A child-centered health dialogue for the prevention of obesity in child health services in Sweden - A randomized controlled trial including an economic evaluation

Scoping review showed that obesity prevention in Nordic countries had limited effects on children from birth to 7 years of age

AIM

The aim of this scoping review was to map and summarise clinical trials that attempted to prevent obesity in children from birth to 7 years of age in any of the Nordic countries.

METHODS

PubMed, CINAHL Plus and clinicaltrials.gov were searched for peer-reviewed papers and registered trials published in English or Swedish. The overall search period was from 1 January 2002 to 13 December 2022. We included randomised and non-randomised trials initiated from birth to 7 years of age that aimed to prevent obesity in Denmark, Finland, Iceland, Norway and Sweden.

RESULTS

The search resulted in 414 papers and 14 were included. Despite having diverse settings and designs, none of them reported consistently favourable results for anthropometric outcomes, apart from beneficial trends in subgroups with a high body mass index at baseline. Most studies reported temporarily improved dietary patterns.

CONCLUSION

There is a gap in the current research about how to best prevent obesity in children. We suggest that researchers should focus on risk groups and that interventions that last a number of years are needed.

A literature review of evidence for primary prevention of overweight and obesity in healthy weight children and adolescents: A report produced by a working group of the Danish Council on Health and Disease Prevention

Primary prevention targets development of overweight in individuals with healthy weight and is a great challenge. This paper summarizes the main findings of a working group of the Danish Council on Health and Disease Prevention that reviewed the literature on primary prevention of overweight and obesity among children and adolescents. The results were presented in a Danish report, in which a 2019 Cochrane review on childhood obesity prevention was complemented by searches in PubMed to include all relevant subsequent studies published from January 2018 until March 2020. In this paper, the review was updated until June 2023. Numerous childhood overweight prevention interventions have been developed during the past decades, primarily targeting diet and/or physical activity. Several of these interventions showed positive effects on diet and physical activity level but did not show effects on risk of developing overweight. The evidence foundation is inconsistent as four out of five interventions did not show positive effects. Previously observed intervention effects may not reflect excessive weight gain prevention among children with healthy weight but rather bodyweight reduction among those with overweight or obesity. We do not have sufficient knowledge about how to prevent children with healthy weight from developing overweight, and creative solutions are urgently needed.

A systematic review of economic evaluations of interventions targeting childhood overweight and obesity

This systematic review critically appraised and synthesized evidence from economic evaluations of interventions targeting childhood excess weight. We conducted systematic searches in 11 databases from inception to April 19, 2023. Studies were eligible if they evaluated interventions targeting children up to 18 years and the study intervention(s) targeted childhood excess weight or sought to improve diet or physical activity, regardless of the type of economic evaluation or the underpinning study design. We synthesized evidence using narrative synthesis methods. One-hundred fifty-one studies met the eligibility criteria and were classified into three groups based on the intervention approach: prevention-only (13 studies), prevention and treatment (100 studies), and treatment-only (38 studies). The predominant setting and study design differed considerably between the three groups of studies. However, compared with usual care, most interventions were deemed cost-effective. The study participants' ages, sex, and socioeconomic status were crucial to intervention cost-effectiveness. Interventions whose effects were projected beyond childhood, such as bariatric surgery, lower protein infant formula, and home-based general practitioner consultations, tended to be cost-effective. However, cost-effectiveness was sensitive to the assumptions underlying the persistence and intensity of such effects. Our findings can inform future recommendations on the conduct of economic evaluations of interventions targeting childhood overweight and obesity, as well as practice and policy recommendations.

Parents' recalled experiences of the child centred health dialogue in children with overweight: a qualitative study

BACKGROUND

Because overweight and obesity are still increasing and prevention of childhood obesity is more likely to be effective when initiated in preschool children, the Child Health Service in the south of Sweden developed a structured child-centred health dialogue model targeting all 4-year-old children and their families. The aim of this study was to describe parents' recalled experiences of this health dialogue in children with overweight.

METHODS

A qualitative inductive approach with purposeful sampling was used. Thirteen individual interviews with parents (including 11 mothers and 3 fathers) were conducted and analysed with qualitative content analysis.

RESULTS

The analysis resulted in two categories: 'A valuable visit with a subtle individual impact' that described parents' recalled experiences of the health dialogue and 'There is a complex interaction between weight and lifestyle' that reflected the parents' perceptions of the relationship between their children's weight and lifestyle.

CONCLUSIONS

Parents recalled the child-centred health dialogue as important and described discussing a healthy lifestyle as one of the obligations of the Child Health Service. Parents wanted confirmation that their family lifestyle was healthy; however, they did not want to discuss the relationship between their family lifestyle and their children's weight. Parents expressed that when their child followed the child's growth curve, then this indicated healthy growth. This study supports using the child-centred health dialogue as a model to provide structure for discussing a healthy lifestyle and growth but highlights the difficulties of discussing body mass index and overweight, especially in the presence of children.

Effectiveness of a Smartphone App (MINISTOP 2.0) integrated in primary child health care to promote healthy diet and physical activity behaviors and prevent obesity in preschool-aged children: randomized controlled trial

BACKGROUND

Childhood overweight and obesity is a public health priority. We have previously reported the efficacy of a parent-oriented mobile health (mHealth) app-based intervention (MINISTOP 1.0) which showed improvements in healthy lifestyle behaviors. However, the effectiveness of the MINISTOP app in real-world conditions needs to be established.

OBJECTIVE

To evaluate the real-world effectiveness of a 6-month mHealth intervention (MINISTOP 2.0 app) on children's intake of fruits, vegetables, sweet and savory treats, sweet drinks, moderate-to-vigorous physical activity, and screen time (primary outcomes), and on parental self-efficacy (PSE) for promoting healthy lifestyle behaviors, and children's body mass index (BMI) (secondary outcomes).

METHODS

A hybrid type 1 effectiveness-implementation design was utilized. For the effectiveness outcomes, a two-arm, individually randomized controlled trial was conducted. Parents (n = 552) of 2.5-to-3-year-old children were recruited from 19 child health care centers across Sweden, and, randomized to either a control (standard care) or intervention group (MINISTOP 2.0 app). The 2.0 version was adapted and translated into English, Somali and Arabic to increase reach. All recruitment and data collection were conducted by the nurses. Outcomes were assessed at baseline and after six months, using standardized measures (BMI) and a questionnaire (health behaviors, PSE).

RESULTS

Among the participating parents (n = 552, age: 34.1 ± 5.0 years), 79% were mothers and 62% had a university degree. Twenty-four percent (n = 132) of children had two foreign-born parents. At follow-up, parents in the intervention group reported lower intakes of sweet and savory treats (-6.97 g/day; p = 0.001), sweet drinks (-31.52 g/day; p < 0.001), and screen time (-7.00 min/day; p = 0.012) in their children compared to the control group. The intervention group reported higher total PSE (0.91; p = 0.006), PSE for promoting healthy diet (0.34; p = 0.008) and PSE for promoting physical activity behaviors (0.31; p = 0.009) compared to controls. No statistically significant effect was observed for children's BMI z-score. Overall, parents reported high satisfaction with the app, and 54% reported using the app at least once a week.

CONCLUSION

Children in the intervention group had lower intakes of sweet and savory treats, sweet drinks, less screen time (primary outcomes) and their parents reported higher PSE for promoting healthy lifestyle behaviors. Our results from this real-world effectiveness trial support the implementation of the MINISTOP 2.0 app within Swedish child health care.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04147039; https://clinicaltrials.gov/ct2/show/NCT04147039.

Study protocol for an effectiveness-implementation hybrid trial to evaluate a health promotion intervention in parents and their 5-year-old child: Saga Stories in health talks in Swedish child healthcare

BACKGROUND

Unhealthy lifestyle behaviours such as a poor diet, inadequate physical activity, and excessive screen time have been shown to be established in childhood and track into adulthood, demonstrating the need for health promotion interventions in the pre-school years. The overall aim of this project is to: (i) evaluate the effectiveness of `Saga Stories in health talks´ within child healthcare (CHC) on parental self-efficacy to promote healthy diet, physical activity, and screen time behaviours in their child; children's intake of key dietary indicators and screen time and (ii) evaluate and explore the implementation of `Saga Stories in health talks´ with regards to acceptability, appropriateness, feasibility, fidelity, adoption, sustainability, satisfaction, and usage.

METHODS

A hybrid type I effectiveness-implementation trial will be conducted. A cluster randomized controlled trial will be used to assess the effectiveness of `Saga Stories in health talks´ in 42 CHC centers across six regions in Sweden. `Saga Stories in health talks´ consists of material for CHC nurses to use to facilitate the health talk with both the child and parent(s) and is complemented with take-home material. Parent and child dyads are recruited (n = 450) from participating CHC centers when they attend their 5-year routine visit. The intervention group receives the health talk using Saga Stories and take-home material, whereas the control group receives the standard health talk. The primary outcome is parental self-efficacy to promote healthy diet, physical activity, and screen time behaviours in their child and secondary outcomes include children's intake of key dietary indicators and screen time. All outcomes are assessed at baseline and 2-months post-intervention. The implementation outcomes that will be assessed are: acceptability, appropriateness, feasibility, satisfaction, usage, fidelity, adoption, and sustainability (assessed quantitatively and qualitatively).

DISCUSSION

The Swedish National Board of Health and Welfare have identified the need of more material, education, and working methods for promoting healthy lifestyle behaviours in CHC. Following this trial `Saga Stories in health talks´ has great potential to be implemented in CHC across Sweden to aid nurses to promote and support healthy lifestyle behaviours in pre-school children and their families.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT05237362 . Registered 2 February 2022.

Changes in perceived parental self-efficacy after a Child-Centred Health Dialogue about preventing obesity

Aim

This randomised controlled trial evaluated changes in parental self‐efficacy and children's weight, after a Child‐Centred Health Dialogue about preventing obesity.

Methods

We randomly assigned 37 Child Health Centres in Skåne county Sweden to provide usual care or the dialogue intervention. They included centres from high and low socioeconomic areas. The outcomes were changes in parental self‐efficacy and any moderating effect on their children's body mass index 1 year later.

Results

The baseline data were based on 1115 mothers and 869 fathers representing 1197 children (52% females) aged 4 years (3.9–4.2) with a standardised body mass index (zBMI) of 0.1 ± 0.9. The participation rates at follow‐up, 1.1 ± 0.2 years after the intervention were 817 mothers and 508 fathers. Overall, parental self‐efficacy had decreased by the 1‐year follow‐up. There was a significant intervention effect on maternal self‐efficacy in promoting physical activity, however with unclear clinical relevance. Mothers' change in perceived self‐efficacy in promoting a healthy diet seemed to moderate the intervention effect on zBMI change in children with zBMI > 0 with −0.01 (95% CI: −0.025 to −0.001; p = 0.03).

Conclusion

Our study suggested a possible link between increased maternal self‐efficacy in promoting a healthy diet and a favourable development of zBMI.

Effect of obesity treatment interventions in preschool children aged 2-6 years: a systematic review and meta-analysis

OBJECTIVES

(1) To summarise the literature on the impact of paediatric weight management interventions on health outcomes in preschool age children with overweight or obesity and (2) to evaluate the completeness of intervention description and real-world applicability using validated tools.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, CINAHL, Cochrane Library and PsychInfo were searched between 10 March 2015 and 21 November 2021.

ELIGIBILITY CRITERIA

Randomised controlled trials addressing weight management in preschool children (2-6 years) with overweight or obesity.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted key information from each study and assessed risk of bias. Random-effects meta-analysis was performed where there was evidence for homogeneous effects. The certainty of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Of the 16 908 studies retrieved, 9 trials (1687 participants) met the inclusion criteria. These interventions used motivational interviewing (MI) or multicomponent educational interventions related to health behaviour approaches and were 6-12 months in duration. All studies contained some risk of bias. A difference was found in the intervention groups compared with controls for body mass index (BMI) z score (mean difference -0.10, 95% CI -0.12 to -0.09; eight trials, 1491 participants; p<0.001; I² 68%), though there was substantial heterogeneity. There were no subgroup effects between studies using MI compared with studies using multicomponent interventions. The certainty of the evidence was considered low. The trials were reported in sufficient detail and were considered pragmatic.

CONCLUSIONS

Paediatric weight management interventions delivered to the parents of young children with obesity result in small declines in BMI z score. The results should be interpreted cautiously as they were inconsistent and the quality of the evidence was low.

PROSPERO REGISTRATION NUMBER

CRD42020166843.