physical activity and healthy eating. This paper presents the methods used to assess implementation of the intervention.MethodsPrevious literature was used to identify the dimensions of intervention process and implementation to be assessed, including adherence, exposure, quality of delivery, participant responsiveness, context, and programme differentiation.ResultsMultiple methods and tools were developed to capture information on all these dimensions. These included observations, logbooks, qualitative evaluation, questionnaires and research team reflection.DiscussionData collection posed several challenges, predominantly when relying on teachers to complete paperwork, which they saw as burdensome on top of their teaching responsibilities. However, the use of multiple methods helped to ensure data on each dimension, where possible, was collected using more than one method. This also allowed for triangulation of the findings when several data sources on any one dimension were available.ConclusionsWe have reported a comprehensive approach to the assessment of the implementation and processes of a complex childhood obesity prevention intervention within a cluster randomised controlled trial. These approaches can be transferred and adapted for use in other complex intervention trials.Trial registration numberISRCTN97000586

A cluster-randomised controlled trial to assess the effectiveness and cost-effectiveness of a childhood obesity prevention programme delivered through schools, targeting 6-7 year old children: the WAVES study protocol.

BackgroundThere is some evidence that school-based interventions are effective in preventing childhood obesity. However, longer term outcomes, equity of effects and cost-effectiveness of interventions have not been assessed.The aim of this trial is to assess the clinical and cost-effectiveness of a multi-component intervention programme targeting the school and family environment through primary schools, in preventing obesity in 6–7 year old children, compared to usual practice.MethodsThis cluster randomised controlled trial is set in 54 primary schools within the West Midlands, UK, including a multi-ethnic, socioeconomically diverse population of children aged 6–7 years.The 12-month intervention consists of healthy diet and physical activity promotion. These include: activities to increase time spent doing physical activity within the school day, participation in the ‘Villa Vitality’ programme (a programme that is delivered by an iconic sporting institution (Aston Villa Football Club), which provides interactive learning opportunities for physical activity and healthy eating), healthy cooking skills workshops in school time for parents and children, and provision of information to families signposting local leisure opportunities. The primary (clinical) outcome is the difference in body mass index (BMI) z-scores between arms at 3 and 18 months post-intervention completion. Cost per Quality Adjusted Life Year (QALY) will also be assessed. The sample size estimate (1000 children split across 50 schools at follow-up) is based on 90% power to detect differences in BMI z-score of 0.25 (estimated ICC ≤ 0.04), assuming a correlation between baseline and follow-up BMI z-score of 0.9. Treatment effects will be examined using mixed model ANCOVA. Primary analysis will adjust for baseline BMI z-score, and secondary analysis will adjust for pre-specified baseline school and child level covariates.DiscussionThe West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study is the first trial that will examine the cost-effectiveness and long term outcomes of a childhood obesity prevention programme in a multi-ethnic population, with a sufficient sample size to detect clinically important differences in adiposity. The intervention was developed using the Medical Research Council framework for complex interventions, and outcomes are measured objectively, together with a comprehensive process evaluation.Trial registrationCurrent Controlled Trials ISRCTN97000586 (registered May 2010).

Physical Activity and Blood Pressure in Primary School Children A Longitudinal Study

High blood pressure (BP) is becoming increasingly common during childhood. Regular physical activity (PA) reduces BP in adults, but limited studies have reported inconsistent results among children. The aim of this study is to examine, for the first time, the cross-sectional and longitudinal associations between BP and objectively measured PA in young children of predominantly South Asian background. Data from the Birmingham healthy Eating and Active lifestyle for CHildren Study were analyzed. Five hundred seventy-four children, aged 5 to 7 years, underwent a series of measures at baseline and were followed up 2 years later. PA was objectively measured using accelerometry and converted to counts per minute (total PA, cpm), and time spent in moderate-vigorous PA (minutes per day). BP was measured by trained staff using standard protocols. Data were available for 512 children at baseline (mean age 6.5 years, range 5.4–7.8 years), and 427 of these children were followed up. Baseline total PA was inversely associated with diastolic BP at both baseline (adjusted regression coefficient: −0.75 mm Hg [95% CI −1.33 to −0.18] per 20 cpm) and follow-up (−0.74 mm Hg [95% CI −1.40 to −0.08]). All associations remained unchanged after further adjustment for weight status. This study strengthens evidence of a causal association between higher PA and lower BP in children as young as 5, independent of weight status. The results provide support for development of interventions to increase PA in young children.

Development of a childhood obesity prevention programme with a focus on UK South Asian communities.

Objective We report the development of a childhood obesity prevention intervention for UK South Asian primary school-aged children, guided by the UK Medical Research Council (MRC) framework for complex intervention development and evaluation. Methods We combined information gained from a literature review, stakeholder focus groups, an expert group, review of local resources and mapping to the Analysis Grid for Environments Linked to Obesity (ANGELO framework) in an intervention development process. The study took place in 2007 in Birmingham, UK. Results Contextual information from the stakeholder focus groups was essential for informing intervention development. The expert group defined guiding principles for the intervention. Informing intervention design by assessing existing local resources addressed intervention sustainability. The use of the ANGELO framework ensured a comprehensive environmental approach to intervention development. The intervention consisted of two broad processes; increasing childrens physical activity levels through school, and increasing skills of families through activity-based learning. The developed intervention is being evaluated in a major study. Conclusions The intervention development process has resulted in a tailored intervention programme to prevent childhood obesity in UK South Asian communities, but also intervention processes that could be applied to other communities and tailored to local context.

Cost-effectiveness of a community-based physical activity programme for adults (Be Active) in the UK: an economic analysis within a natural experiment

Objective To determine the cost-effectiveness of a physical activity programme (Be Active) aimed at city-dwelling adults living in Birmingham, UK. Methods Very little is known about the cost-effectiveness of public health programmes to improve city-wide physical activity rates. This paper presents a cost-effectiveness analysis that compares a physical activity intervention (Be Active) with no intervention (usual care) using an economic model to quantify the reduction in disease risk over a lifetime. Metabolic equivalent minutes achieved per week, quality-adjusted life years (QALYs) gained and healthcare costs were all included as the main outcome measures in the model. A cost-benefit analysis was also conducted using ‘willingness-to-pay’ as a measure of value. Results Under base-case assumptions—that is, assuming that the benefits of increased physical activity are sustained over 5 years, participation in the Be Active programme increased quality-adjusted life expectancy by 0.06 years, at an expected discounted cost of £3552, and thus the cost-effectiveness of Be Active is £400 per QALY. When the start-up costs of the programme are removed from the economic model, the cost-effectiveness is further improved to £16 per QALY. The societal value placed on the Be Active programme was greater than the operation cost therefore the Be Active physical activity intervention results in a net benefit to society. Conclusions Participation in Be Active appeared to be cost-effective and cost-beneficial. These results support the use of Be Active as part of a public health programme to improve physical activity levels within the Birmingham-wide population.

Teacher Experiences of Delivering an Obesity Prevention Programme (The WAVES Study Intervention) in a Primary School Setting.

Objective: There has been a wealth of childhood obesity prevention studies in school-based settings. However, few have investigated the experiences of school staff charged with delivery of such programmes. This study aimed to elicit teachers’ experiences of delivering a childhood obesity prevention programme for children aged 6–7 years. Design: Descriptive-interpretive qualitative study. Setting: Primary schools participating in the UK West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study. Method: In all, 14 teachers were recruited from 12 primary schools. Semi-structured interviews were conducted and data analysis was guided by the Framework Approach. Results: Teachers recognised the importance of obesity prevention in primary schools. They reported positively on aspects of the intervention, in particular its flexibility and the ready-prepared materials. Time constraints and gaining support of parents were seen as key challenges to intervention delivery. Conclusions: Delivering an obesity prevention programme in school is feasible but challenging for teachers. Our findings suggest that to maximise the likelihood of delivery, interventions should be hands-on, easy to manage and flexible to the needs of individual schools. The perceived importance of the promotion of healthy lifestyle behaviours by schools was evident, but teachers felt restricted in the resources that could be devoted to achieve and encourage this. National combined with local level direction and support for healthy lifestyles in children would help schools to give this the priority it requires.