Zoe McCallum

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.

A Parent-Focused Intervention to Reduce Infant Obesity Risk Behaviors: A Randomized Trial

OBJECTIVE: To assess the effectiveness of a parent-focused intervention on infants’ obesity-risk behaviors and BMI. METHODS: This cluster randomized controlled trial recruited 542 parents and their infants (mean age 3.8 months at baseline) from 62 first-time parent groups. Parents were offered six 2-hour dietitian-delivered sessions over 15 months focusing on parental knowledge, skills, and social support around infant feeding, diet, physical activity, and television viewing. Control group parents received 6 newsletters on nonobesity-focused themes; all parents received usual care from child health nurses. The primary outcomes of interest were child diet (3 × 24-hour diet recalls), child physical activity (accelerometry), and child TV viewing (parent report). Secondary outcomes included BMI z-scores (measured). Data were collected when children were 4, 9, and 20 months of age. RESULTS: Unadjusted analyses showed that, compared with controls, intervention group children consumed fewer grams of noncore drinks (mean difference = –4.45; 95% confidence interval [CI]: –7.92 to –0.99; P = .01) and were less likely to consume any noncore drinks (odds ratio = 0.48; 95% CI: 0.24 to 0.95; P = .034) midintervention (mean age 9 months). At intervention conclusion (mean age 19.8 months), intervention group children consumed fewer grams of sweet snacks (mean difference = –3.69; 95% CI: –6.41 to –0.96; P = .008) and viewed fewer daily minutes of television (mean difference = –15.97: 95% CI: –25.97 to –5.96; P = .002). There was little statistical evidence of differences in fruit, vegetable, savory snack, or water consumption or in BMI z-scores or physical activity. CONCLUSIONS: This intervention resulted in reductions in sweet snack consumption and television viewing in 20-month-old children.

Physical activity levels and patterns of 19-month-old children.

PURPOSE It is a commonly held perception that most young children are naturally active and meet physical activity recommendations. However, there is no scientific evidence available on which to confirm or refute such perceptions. The purpose of this study was to describe the physical activity levels and patterns of Australian toddlers. METHODS Physical activity and demographic data of two hundred ninety-five 19-month-old children from the Melbourne InFANT Program were measured using accelerometers and parent surveys. Validated cut points of 192-1672 and >1672 counts per minute were used to determine time spent in light- (LPA) and moderate-to-vigorous- (MVPA) intensity physical activity, respectively. To be included in the analysis, children were required to have four valid days of accelerometer data to provide an acceptable (>0.70) reliability estimate of LPA and MVPA. Physical activity data for different periods of the day were examined. RESULTS On average, toddlers engaged in 184 min of LPA and 47 min of MVPA daily, and 90.5% met the current Australian physical activity recommendations for 0- to 5-yr-olds (180 min of LPA/MVPA per day). Physical activity levels during mid morning and mid afternoon were higher than those during other periods. Physical activity patterns for boys and girls were similar, although boys engaged in more physical activity during the morning hours than girls did. CONCLUSIONS Most children meet the physical activity recommendations, although the majority of activity undertaken in the study was of light intensity. Boys were more active than girls were in the morning hours, but there were no differences between sexes over the entire day. Certain periods of the day may hold more promise for intervention implementation than others do.

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.

Are general practitioners equipped to detect child overweight/obesity? Survey and audit

Aim:  To ascertain the extent to which general practitioners (GPs) routinely weigh, measure and calculate body mass index (BMI) in children, and to assess the accuracy and accessibility of their anthropometric equipment.

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.

Economic Evaluation of a Primary Care Trial to Reduce Weight Gain in Overweight/Obese Children: The LEAP Trial

BACKGROUND A common policy response to the childhood obesity epidemic is to recommend that primary care physicians screen for and offer counseling to the overweight/obese. As the literature suggests, this approach may be ineffective; it is important to document the opportunity costs incurred by brief primary care obesity interventions that ultimately may not alter body mass index (BMI) trajectory. METHODS Live, Eat and Play (LEAP) was a randomized controlled trial of a brief secondary prevention intervention delivered by family physicians in 2002-2003 that targeted overweight/mildly obese children aged 5 to 9 years. Primary care utilization was prospectively audited via medical records, and parents reported family resource use by written questionnaire. Outcome measures were BMI (primary) and parent-reported physical activity and dietary habits (secondary) in intervention compared with control children. RESULTS The cost of LEAP per intervention family was AU

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

4094 greater than for control families, mainly due to increased family resources devoted to child physical activity. Total health sector costs were AU

The extended Infant Feeding, Activity and Nutrition Trial (InFANT Extend) Program: a cluster-randomized controlled trial of an early intervention to prevent childhood obesity.

873 per intervention family and AU