Four-year outcome of randomly assigned lifestyle treatments in primary care of children with obesity

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions

The objective of this technical report is to provide clinicians with evidence-based, actionable information upon which to make assessment and treatment decisions for children and adolescents with obesity. In addition, this report will provide an evidence base to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are clinically based, effective treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori key questions.

A Systematic Review Looking at the Current Best Practices as well as Primary Care Practitioner's Views on the Diagnosis and Treatment of Childhood Obesity

Childhood obesity is a significant and growing issue, with the WHO recognising worldwide childhood obesity rates as an epidemic. Primary care is often the first point for monitoring a child's development over time, hence could play an integral part in recognising and addressing childhood obesity. As a result, our systematic review has two objectives. The primary objective is to review the current evidence on best practices in diagnosing and treating childhood obesity. The secondary objective is to review recent qualitative studies looking into the view of primary care practitioners on the treatment and diagnosis of childhood obesity. The rationale for this is to help determine what opportunities there are in primary care in the NHS to tackle childhood obesity. Using searches in MEDLINE, EMBASE, PSYCHINFO, HMIC and NHS evidence over a five-year period from March 2014 to March 2019, a total of 37 studies were eligible for inclusion in the review. Out of these, 25 studies identified exploring the diagnosis and treatment of childhood obesity. A few key themes in these studies were identified, including motivational interviewing, m-health, tools and resources used in consultations, the use of dieticians in the primary care team and factors concerned with the identification of obesity in children. The rest of the 12 qualitative studies involved eliciting the views of direct stakeholders about the diagnosis and treatment of obesity in children. Eight of the studies investigated providers' views towards the role of primary care practitioners in treating childhood obesity, two investigated the parents of obese children's perspectives and the other two investigated general practitioners' (GPs) views towards specific tools and resources. Regarding our primary objective, our findings showed many studies looking at interventions to reduce the BMI in obese children fail to do so in a statistically significant way. However, a few interventions have been more consistent in reducing BMI and obesogenic behaviours. Those interventions include ones utilising the motivational interviewing technique and those targeting families, rather than children. Another key finding was that tools and resources available to primary care providers can significantly impact their ability to diagnose and treat obesity, particularly when looking at the detection. Finally, evidence regarding the clinical effectiveness of e-health is limited, with views on their use also mixed. Regarding our secondary objective, the qualitative research identified demonstrated many common views from GPs across different countries. It showed healthcare providers (HCPs) perceiving the parents as lacking in motivation to address the issue, HCPs not wanting to damage the relationship with their patients due to it being a sensitive topic to bring up, and a lack of time, training and confidence. However, some of these views may not be generalisable to the UK due to cultural and system differences.

Usability and Engagement Testing of mHealth Apps in Paediatric Obesity: A Narrative Review of Current Literature

Mobile health (mHealth) platforms have become increasingly popular for delivering health interventions in recent years and particularly in light of the COVID-19 pandemic. Childhood obesity treatment is an area where mHealth interventions may be useful due to the multidisciplinary nature of interventions and the need for long-term care. Many mHealth apps targeting youth exist but the evidence base underpinning the methods for assessing technical usability, user engagement and user satisfaction of such apps with target end-users or among clinical populations is unclear, including for those aimed at paediatric overweight and obesity management. This review aims to examine the current literature and provide an overview of the scientific methods employed to test usability and engagement with mHealth apps in children and adolescents with obesity. A narrative literature review was undertaken following a systematic search. Four academic databases were searched. Inclusion criteria were studies describing the usability of mHealth interventions for childhood obesity treatment. Following the application of inclusion and exclusion criteria, fifty-nine articles were included for full-text review, and seven studies met the criteria for usability and engagement in a clinical paediatric population with obesity. Six apps were tested for usability and one for engagement in childhood obesity treatment. Sample sizes ranged from 6–1120 participants. The included studies reported several heterogenous measurement instruments, data collection approaches, and outcomes. Recommendations for future research include the standardization and validation of instruments to measure usability and engagement within mHealth studies in this population.

The effectiveness of nurse-led interventions to prevent childhood and adolescent overweight and obesity: A systematic review of randomised trials

BACKGROUND

Obesity among children and adolescents continues to rise worldwide. Despite the efforts of the healthcare workforce, limited high-quality evidence has been put forward demonstrating effective childhood obesity interventions. The role of nurses as primary actors in childhood obesity prevention has also been underresearched given the size of the workforce and their growing involvement in chronic disease prevention.

AIM

To examine the effectiveness of nurse-led interventions to prevent childhood and adolescent overweight and obesity.

DESIGN

A systematic review of randomised trials.

DATA SOURCES

Medline, CINAHL, EMBASE, Cochrane (CENTRAL), ProQuest Central and SCOPUS were searched from inception to March 2020.

REVIEW METHODS

This review was informed by the Cochrane handbook for systematic reviews of interventions.

RESULTS

Twenty-six publications representing 18 discrete studies were included (nine primary prevention and nine secondary prevention). Nurse-led interventions were conducted in diverse settings, were multifaceted, often involved parents and used education, counselling and motivational interviewing to target behaviour change in children and adolescents' diet and physical activity. Most studies did not determine that nurse-led interventions were more effective than their comparator(s) in preventing childhood and adolescent overweight and obesity.

CONCLUSIONS

Nurse-led interventions to prevent juvenile obesity are feasible but have not yet determined effectiveness. With adequate training, nurses could make better use of existing clinical and situational opportunities to assist in the effort to prevent childhood obesity.

Development, implementation and early results of a 12-week web-based intervention targeting 51 children age 5-13 years and their families

Background

Internet-based treatments have proven effective for various health issues. There is a need to scale up interventions targeting children with obesity, also in less densely populated areas where the prevalence in many countries is higher than in urban areas. The aim of this study was to design and implement an internet-based program as an add-on to standard treatment for childhood obesity.

Methods

Web-Childhood Obesity Prevention (Web-COP) was a prospective feasibility study with a pre- post- design. The intervention consisted of four group-based education sessions at the clinic, physical activity on prescription, and a new 12-week internet-based program. Web-COP was offered to children with obesity (International Obesity Task Force Body Mass Index (IOTF-BMI) ≥ 30 kg/m2) and their parents in two counties in Northern Sweden from August 2018 to June 2019. The primary outcome was change in BMI standard deviation score (BMI-SDS).

Results

The study included 55 children 5-13 years of age. The internet-based component was well received, and retention rate was 51/55 (92.7%). Data was analysed for 51 children. Mean BMI-SDS was 3.3 at start and decreased by 0.2, 0.3, and 0.4 at two, four, and six months from baseline. Using a continuous algorithm, 42/51 (81%), children lowered their BMI-SDS and 33/51 (65%) lowered their BMI.

Conclusion

Adding group sessions and an internet-based program to standard care was feasible and two thirds of included children with obesity reduced their BMI.

A novel interactive mobile health support system for pediatric obesity treatment: a randomized controlled feasibility trial

BACKGROUND

In order to achieve improved weight status, behavioral pediatric obesity treatment is resource intensive. Mobile Health (mHealth) is more accessible than standard care but effective approaches are scarce. Therefore, the aim of this feasibility trial was to study trial design, mHealth usage, compliance, and acceptability of a novel mHealth approach in pediatric obesity treatment.

METHODS

This six-month parallel two-arm feasibility trial took place at three pediatric outpatient clinics in Stockholm, Sweden. Participants, 5-12 years, starting obesity treatment were randomized to using an mHealth support system as an addition to standard care (intervention) or to standard care alone (control). The intervention included daily self-monitoring of weight transferred to a mobile application (app) used by parents, a website in which clinicians could track treatment progress, prespecified treatment goals for change in degree of obesity shown in the app and on the website, and text message interactions between clinicians and parents. The main outcome was description of feasibility. Height and weight were measured at baseline, three, and 6 months to explore changes in body mass index standard deviation score (BMI SDS).

RESULTS

Of 40 children eligible for inclusion, 28 agreed to participate (54% girls) and were randomized to intervention (n = 15) or control (n = 13). Weight was measured at home regularly throughout the entire trial period by 12/15 children in the intervention group. Attendance at appointments were better in the intervention group (p = 0.024). Both parents and clinicians had a positive experience and found the mHealth support system accessible. At 6 months the intervention group had a greater reduction of 0.24 units in BMI SDS than standard care (- 0.23 vs. 0.01, p = 0.002).

CONCLUSIONS

The mHealth support system was a feasible and innovative treatment approach which, in addition to standard care, generated better treatment results than standard care alone. Future research should evaluate the treatment effects over a longer follow-up time in a larger study sample.

TRIAL REGISTRATION

This trial was retrospectively registered at ClinicalTrials.gov , ID: NCT03380598 , on November 8, 2017.

Promising results from an implemented treatment model for paediatric obesity

AIM

To investigate the implementation of a plan of action for treatment of childhood obesity, and the effect after 2 years of treatment.

METHODS

Children aged 6-12.9 years who started obesity treatment between 2008 and 2015 in a paediatric clinic in Stockholm County were included. The treatment model included staff education and support and group activities for parents and children separately followed by individual sessions to a multidisciplinary team. The main outcome was change in body mass index standard deviation score (BMI SDS), in comparison to a matched control group.

RESULTS

In the intervention group, 1334 children (52% boys) with an average age of 9.3 years and BMI SDS of 2.7 and 3012 children in the control group were included. The intervention group decreased their BMI SDS more after two years compared with the control group, (-0.31 vs -0.23, P < .001). Younger age and higher BMI SDS at treatment initiation and families that completed the group sessions (all P < .001) had greater decreases in BMI SDS after 2 years. Sex did not affect the outcome.

CONCLUSION

Even though the treatment in the control group was effective, the implementation of the action plan yielded a better treatment response compared with the control group.

A family-oriented intervention programme to curtail obesity from five years of age had no effect over no intervention

AIM

To examine the effect of a family-oriented multidisciplinary intervention programme to curtail weight increase in young children with obesity.

METHODS

Children who weighed more than one kilogram above the 97th percentile for height at the preschool assessment in Oppland County, Norway, were identified. Parents residing in one part of the county were invited to participate in a group-based three-year intervention programme while the rest had no interventions. Body mass index (BMI) and family characteristics at entry and measurements at birth were explanatory variables, and change in BMI standard deviation score (SDS) the outcome measure. For the intervention group, outcome was also related to skinfold thicknesses, waist-to-height ratio and physical ability.

RESULTS

The programme was completed by 31 families in the intervention and 33 in the control group. At entry, the respective median (interquartile) age was 5.83 (0.36) and 5.74 (0.66) years, and the BMI SDS 2.35 (1.06) and 1.95 (0.49), P = .012. The median decrease in BMI SDS was 0.19 in both groups. The decline increased with increasing BMI SDS at entry, but irrespective of group. Social or behavioural factor or other anthropometric measures were not associated with outcome.

CONCLUSION

The intervention programme had no effect on BMI SDS.