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Ocariza LM, Leong GM, Gandham S, Poulton A, Liu A, Bhurawala H. Paediatric obesity diagnosis and intervention practices in Australian hospitals - Australia-wide survey. J Paediatr Child Health 2024; 60:279-287. [PMID: 38766842 DOI: 10.1111/jpc.16564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 11/09/2023] [Accepted: 05/04/2024] [Indexed: 05/22/2024]
Abstract
AIM Previous studies suggest a lack of a unified approach in identifying and addressing children with obesity while being inpatients in individual Australian hospitals. Our study aimed to describe current clinical practice across Australia and identify discrepancies that can aid in developing a more unified response to children identified with obesity as hospital inpatients. METHODS A cross-sectional exploratory online survey was distributed to major paediatric in-patient departments in Australia, with a response rate of 68%. Questions focused on education, identification, interventions and attitudes towards a national protocol. RESULTS Twenty percent of respondents indicated that staff in their department regularly record body mass index, 66% address weight issues and only 8% consistently refer to appropriate outpatient services. Although 88% of respondents believe that a national protocol for addressing paediatric obesity would be beneficial, respondents emphasised concerns regarding their local resources. CONCLUSION Our study can inform the development of a guideline for a unified response to opportunistically identify children with overweight and obesity as inpatients.
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Affiliation(s)
| | - Gary M Leong
- The University of Sydney Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Paediatrics, Nepean Blue Mountains Metabolic Health Service, Nepean Hospital, Sydney, New South Wales, Australia
| | - Sowmya Gandham
- Paediatric Department, Nepean Hospital, Sydney, New South Wales, Australia
- Blue Mountains Hospital, Katoomba, New South Wales, Australia
| | - Alison Poulton
- Paediatrics, The University of Sydney Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Liu
- Paediatrics, The University of Sydney Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Habib Bhurawala
- Paediatric Department, Nepean Hospital, Sydney, New South Wales, Australia
- Paediatrics, The University of Sydney Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Paediatrics, School of Medicine, The University of Notre Dame, Australia, Sydney, New South Wales, Australia
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Norman J, Furber S, Bauman A, Okely AD. The feasibility, acceptability and potential efficacy of a parental text message and social media program on children's vegetable consumption and movement behaviours: A pilot randomised controlled trial. Health Promot J Austr 2024. [PMID: 38200657 DOI: 10.1002/hpja.839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 11/29/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
ISSUE ADDRESSED Australian children fall short of meeting the dietary, physical activity and sedentary behaviour guidelines. This study aimed to test the feasibility, acceptability and potential efficacy of a parental text message and social media program on, primarily, their school-aged children's vegetable consumption and movement behaviours, and, secondarily, their own. METHODS Between August and November 2022, we conducted a two-armed randomised controlled trial with 242 parents/caregivers of primary school-aged children in New South Wales. The 'Adventure & Veg' intervention ran for 8 weeks, promoting vegetable eating behaviours, local outdoor physical activity opportunities and ideas for reducing screen time. Feasibility and acceptability were assessed via recruitment and retention data, intervention metrics and self-reported participant data. Vegetable intake and movement behaviour data were collected via online-surveys and effect sizes were examined. RESULTS Most participants reported that they enjoyed receiving the text messages (88%) and the delivery frequency was acceptable (94%). Limitations to Facebook as a delivery platform were reported. The majority of participants used the text messages to influence the vegetable eating (65%) and movement (77%) behaviours of their child. Significant effects were observed among intervention child participants compared with control for mean daily vegetable consumption (0.45 serves, CI: .19; .71, p = .001, d = .5); weekly vegetable variety (1.85, CI: .25; 3.45, p < .001, d = .6); and weekly physical activity variety (.64 CI: .09; 1.19, p = .022, d = .3). Parents in the intervention group increased their daily vegetable intake by .44 serves (CI: .11; .78, p = .01, d = .4). CONCLUSIONS A parental text message and social media program has potential to support children's vegetable intake and movement behaviours. Further research is required to explore different online delivery methods to promote local outdoor activity options. SO WHAT?: The Adventure & Veg program holds promise as a stand-alone health promotion intervention or as a useful adjunct to current family or school-based healthy lifestyle programs.
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Affiliation(s)
- Jennifer Norman
- Health Promotion Service, Illawarra Shoalhaven Local Health District, New South Wales Health, Wollongong, New South Wales, Australia
- School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Susan Furber
- Health Promotion Service, Illawarra Shoalhaven Local Health District, New South Wales Health, Wollongong, New South Wales, Australia
- School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Adrian Bauman
- School of Public Health, and the Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony D Okely
- Early Start, School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
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Zhu D, Dordevic AL, Gibson S, Davidson ZE. Evaluating a 10-Week Family-Focused E-Health Healthy Lifestyle Program for School-Aged Children with Overweight or Obesity: A Randomized Controlled Trial Study Protocol. Nutrients 2023; 15:2909. [PMID: 37447233 DOI: 10.3390/nu15132909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
E-Health childhood obesity treatment interventions may serve as favorable alternatives to conventional face-to-face programs. More studies are needed to evaluate the effectiveness of such interventions beyond immediately post-program completion, including exploring program features impacting effectiveness. This randomized controlled trial with a qualitative component and waitlisted control group will evaluate the effectiveness of a 10-week family-focused e-Health program for school-aged children with overweight/obesity and explore the experience of families completing the program. The primary outcome is the change in BMI z-score and will be assessed from baseline to 10 weeks. Secondary outcomes include (the change in) waist circumference, dietary intake, physical activity, quality of life, and experiences, and will be assessed at baseline, post-10 weeks, and/or immediately, 3-, 6-, and/or 12-months post-program completion. Independent t-tests will be used to compare the differences in means and analyses of variances (ANOVAs) will be conducted to investigate the impact of the program or of being waitlisted and the effect size of the program on quantitative outcome measures. Reflexive thematic analysis will be used with qualitative data. Findings from this study are expected to provide learnings to upscale conventional childhood obesity treatment services, in the hopes of curbing the rising rate of childhood obesity.
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Affiliation(s)
- Diana Zhu
- Department of Nutrition Dietetics and Food, Monash University, Level 1, 264 Ferntree Gully Road, Notting Hill, Melbourne, VIC 3168, Australia
| | - Aimee L Dordevic
- Department of Nutrition Dietetics and Food, Monash University, Level 1, 264 Ferntree Gully Road, Notting Hill, Melbourne, VIC 3168, Australia
| | - Simone Gibson
- School of Clinical Sciences, Monash University, Level 5 Block E, Monash Medical Centre, Clayton, Melbourne, VIC 3168, Australia
| | - Zoe E Davidson
- Department of Nutrition Dietetics and Food, Monash University, Level 1, 264 Ferntree Gully Road, Notting Hill, Melbourne, VIC 3168, Australia
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Southcombe F, Vivekanandarajah S, Krstic S, Lin F, Chay P, Williams M, Khan JR, Hu N, Eapen V, Dennis S, Denney‐Wilson E, Lingam R. More than just body mass index: Using the Edmonton obesity staging system for pediatrics to define obesity severity in a multi-ethnic Australian pediatric clinical cohort. Obes Sci Pract 2023; 9:285-295. [PMID: 37287524 PMCID: PMC10242255 DOI: 10.1002/osp4.648] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/20/2022] [Accepted: 11/28/2022] [Indexed: 09/20/2024] Open
Abstract
Background Despite advancements in the use of body mass index (BMI) to categorize obesity severity in pediatrics, its utility in guiding individual clinical decision making remains limited. The Edmonton Obesity Staging System for Pediatrics (EOSS-P) provides a way to categorize the medical and functional impacts of obesity according to the severity of impairment. The aim of this study was to describe the severity of obesity among a sample of multicultural Australian children using both BMI and EOSS-P tools. Methods This cross-sectional study included children aged 2-17 years receiving obesity treatment through the Growing Health Kids (GHK) multi-disciplinary weight management service in Australia between January to December 2021. BMI severity was determined using the 95th percentile for BMI on age and gender standardized Centre for Disease Control and Prevention (CDC) growth charts. The EOSS-P staging system was applied across the four health domains (metabolic, mechanical, mental health and social milieu) using clinical information. Results Complete data was obtained for 338 children (age 10.0 ± 3.66 years), of whom 69.5% were affected by severe obesity. An EOSS-P stage 3 (most severe) was assigned to 49.7% of children, the remaining 48.5% were assigned stage 2 and 1.5% were assigned stage 1 (least severe). BMI predicted health risk as defined by EOSS-P overall score. BMI class did not predict poor mental health. Conclusion Used in combination, BMI and EOSS-P provide improved risk stratification of pediatric obesity. This additional tool can help focus resources and develop comprehensive multidisciplinary treatment plans.
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Affiliation(s)
- Faye Southcombe
- South Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | | | - Slavica Krstic
- South Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Fang Lin
- South Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Paul Chay
- South Western Sydney Local Health DistrictSydneyNew South WalesAustralia
| | - Mandy Williams
- South Western Sydney Local Health DistrictSydneyNew South WalesAustralia
| | | | - Nan Hu
- School of Clinical MedicineUniversity of NSWSydneyNew South WalesAustralia
- School of PsychiatryFaculty of MedicineUniversity of NSWSydneyNew South WalesAustralia
| | - Valsa Eapen
- South Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- School of PsychiatryFaculty of MedicineUniversity of NSWSydneyNew South WalesAustralia
- Ingham Institute of Applied Medical ResearchLiverpoolNew South WalesAustralia
| | - Sarah Dennis
- South Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Ingham Institute of Applied Medical ResearchLiverpoolNew South WalesAustralia
| | | | - Raghu Lingam
- School of Clinical MedicineUniversity of NSWSydneyNew South WalesAustralia
- Ingham Institute of Applied Medical ResearchLiverpoolNew South WalesAustralia
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Carrello J, Hayes A, Baur LA, Lung T. Potential cost-effectiveness of e-health interventions for treating overweight and obesity in Australian adolescents. Pediatr Obes 2023; 18:e13003. [PMID: 36649693 PMCID: PMC10909552 DOI: 10.1111/ijpo.13003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/04/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND E-health, defined as the use of information and communication technologies to improve healthcare delivery and health outcomes, has been promoted as a cost-effective strategy to treat adolescent overweight and obesity. However, evidence supporting this claim is lacking. OBJECTIVES Assess the potential cost-effectiveness of a hypothetical e-health intervention for adolescents with overweight and obesity. METHODS The costs and effect size (BMI reduction) of the hypothetical intervention were sourced from recent systematic reviews. Using a micro-simulation model with a lifetime time horizon, we conducted a modelled cost-utility analysis of the intervention compared to a 'do-nothing' approach. To explore uncertainty, we conducted bootstrapping on individual-level costs and quality-adjusted life years (QALYs) and performed multiple one-way sensitivity analyses. RESULTS The incremental cost-effectiveness ratio (ICER) for the e-health intervention was dominant (cheaper and more effective), with a 96% probability of being cost-effective at a willingness-to-pay (WTP) of $50 000/QALY. The ICER remained dominant in all sensitivity analyses except when using the lower bounds of the hypothetical intervention effect size, which reduced the probability of cost-effectiveness at a WTP of $50 000/QALY to 51%. CONCLUSION E-health interventions for treatment of adolescent overweight and obesity demonstrate very good cost-effectiveness potential and should be considered by healthcare decision makers. However, further research on the efficacy of such interventions is warranted to strengthen the case for investment.
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Affiliation(s)
- Joseph Carrello
- School of Public Health, Faculty of Medicine and HealthThe University of SydneyCamperdownAustralia
| | - Alison Hayes
- School of Public Health, Faculty of Medicine and HealthThe University of SydneyCamperdownAustralia
| | - Louise A. Baur
- School of Public Health, Faculty of Medicine and HealthThe University of SydneyCamperdownAustralia
- Weight Management Services, The Children's Hospital at WestmeadWestmeadAustralia
| | - Thomas Lung
- School of Public Health, Faculty of Medicine and HealthThe University of SydneyCamperdownAustralia
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Partridge SR, Reece L, Sim KA, Todd A, Jia SS, Raeside R, Schirmer T, Phongsavan P, Redfern J. An analysis of current obesity strategies for adolescents in NSW against best practice recommendations: Implications for researchers, policymakers and practitioners. Health Promot J Austr 2023; 34:390-397. [PMID: 35411703 PMCID: PMC10946797 DOI: 10.1002/hpja.606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/24/2022] [Accepted: 04/05/2022] [Indexed: 11/06/2022] Open
Abstract
ISSUE ADDRESSED Obesity is a significant health challenge facing adolescents. There is a critical need for government action to support all adolescents to improve risk factors for obesity. This study critically appraised initiatives, guidelines and policies (termed "strategies") from local health districts (LHDs), speciality health networks and Primary Health Networks (PHNs) across New South Wales (NSW), relevant to the prevention and management of obesity amongst adolescents and compare these to best practice recommendations. METHODS We critically appraised strategies against best practice recommendations that included support, access, responsiveness to needs, supportive environment, monitoring and evaluation and health equity. Strategies were collected by systematically searching websites of 15 LHDs, one speciality health network and 10 PHNs. RESULTS There was evidence of strategies regarding adolescent obesity prevention and management across all best practice recommendations. There was limited evidence of adolescent consumer participation, digital strategies for health services and online health information. There were minimal targeted public or school-based education campaigns and interventions on physical activity or nutrition. Place-based approaches such as sports and recreation facilities were not included in policies regarding the sale of healthy food and drinks. Evaluation evidence across all strategies was minimal. CONCLUSIONS Numerous strategies are being implemented across NSW to address adolescent obesity. Despite this, the alignment of strategies with best practice recommendations is poor and evidence of progress in tackling adolescent obesity remains unclear. SO WHAT?: Opportunities to generate and translate best practice evidence within government strategies for obesity must be prioritised with embedded measurement and evaluation plans.
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Affiliation(s)
- Stephanie R. Partridge
- Engagement and Co‐design Hub, School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Prevention Research Collaboration, Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Charles Perkins CentreThe University of SydneySydneyNew South WalesAustralia
| | - Lindsey Reece
- Prevention Research Collaboration, Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Charles Perkins CentreThe University of SydneySydneyNew South WalesAustralia
| | - Kyra A. Sim
- Charles Perkins CentreThe University of SydneySydneyNew South WalesAustralia
- Sydney Local Health DistrictCamperdownNew South WalesAustralia
| | - Allyson Todd
- Engagement and Co‐design Hub, School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Si Si Jia
- Engagement and Co‐design Hub, School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Rebecca Raeside
- Engagement and Co‐design Hub, School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Teisha Schirmer
- Mid North Coast Local Health DistrictPort MacquarieNew South WalesAustralia
| | - Philayrath Phongsavan
- Prevention Research Collaboration, Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Charles Perkins CentreThe University of SydneySydneyNew South WalesAustralia
| | - Julie Redfern
- Engagement and Co‐design Hub, School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- The George Institute for Global HealthThe University of New South WalesCamperdownNew South WalesAustralia
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Kwok C, Forward V, Lister NB, Garnett SP, Baur LA, Jebeile H. Considerations of eating disorder risk during obesity treatment in Australia: Current practice, attitudes and barriers. Obes Res Clin Pract 2023; 17:151-157. [PMID: 36906489 DOI: 10.1016/j.orcp.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/07/2023] [Accepted: 02/23/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION People with obesity are vulnerable to eating disorders. It has been suggested that screening for eating disorder risk be part of obesity care. However, it is unclear what current practice entails. OBJECTIVE To explore considerations of eating disorder risk during treatment of obesity, including assessment and intervention strategies used in clinical practice. MATERIALS AND METHODS An online (REDCap) cross-sectional survey was distributed to health professionals working with individuals with obesity in Australia through professional societies and social media. The survey had three sections: 1. Characteristics of Clinician/Practice, 2. Current Practice, 3. Attitudes. Data were summarised using descriptive statistics and free-text comments were independently coded in duplicate to identify themes. RESULTS 59 health professionals completed the survey. Most were dietitians (n = 29), identified as women (n = 45) and worked within a public hospital (n = 30) and/or private practice (n = 29). Overall, 50 respondents reported assessing for eating disorder risk. Most reported that having a history of, or risk factors of eating disorders should not preclude obesity care but emphasised the importance of treatment modification including using a patient-centred approach involving a multidisciplinary team and promoting healthy eating behaviours, with less emphasis on calorie restriction or bariatric surgery. Management approaches did not differ for those with eating disorder risk factors or a diagnosed eating disorder. Clinicians identified the need for additional training and clear referral pathways. CONCLUSION Individualised care, balancing models of care for eating disorders and obesity and further access to training and services will be important in improving care of patients with obesity.
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Affiliation(s)
- Cathy Kwok
- The University of Sydney, Children's Hospital Westmead Clinical School, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW 2145, Australia
| | - Victoria Forward
- Nutrition and Dietetics Group, Susan Wakil School of Nursing and Midwifery, The University of Sydney, John Hopkins Drive, Camperdown, NSW 2005, Australia
| | - Natalie B Lister
- The University of Sydney, Children's Hospital Westmead Clinical School, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW 2145, Australia
| | - Sarah P Garnett
- The University of Sydney, Children's Hospital Westmead Clinical School, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW 2145, Australia; Kids Research, The Children's Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW 2145, Australia
| | - Louise A Baur
- The University of Sydney, Children's Hospital Westmead Clinical School, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW 2145, Australia
| | - Hiba Jebeile
- The University of Sydney, Children's Hospital Westmead Clinical School, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW 2145, Australia.
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Mears R, Leadbetter S, Candler T, Sutton H, Sharp D, Shield JPH. Cross-sectional survey of child weight management service provision by acute NHS trusts across England in 2020/2021. BMJ Open 2022; 12:e061971. [PMID: 36356995 PMCID: PMC9670955 DOI: 10.1136/bmjopen-2022-061971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE With one in five children in England living with obesity, we mapped the geographical distribution and format of child weight management services provided by acute National Health Service (NHS) trusts across England, to identify breadth of service provision. DESIGN A cross-sectional survey. SETTING The survey was sent to acute NHS trusts (n=148) in England in 2020, via a freedom of information request. PARTICIPANTS Responses were received from 139 of 148 (94%) acute NHS trusts, between March 2020 to March 2021. OUTCOME MEASURES The survey asked each acute NHS trust whether they provide a weight management service for children living with obesity. For those trusts providing a service, data were collected on eligibility criteria, funding source, personnel involved, number of new patients seen per year, intervention duration, follow-up length and outcome measures. Service characteristics were reported using descriptive statistics. Service provision was analysed in the context of ethnicity and Index of Multiple Deprivation score of the trust catchment area. RESULTS From the 139 survey respondents, 23% stated that they provided a weight management service for children living with obesity. There were inequalities in the proportion of acute NHS trusts providing a service across the different regions of England, ranging from 4% (Midlands) to 36% (London). For trusts providing a service, there was variability in the number of new cases seen per year, eligibility criteria, funding source, intervention format and outcome measures collected. A multidisciplinary approach was not routinely provided, with only 41% of services reporting ≥3 different staff disciplines. CONCLUSION In 2020/2021, there were geographical inequalities in weight management service provision by acute NHS trusts for children living with obesity. Services provided lacked standardisation, did not routinely offer children multidisciplinary care and were insufficient in size to meet need.
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Affiliation(s)
- Ruth Mears
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
- Centre for Exercise Nutrition and Health Sciences, University of Bristol, Bristol, UK
| | - Sofia Leadbetter
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Toby Candler
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Hannah Sutton
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Deborah Sharp
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Julian P H Shield
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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