The effect of a multi-disciplinary obesity intervention compared to usual practice in those ready to make lifestyle changes: design and rationale of Whanau Pakari

Changes in weight status of caregivers of children and adolescents enrolled in a community-based healthy lifestyle programme: Five-year follow-up

Whānau Pakari is a family-centred healthy lifestyle programme for children/adolescents with overweight/obesity in New Zealand. This secondary analysis from our randomised trial within the clinical service assessed 5-year BMI changes in accompanying caregivers (n = 23), mostly mothers. Overall, baseline and 5-year caregivers' BMI were similar (32.50 vs 31.42 kg/m2, respectively; p = 0.31) but two-thirds (65%) experienced BMI reductions. Five-year BMI change was similar in High-intensity and Low-intensity randomisation groups [-1.37 kg/m2 (-4.95, 2.21); p = 0.44]. Caregiver's BMI change was not associated with child's BMI change. Despite no overall BMI reduction, our findings contrast with upward BMI trajectories predicted for NZ adults with overweight/obesity.

A Multisource Process Evaluation of a Community-Based Healthy Lifestyle Programme for Child and Adolescent Obesity

Whānau Pakari is a healthy lifestyle assessment and intervention programme for children and adolescents with obesity in Taranaki (Aotearoa/New Zealand), which, in this region, replaced the nationally funded Green Prescription Active Families (GRxAF) programme. We compared national referral rates from the GRxAF programme (age 5-15 years) and the B4 School Check (B4SC, a national preschool health and development assessment) with referral rates in Taranaki from Whānau Pakari. We retrospectively analysed 5 years of clinical data (2010-2015), comparing referral rates before, during, and after the Whānau Pakari clinical trial, which was embedded within the programme. We also surveyed programme referrers and stakeholders about their experiences of Whānau Pakari, analysing their responses using a multiple-methods framework. After the Whānau Pakari trial commenced, Taranaki GRxAF referral rates increased markedly (2.3 pretrial to 7.2 per 1000 person-years), while NZ rates were largely unchanged (1.8-1.9 per 1000 person-years) (p < 0.0001 for differences during the trial). Post-trial, Taranaki GRxAF referral rates remained higher irrespective of ethnicity, being 1.8 to 3.2 times the national rates (p < 0.001). Taranaki B4SC referrals for obesity were nearly complete at 99% in the last trial year and 100% post-trial, compared with national rates threefold lower (31% and 32%, respectively; p < 0.0001), with Taranaki referral rates for extreme obesity sustained at 80% and exceeding national rates for both periods (58% and 62%, respectively; p < 0.01). Notably, a referral was 50% more likely for referrers who attended a Whānau Pakari training half-day (RR = 1.51; p = 0.009). Stakeholders credited the success of Whānau Pakari to its multidisciplinary team, family-centred approach, and home-based assessments. However, they highlighted challenges such as navigating multidisciplinary collaboration, engaging with families with complex needs, and shifting conventional healthcare practices. Given its favourable referral trends and stakeholder endorsement, Whānau Pakari appears to be a viable contemporary model for an accessible and culturally appropriate intervention on a national and potentially international scale.

Participant and caregiver perspectives on health feedback from a healthy lifestyle check

INTRODUCTION

The usual output following health consultations from paediatric services is a clinical letter to the referring professional or primary care provider, with a copy sent to the patient's caregiver. There is little research on how patients and caregivers perceive the letter content. We aimed to: first understand child, young people and caregiver experiences of and preferences for receiving a health feedback letter about the child/young person's health measures within a healthy lifestyle programme; and second to provide a set of recommendations for designing letters to children, young people and their families within a healthy lifestyle programme.

METHODS

This qualitative study, informed by Kaupapa Māori principles, included focus groups of children aged 5-11 years and young people aged 12-18 years who were participants in a healthy lifestyle programme in Taranaki, Aotearoa New Zealand and of their respective caregivers (total n = 47). Discussions were audio-recorded, transcribed and analysed using thematic analysis.

FINDINGS

Key themes were identified: letters sometimes acted as 'discourses of disempowerment'-some participants experienced a lack of safety, depersonalisation with medical jargon and 'feeling like a number'. Participants described the need for acknowledgement and affirmation in written communication-health feedback should include validation, choice regarding content, respectful tone and a strengths-based approach to health messages.

INTERPRETATION

Letters to referrers, copied to families, can be perceived as disempowering, and participant and caregiver perspectives of content should be considered. This study challenges conventional practice in communicating health feedback with broader implications for written communication in healthcare. We propose separate letters aimed at the child/young person and their caregiver that offer choice in the information they receive. The administrative burden of multiple letters can be mitigated by advances in digital health.

PATIENT CONTRIBUTION

This study originated in response to feedback from service users that current health feedback was not meeting their needs or expectations. Patient perspectives, especially from children, are rarely considered in the generation of clinic letters from health professionals. Participants were child participants in the community-based clinical service and their caregivers, and care was taken to represent the demographic backgrounds of service users. Collection and interpretation of Māori data were led by researchers who were local community members to ensure prioritisation and preservation of participant voice. Where possible, results are illustrated in the text by direct quotes from participants, whose identities are protected with a pseudonym.

Comparison of percentile tables and algorithm-based calculators for classification of blood pressures in children and adolescents with obesity: A secondary analysis of a clinical trial

AIM

Obesity as a major risk factor for childhood hypertension necessitates careful blood pressure (BP) monitoring of those affected. This study aimed to compare BP classification in a cohort of children affected by obesity using tables versus digital calculations in two sets of guidelines.

METHODS

This study was a secondary analysis of data collected from a randomised clinical trial of a multidisciplinary life-style assessment and intervention program. Baseline data from 237 children with a body mass index >99th percentile or >91st percentile with weight-related comorbidities and available BP measurements were analysed. We assessed agreement between tables and algorithms in classification of elevated BP/pre-hypertension and hypertension based on the American Academy of Paediatrics (AAP) clinical practice guidelines (CPG) and the older Fourth Report using Cohen's weighted kappa. The prevalence of hypertensive diagnoses was also compared between the two guidelines.

RESULTS

Agreement between BP tables and algorithmic calculation of percentiles was discordant, though improved in the AAP CPG compared to the Fourth Report (Cohen's kappa = 0.70 vs. 0.57, respectively). None (0%) were missed diagnoses, and 59 (24.9%) were false positives for the Fourth Report, and 0 (0%) were missed diagnoses, and 49 (20.9%) were false positives for the AAP CPG. Under the recent guidelines, there was an increase in prevalence of 6.0% (95% confidence interval (CI) 2.5-9.4%; P = 0.0001) for BP ≥90th percentile, and of 3.0% (95% CI 0.4-5.6%; p = 0.016) for hypertension (BP ≥ 95th percentile) in the cohort (18.0% and 6.8%, respectively, increased from 12.0% and 3.8%).

CONCLUSIONS

Digital calculators over tables in clinical practice are recommended where possible to improve the accuracy of paediatric BP classification. Substantial rates of elevated BP/Hypertension were found in this cohort of children and adolescents with overweight and obesity.

Changes in referral patterns for weight in association with the preschool Raising Healthy Kids target

Introduction The 'Raising Healthy Kids (RHK) health target ' recommended that children identified as having obesity [body mass index (BMI) ≥98th centile] through growth screening at the B4 School Check (B4SC) be offered referral for subsequent assessment and intervention. Aim To determine the impact of the 'RHK health target ' on referral rates for obesity in Aotearoa New Zealand (NZ). Methods A retrospective audit was undertaken of 4-year-olds identified to have obesity in the B4SC programme in Taranaki and nationally in 2015-19. Key outcomes were: 'RHK health target ' rate [proportion of children with obesity for whom District Health Boards (DHBs) applied the appropriate referral process]; Acknowledged referral rate (proportion of children with a referral for obesity whose referral was acknowledged by DHBs); and Declined referral rate (proportion of children offered a referral for obesity who declined their referral). Results Data were audited on 266 448 children, including 7464 in Taranaki. 'RHK health target ' rates increased markedly between 2015-16 and 2016-17 following the health target implementation (NZ: 34-87%; P  P  Acknowledged referral rates also increased post-target nationally (56-90%; P  Declined referral rates across NZ (26-31%) and in Taranaki (although variable: 38-69%). Discussions The 'RHK health target's' focus on referral rather than intervention uptake limited the policy's impact on improving preschool obesity. Future policy should focus on ensuring access to multidisciplinary intervention programmes across NZ to support healthy lifestyle change.

The Impact of a Family-Based Assessment and Intervention Healthy Lifestyle Programme on Health Knowledge and Beliefs of Children with Obesity and Their Families

Objective: To determine the impact of a family-based assessment-and-intervention healthy lifestyle programme on health knowledge and beliefs of children and families affected by obesity. Second, to compare the health knowledge of the programme cohort to those of a national cohort in Aotearoa/New Zealand (NZ). Design: This mixed-methods study collected health knowledge and health belief data in a questionnaire at baseline and 12-, 24-, and 60-month follow-up assessments. Health knowledge over time was compared with baseline knowledge and with data from a nationally representative survey. A data-driven subsumption approach was used to analyse open-text responses to health belief questions across the study period. Setting: Taranaki region, a mixed urban−rural setting in NZ. Participants: Participants (caregiver/child dyads) from the Whānau Pakari randomised trial. Results: A greater proportion of the cohort correctly categorised foods and drinks as healthy or unhealthy at 12 months compared to baseline for most questionnaire items. Retention of this health knowledge was evident at 24- and 60-month follow-ups. More than twice as many participants correctly reported physical activity recommendations at follow-up compared to baseline (p < 0.001). Health knowledge of participants was similar to the national survey cohort at baseline, but surpassed it at 12 and 24 months. Participant beliefs around healthy lifestyles related to physical functioning, mental and emotional wellbeing, and enhancement of appearance, and gained greater depth and detail over time. Conclusions: This study demonstrates the important role that community-level healthy lifestyle programmes can have in knowledge-sharing and health promotion.

"It's more personal if you can have that contact with a person": Qualitative study of health information preferences of parents and caregivers of children with obesity in New Zealand

The objective of this study was to understand how participants referred to a childhood obesity intervention programme prefer to receive health information, and secondly, to determine acceptability of digital technologies such as a social media platform or IT application for programme engagement. This study includes a subset of interviews (n = 64) of a wider study of the barriers and facilitators of engagement in a multidisciplinary healthy lifestyle programme for childhood obesity, based in Taranaki, Aotearoa/New Zealand. The topics of health information and social media and/or app use were covered in 53 and 30 interviews, respectively. Participants were parents and caregivers of children and adolescents referred to the programme, and interviews were mostly conducted in family homes. Findings showed that participants consulted a range of people, places and resources for information about their health, notably the internet, health professionals, and family and friends. Participants reported using the internet to complement or supplement information from health professionals. A strong relationship with health professionals built on trust was important. Use of digital technologies such as an IT application or social media platform for engagement with the programme was generally acceptable, with the caveat that this did not replace face-to-face communication with their primary care provider. In conclusion, the high usage of digital sources of health information requires accurate and reliable information. Digital technologies such as IT applications or social media platforms may have a role in terms of supplementing the patient journey; however, the importance of in-person communication and an ongoing relationship with a health professional or practice remains paramount.

Associations between changes in caregiver's and child's weight status in a community-based obesity intervention programme

OBJECTIVES

We examined whether caregivers of children/adolescents enroled in a randomised controlled trial (RCT) of a family-centred intervention indirectly achieved reductions in body mass index (BMI), and if these were associated with changes in their children's BMI.

METHODS

RCT participants were New Zealand children/adolescents aged 4.8-16.8 years with BMI ≥ 98th percentile or >91st with weight-related comorbidities. Participants and accompanying caregivers were assessed at baseline, 12, and 24 months.

RESULTS

Overall, caregivers' BMI was unchanged at 12 or 24 months. Among Māori participants, reductions in caregivers' BMI at 12 months were associated with reductions in their children's BMI SDS at 12 (r = 0.30; p = 0.038) and 24 months (r = 0.39; p = 0.009). Further, children identifying as Māori whose caregivers' BMI decreased at 12 months had greater BMI SDS reductions at 12 months [-0.30 (95% CI -0.49, -0.10); p = 0.004] and 24 months [-0.39 (95% CI -0.61, -0.16); p = 0.001] than children of caregivers with increased/unchanged BMI.

CONCLUSIONS

This intervention programme for children/adolescents with obesity did not indirectly reduce caregiver weight status. However, reductions in caregivers' BMI were key to BMI SDS reductions among Māori participants. Given the intergenerational nature of obesity, our findings highlight the importance of culturally relevant, family-focused programmes to achieve clinically meaningful improvements in weight status across the family.

Adult obesity management in New Zealand general practice: a review

INTRODUCTION Obesity is an important issue that leads to further health complications, increases the strain on the national health system and lowers quality of life. There is little available information on obesity management to guide best practice in general practice, despite 32% of New Zealand adults reported to be obese. AIM To review obesity management in New Zealand general practice. METHODS We searched six online databases for peer-reviewed research about adult obesity management. Inclusion criteria were original research, a New Zealand adult sample aged 25-64 years with a body mass index (BMI) >30 (or >25 BMI if participants had comorbidities) with weight loss (kg) as a measurable outcome. RESULTS Eleven articles were identified: nine studies reported statistically significant weight loss from baseline, and two studies reported no significant weight loss. Three studies used a Kaupapa Māori approach. Weight loss results ranged from 0.56 to 12.1 kg. Weight loss interventions varied in strategy and suitability for individual patients. DISCUSSION We found that there are effective weight loss interventions available for primary health-care professionals to refer to. Although most interventions did produce some weight loss, patients may need more comprehensive interventions that include a combination of diet, exercise and behaviour modifications in culturally appropriate ways. Future research should aim to identify and mitigate potential barriers to obesity management in primary care, as well as develop comprehensive, multileveled interventions that are effective for the local population.

Five-year follow-up of a family-based multidisciplinary program for children with obesity

OBJECTIVE

This study aimed to determine 5-year outcomes from a 12-month, family-based, multidisciplinary lifestyle intervention program for children.

METHODS

This study was the 5-year follow-up of a randomized clinical trial comparing a low-intensity control group (home-based assessments) with a high-intensity intervention group (assessments plus weekly sessions) in New Zealand. Participants were aged 5 to 16 years with BMI ≥ 98th centile or > 91st centile with weight-related comorbidities. The primary outcome was BMI standard deviation score (BMISDS). Secondary outcomes included various health markers.

RESULTS

Of the 199 children included in the study at baseline (47% who identified as Māori, 53% who identified as female, 28% in the most deprived quintile, mean age = 10.7 years, mean BMISDS = 3.12), 86 completed a 5-year assessment (43%). BMISDS reduction at 12 months was not retained (control = 0.00 [95% CI: -0.22 to 0.21] and intervention = 0.17 [95% CI: -0.01 to 0.34]; p = 0.221) but was greater in participants aged <10 years versus >10 years at baseline (-0.15 [95% CI: -0.33 to 0.03] vs. 0.21 [95% CI: 0.03 to 0.40]; p = 0.008). BMISDS trajectory favored participants with high attendance (p = 0.013). There were persistent improvements in water intake and health-related quality of life in both groups as well as reduced sweet drink intake in the intervention group.

CONCLUSIONS

This intervention, with high engagement from those most affected by obesity, did not achieve long-term efficacy of the primary outcome. Attendance and age remain important considerations for future interventions to achieve long-term BMISDS reduction.

Improving spatial data in health geographics: a practical approach for testing data to measure children's physical activity and food environments using Google Street View

Background

Geographic information systems (GIS) are often used to examine the association between both physical activity and nutrition environments, and children’s health. It is often assumed that geospatial datasets are accurate and complete. Furthermore, GIS datasets regularly lack metadata on the temporal specificity. Data is usually provided ‘as is’, and therefore may be unsuitable for retrospective or longitudinal studies of health outcomes. In this paper we outline a practical approach to both fill gaps in geospatial datasets, and to test their temporal validity. This approach is applied to both district council and open-source datasets in the Taranaki region of Aotearoa New Zealand.

Methods

We used the ‘streetview’ python script to download historic Google Street View (GSV) images taken between 2012 and 2016 across specific locations in the Taranaki region. Images were reviewed and relevant features were incorporated into GIS datasets.

Results

A total of 5166 coordinates with environmental features missing from council datasets were identified. The temporal validity of 402 (49%) environmental features was able to be confirmed from council dataset considered to be ‘complete’. A total of 664 (55%) food outlets were identified and temporally validated.

Conclusions

Our research indicates that geospatial datasets are not always complete or temporally valid. We have outlined an approach to test the sensitivity and specificity of GIS datasets using GSV images. A substantial number of features were identified, highlighting the limitations of many GIS datasets.

Health system barriers to accessing care for children with weight issues in New Zealand: An interview-based study

OBJECTIVE

To identify barriers created and maintained by the health system affecting engagement in a family-based multidisciplinary healthy lifestyle programme for children and adolescents in New Zealand.

METHODS

We conducted 64 semi-structured interviews with participants of the programme (n = 71) with varying levels of engagement, including those who declined contact after their referral. Half the interviews were with families with Māori children, allowing for appropriate representation. Interviews were analysed using thematic analysis.

RESULTS

Five health system factors affecting engagement were identified: the national policy environment, funding constraints, lack of coordination between services, difficulty navigating the health system, and the cost of primary health care.

CONCLUSIONS

Engaging with a health system that creates and maintains substantial barriers to accessing services is difficult, affecting programme engagement, even where service-level barriers have been minimised. Lack of access remains a crucial barrier to improved health outcomes for children and their families experiencing childhood obesity in New Zealand. There is a need for comprehensive approaches that are accompanied by a clear implementation strategy and coordinated across sectors.

A Collaborative Indigenous-non-Indigenous Partnership Approach to Understanding Participant Experiences of a Community-Based Healthy Lifestyles Program

We describe the approach of an Indigenous-non-Indigenous research partnership in the context of a qualitative study which aimed to understand barriers and facilitators to engagement in a community-based healthy lifestyles program in Aotearoa/New Zealand. Informed by Kaupapa Māori research principles and by "Community-Up" research values, this collaborative approach between the mixed Māori-non-Māori research team effectively engaged with Māori and non-Māori families for in-depth interviews on participant experience, including with non-service users. "Community-Up" research principles allowed for a respectful process which upheld the mana (status, dignity) of the interview participants and the research team. Challenges included maintaining flexibility in our conceptions of ethnicity to reflect the complexity of modern family life in Aotearoa/New Zealand. We were committed to ongoing communication, awareness, and attention to the relationships that formed the basis of our research partnership, which allowed effective navigation of challenges and was critical to the study's success.

Participants' and caregivers' experiences of a multidisciplinary programme for healthy lifestyle change in Aotearoa/New Zealand: a qualitative, focus group study

OBJECTIVE

Child and adolescent obesity continues to be a major health issue internationally. This study aims to understand the views and experiences of caregivers and participants in a child and adolescent multidisciplinary programme for healthy lifestyle change.

DESIGN

Qualitative focus group study.

SETTING

Community-based healthy lifestyle intervention programme in a mixed urban-rural region of Aotearoa/New Zealand.

PARTICIPANTS

Parents/caregivers (n=6) and children/adolescents (n=8) who participated in at least 6 months of an assessment and weekly session, family-based community intervention programme for children and adolescents affected by obesity.

RESULTS

Findings covered participant experiences, healthy lifestyle changes due to participating in the programme, the delivery team, barriers to engagement and improvements. Across these domains, four key themes emerged from the focus groups for participants and their caregivers relating to their experience: knowledge-sharing, enabling a family to become self-determining in their process to achieve healthy lifestyle change; the importance of connectedness and a family-based programme; the sense of a collective journey and the importance of a nonjudgemental, respectful welcoming environment. Logistical challenges and recommendations for improvement were also identified.

CONCLUSIONS

Policymakers need to consider the experiences of participants alongside quantitative outcomes when informing multidisciplinary intervention programmes for children and adolescents affected by obesity.Trial registration number Australian New Zealand Clinical Trials Registry (ANZCTR):12611000862943; Post-results.

What affects programme engagement for Māori families? A qualitative study of a family-based, multidisciplinary healthy lifestyle programme for children and adolescents

AIM

It is important that intervention programmes are accessible and acceptable for groups most affected by excess weight. This study aimed to understand the barriers to and facilitators of engagement for Māori in a community-based, assessment-and-intervention healthy lifestyle programme (Whānau Pakari).

METHODS

Sixty-four in-depth, home-based interviews were conducted with past service users. Half of these were with families with Māori children and half with non-Māori families. The interviews were thematically analysed with peer debriefing for validity.

RESULTS

Māori families experienced barriers due to racism throughout the health system and society, which then affected their ability to engage with the programme. Key barriers included the institutionalised racism evident through substantial structural barriers and socio-economic challenges, the experience of interpersonal racism and its cumulative impact with weight stigma, and internalised racism and beliefs of biological determinism. Responses to these barriers were distrust of health services, followed by renewed engagement or complete disengagement. Participants identified culturally appropriate care as that which was compassionate, respectful, and focused on relationship building.

CONCLUSIONS

While Whānau Pakari is considered appropriate due to the approach of the delivery team, this is insufficient to retain some Māori families who face increased socio-economic and structural barriers. Past instances of weight stigma and racism have enduring effects when re-engaging with future health services, and inequities are likely to persist until these issues are addressed within the health system and wider society.

A global perspective of Indigenous child health research: a systematic review of longitudinal studies

BACKGROUND

Rigorously designed longitudinal studies can inform how best to reduce the widening health gap between Indigenous and non-Indigenous children.

METHODS

A systematic review was performed to identify and present the breadth and depth of longitudinal studies reporting the health and well-being of Indigenous children (aged 0-18 years) globally. Databases were searched up to 23 June 2020. Study characteristics were mapped according to domains of the life course model of health. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Reported level of Indigenous involvement was also appraised; PROSPERO registration CRD42018089950.

RESULTS

From 5545 citations, 380 eligible papers were included for analysis, representing 210 individual studies. Of these, 41% were located in Australia (n = 88), 22.8% in the USA (n = 42), 11.9% in Canada (n = 25) and 10.9% in New Zealand (n = 23). Research tended to focus on either health outcomes (50.9%) or health-risk exposures (43.8%); 55% of studies were graded as 'good' quality; and 89% of studies made at least one reference to the involvement of Indigenous peoples over the course of their research.

CONCLUSIONS

We identified gaps in the longitudinal assessment of cultural factors influencing Indigenous child health at the macrosocial level, including connection to culture and country, intergenerational trauma, and racism or discrimination. Future longitudinal research needs to be conducted with strong Indigenous leadership and participation including holistic concepts of health. This is critical if we are to better understand the systematic factors driving health inequities experienced by Indigenous children globally.

Response to 'Systematic reviews do not always capture context of real-world intervention programmes for childhood obesity' by Wild et al., 2021 in BMC Public Health

In a correspondence to BMC Public Health, Wild et al. respond to our systematic review that synthesised results of interventions to prevent or treat childhood obesity in Māori and Pacific Islanders. Our review included the Whānau Pakari study as one of six included studies – a multidisciplinary intervention for Māori children and adolescents living with obesity led by their research team. Our review suggested that future research can incorporate stronger co-design principles when designing culturally-tailored interventions to maximise cultural specificity, enhance engagement, facilitate program ownership and contribute to improved health and weight-related outcomes. We commend Whānau Pakari and the team of Wild et al. on their sustained commitment to addressing obesity in priority populations and agree that systematic reviews struggle to capture real-world context of interventions for complex diseases such as obesity. In this article, we respond sequentially to the comments made by Wild et al. and (1) clarify the scope of our review article (2) reiterate our commendation of mixed-methods approaches that capture real-world context (3) explain a referencing error that caused a misinterpretation of our results (4) clarify our interpretation of some Whānau Pakari characteristics (5) welcome partnership to facilitate shared learning with Wild et al.

Correspondence: systematic reviews do not always capture context of real-world intervention programmes for childhood obesity (response to Littlewood, et al., 2020 in BMC Public Health)

In a recent issue of the BMC Public Health journal, Littlewood et al. described the results of a systematic review of interventions to prevent or treat childhood obesity in Māori or Pacific Island peoples. They found that studies to date have had limited impact on improving health outcomes for Māori and Pacific Island peoples, and suggest this may be due to a lack of co-design principles in the conception of the various studies. Ensuring that interventions are appropriate for groups most affected by obesity is critical; however, some inaccuracies should be noted in the explanation of these findings. There is a risk with systematic reviews that the context of intervention trials is lost without acknowledging the associated body of literature for programmes that refer to the ongoing commitment to communities and groups most affected by obesity.

Two-year outcomes of Whānau Pakari, a multi-disciplinary assessment and intervention for children and adolescents with weight issues: A randomized clinical trial

OBJECTIVE

To determine whether 12-month BMI SDS reductions persisted at 24 months in a multi-disciplinary assessment and intervention program for children and adolescents with obesity, and whether secondary outcomes improved.

METHODS

This was a community-based 12-month RCT in Aotearoa/New Zealand. Eligible participants were aged 5 to 16 years with BMI ≥98th centile or BMI >91st centile with weight-related comorbidities. The low-intensity control received comprehensive home-based baseline assessments and advice, and 6-monthly follow-up. The high-intensity intervention received the same assessments and advice, but also weekly multidisciplinary sessions. Primary outcome was BMI SDS at 12 months. Secondary outcomes included cardiovascular and metabolic markers.

RESULTS

121 participants (60% of participants at baseline) were assessed at 24 months. BMI SDS reduction at 12 months was lost at 24 months in the modified intention-to-treat analysis [Control -0.03 (95%CI -0.14, 0.09) and Intervention -0.02 (-0.12, 0.08); P = .93]. However, sweet drink intake was reduced, water intake increased, and there were improvements in cardiovascular fitness in the high-intensity intervention. ≥70% attendance in the high-intensity intervention resulted in a persistent BMI SDS reduction of -0.22 after 24 months (95%CI -0.38, -0.06).

CONCLUSIONS

This trial was negative in terms of primary outcome at 24 months. However, high engagement led to sustained treatment effect, and there were multiple improvements in health measures.

Challenges of making healthy lifestyle changes for families in Aotearoa/New Zealand

Objective:

The objective of the current study was to identify challenges of making and sustaining healthy lifestyle changes for families with children/adolescents affected by obesity, who were referred to a multicomponent healthy lifestyle assessment and intervention programme in Aotearoa/New Zealand (NZ).

Design:

Secondary qualitative analysis of semi-structured interviews.

Setting:

Taranaki region of Aotearoa/NZ.

Participants:

Thirty-eight interviews with parents/caregivers (n 42) of children/adolescents who had previously been referred to a family-focused multidisciplinary programme for childhood obesity intervention, who identified challenges of making healthy lifestyle changes. Participants had varying levels of engagement, including those who declined contact after their referral.

Results:

Participant-identified challenges included financial cost, impact of the food environment, time pressures, stress, maintaining consistency across households, independence in adolescence, concern for mental health and frustration when not seeing changes in weight status.

Conclusions:

Participants recognised a range of factors that contributed towards their ability to make and sustain change, including factors at the wider socio-environmental level beyond their immediate control. Even with the support of a multidisciplinary healthy lifestyle programme, participants found it difficult to make sustained changes within an obesogenic environment. Healthy lifestyle intervention programmes and families’ abilities to make and sustain changes require alignment of prevention efforts, focusing on policy changes to improve the food environment and eliminate structural inequities.

Determining barriers and facilitators to engagement for families in a family-based, multicomponent healthy lifestyles intervention for children and adolescents: a qualitative study

OBJECTIVES

Recruitment and retention in child and adolescent healthy lifestyle intervention services for childhood obesity is challenging, and inequalities across social groups are persistent. This study aimed to understand the barriers and facilitators to engagement in a multicomponent assessment-and-intervention healthy lifestyle programme for children and their families, based in the home and community.

DESIGN

Qualitative interview-based study of past users (n=76) of a family-based multicomponent healthy lifestyle programme in a mixed urban-rural region of New Zealand. Semistructured, home-based interviews were conducted and thematically analysed with peer debriefing for validity.

PARTICIPANTS

Families were selected through stratified random sampling to include a range of levels of engagement, including those who declined their referral, with equal numbers of interviews with Indigenous and non-Indigenous families.

RESULTS

Three interactive and compounding determinants were identified as influencing engagement in Whānau Pakari: acute and chronic life stressors, societal norms of weight and body size and historical experiences of healthcare. These determinants were present across societal, system and healthcare service levels. A negative referral experience to Whānau Pakari often resulted in participants declining further input or disengaging from the programme. A fourth domain, respectful and compassionate healthcare, was identified as a mitigator of these three themes, facilitating participant engagement despite previous negative experiences.

CONCLUSIONS

While participant engagement in healthy lifestyle programmes is affected by determinants which appear to operate outside immediate service provision, the programme is an opportunity to acknowledge past instances of stigma and the wider challenges of healthy lifestyle change. The experience of the referral to Whānau Pakari is important for setting the scene for future engagement in the programme. Respectful, compassionate care is critical to enhanced retention in multidisciplinary healthy lifestyle programmes and ongoing engagement in healthcare services overall.

Interventions to prevent or treat childhood obesity in Māori & Pacific Islanders: a systematic review

Background

Māori and Pacific Islander people are a priority population originating from Australasia. Māori and Pacific Islander children exhibit greater risk of obesity and associated morbidities compared to children of other descent, secondary to unique cultural practices and socioeconomic disadvantage. Despite these known risk factors, there is limited synthesised evidence for preventing and treating childhood obesity in this unique population. The objective of this systematic review was to identify and evaluate global prevention or treatment interventions for overweight or obesity that targeted Māori and Pacific Islander children and adolescents (aged 2–17 years).

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The databases PubMed, EMBASE, Scopus, Web of Science and CINAHL were searched from inception to August 2018. Study quality and risk of bias was assessed using a modified Downs and Black Quality Checklist for Health Care Intervention Studies. Studies were included if RCT/intervention/case control/ or prevention study designs. The study group was defined under the search term ‘Oceanic Ancestry Group’.

Results

Of the initial 94 articles identified, six were included describing two prevention and three treatment interventions. Interventions were heterogenous in setting, design, length and outcomes. Four interventions were implemented in New Zealand. Most studies were of ‘fair’ quality. One study recruited an exclusive population of Māori and Pacific Islander participants. In the five studies that recruited mixed populations, one performed sub-group analysis on Māori and Pacific Islander participants. No study reported an improvement in anthropometric outcomes post-intervention in complete or sub-group analysis. Improvements in cardiometabolic or psychological secondary outcomes were inconsistent across all studies.

Conclusions

There is a lack of evidence to recommend specific intervention characteristics to optimise obesity prevention or treatment outcomes for Māori and Pacific Islander children. Future research requires greater consideration of cultural values and beliefs, community engagement, exclusive targeting of Māori and Pacific Islander children and families, and sub-group analyses for mixed-population studies. Incorporating co-design principles during study design and implementation can maximise the cultural specificity of interventions and may contribute to improved health and weight-related outcomes for this at-risk, priority population.

Trial registration

PROSPERO CRD42019121790 (26 March 2019).

Survey of Barriers and Facilitators to Engagement in a Multidisciplinary Healthy Lifestyles Program for Children

OBJECTIVE

To understand facilitators and barriers to engagement in a multidisciplinary assessment and intervention program for children and adolescents with obesity, particularly for Māori, the Indigenous people of New Zealand.

METHODS

Whānau Pakari participants and caregivers (n = 71, 21% response rate) referred to the family-based healthy lifestyles program in Taranaki, New Zealand, were asked to participate in a confidential survey, which collected self-reported attendance levels and agreement with statements around service accessibility and appropriateness and open-text comments identifying barriers and facilitators to attendance.

RESULTS

Self-reported attendance levels were higher when respondents reported sessions to be conveniently located (P = .03) and lower when respondents considered other priorities as more important for their family (P = .02). Māori more frequently reported that past experiences of health care influenced their decision to attend (P = .03). Facilitators included perceived convenience of the program, parental motivation to improve child health, and ongoing support from the program.

CONCLUSIONS AND IMPLICATIONS

Program convenience and parental and/or self-motivation to improve health were facilitators of attendance. Further research is required to understand the relationship between past experiences with health care and subsequent engagement with services.

Caregiver's readiness for change as a predictor of outcome and attendance in an intervention programme for children and adolescents with obesity: a secondary data analysis

OBJECTIVE/DESIGN

It remains unclear as to the efficacy of readiness for change measurements in child and adolescent obesity intervention programmes. This observational study aimed to determine whether the caregiver's stage of change could predict outcome and adherence to treatment in an intensive intervention programme for children and adolescents with obesity.

SETTING

Participants were from the Whānau Pakari randomised clinical trial, a community based multi-disciplinary intervention programme for obesity in Taranaki, New Zealand.

PARTICIPANTS

Eligible participants (recruited January 2012 to August 2014) were aged 5-16 years and had a body mass index (BMI) ≥98th centile or BMI >91st centile with weight-related comorbidities.

INTERVENTIONS

This study only assessed participants randomised to the high-intensity intervention programme (6-month assessments with weekly group sessions for 12 months) given attendance data were required (n=96).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary trial outcome was BMI SD score (SDS). Secondary outcome measures included indices such as fruit and vegetable intake, 550-m run/walk time and quality of life scores. At baseline assessment, participants (if >11 years old) and their accompanying adult were assessed for readiness to make healthy lifestyle change.

RESULTS

A quantitative measure of stage of change in caregivers was not a predictor of primary or secondary outcomes (change in BMI SDS pre-contemplation/contemplation -0.08, 95% CI -0.18 to 0.03, action -0.16, 95% CI -0.27 to -0.05, p=0.27), or overall attendance in the weekly activity sessions (40.0% vs 37.1%, respectively, p=0.54) in the child or adolescent.

CONCLUSIONS

Caregiver's stage of change was not a predictor of success in this multi-disciplinary assessment and intervention programme for children and adolescents with obesity. Future research needs to determine participants' factors for success.

TRIAL REGISTRATION NUMBER

ANZCTR12611000862943; Post-results.

Do changes in weight status affect cognitive function in children and adolescents with obesity? A secondary analysis of a clinical trial

OBJECTIVES

It is unclear whether an association exists between obesity in children/adolescents and cognitive function, and whether the latter can be altered by body mass index (BMI) standard deviation score (SDS) reductions. We aimed to determine whether an association exists between BMI SDS and cognitive function in children/adolescents with obesity engaged in an obesity intervention. Second, we sought to determine if BMI SDS reduction at 12 months was associated with improved cognitive function.

DESIGN

Secondary analysis of a clinical trial.

PARTICIPANTS

Participants (n=69) were recruited from an obesity intervention. Eligible participants (recruited June 2013 to June 2015) were aged 6-16 years, with a BMI ≥98th centile or BMI >91st centile with weight-related comorbidities.

OUTCOME MEASURES

Primary outcome measure was change in BMI SDS from baseline at 12 months. Dependent variables of cognitive functioning and school achievement were assessed at baseline and 12 months, using dependent variables of cognitive functioning (elements of Ravens Standard Progressive Matrices, Wide Range Achievement Test-fourth edition and Wechsler Intelligence Scale for Children-fourth edition).

RESULTS

At baseline, BMI SDS was not associated with all aspects of cognitive function tested (n=69). Reductions in BMI SDS over time did not alter cognitive function overall. However, there was a greater reduction in comprehension standard scores in participants who increased their BMI SDS (adjusted estimated difference -6.1, 95% CI -11.6 to -0.6; p=0.03).

CONCLUSIONS

There were no observed associations between BMI SDS and cognitive function in participants, apart from comprehension in the exploratory analyses, which may have been a random finding. Further studies need to include larger longitudinal cohorts incorporating a wider BMI range at entry to determine whether our findings persist.

TRIAL REGISTRATION NUMBER

ANZCTR12611000862943; Pre-results.

A Novel Home-Based Intervention for Child and Adolescent Obesity: The Results of the Whānau Pakari Randomized Controlled Trial

OBJECTIVE

To report 12-month outcomes from a multidisciplinary child obesity intervention program, targeting high-risk groups.

METHODS

In this unblinded randomized controlled trial, participants (recruited January 2012-August 2014) were aged 5 to 16 years, resided in Taranaki, Aotearoa/New Zealand, and had BMI ≥ 98th percentile or BMI > 91st percentile with weight-related comorbidities. Randomization was by minimization (age and ethnicity), with participants assigned to an intense intervention group (home-based assessments at 6-month intervals and a 12-month multidisciplinary program with weekly group sessions) or to a minimal-intensity control group with home-based assessments and advice at each 6-month follow-up. The primary outcome was the change in BMI standard deviation score (SDS) at 12 months from baseline. A mixed model analysis was undertaken, incorporating all 6- and 12-month data.

RESULTS

Two hundred and three children were randomly assigned (47% Māori, 43% New Zealand European, 53% female, 28% from the most deprived quintile, mean age 10.7 years, mean BMI SDS 3.12). Both groups displayed a change in BMI SDS at 12 months from baseline (-0.12 control, -0.10 intervention), improvements in cardiovascular fitness (P < 0.0001), and improvements in quality of life (P < 0.001). Achieving ≥ 70% attendance in the intense intervention group resulted in a change in BMI SDS of -0.22.

CONCLUSIONS

This program achieved a high recruitment of target groups and a high rate of BMI SDS reduction, irrespective of intervention intensity. If retention is optimized, the intensive program doubles its effect.

Assessment of health-related quality of life and psychological well-being of children and adolescents with obesity enrolled in a New Zealand community-based intervention programme: an observational study

OBJECTIVE

To describe health-related quality of life (HRQOL) and psychological well-being of children and adolescents at enrolment in a multidisciplinary community-based obesity programme and to determine association with ethnicity. This programme targeted indigenous people and those from most deprived households. Further, this cohort was compared with other populations/normative data.

METHODS

This study examines baseline demographic data of an unblinded randomised controlled clinical trial. Participants (recruited from January 2012-August 2014) resided in Taranaki, New Zealand, and for this study we only included those with a body mass index (BMI) ≥98th percentile (obese). HRQOL and psychological well-being were assessed using the Pediatric Quality of Life Inventory (PedsQL V.4.0^TM) (parent and child reports), and Achenbach's Child Behavior Checklist (CBCL)/Youth Self Report (YSR).

RESULTS

Assessments were undertaken for 233 participants (45% Māori, 45% New Zealand European, 10% other ethnicities, 52% female, 30% from the most deprived household quintile), mean age 10.6 years. The mean BMI SD score (SDS) was 3.12 (range 2.01-5.34). Total PedsQL generic scaled score (parent) was lower (mean=63.4, SD 14.0) than an age-matched group of Australian children without obesity from the Health of Young Victorians study (mean=83.1, SD 12.5). In multivariable models, child and parental generic scaled scores decreased in older children (β=-0.70 and p=0.031, β=-0.64 and p=0.047, respectively). Behavioural difficulties (CBCL/YSR total score) were reported in 43.5% of participants, with the rate of emotional/behavioural difficulties six times higher than reported norms (p<0.001).

CONCLUSIONS

In this cohort, children and adolescents with obesity had a low HRQOL, and a concerning level of psychological difficulties, irrespective of ethnicity. Obesity itself rather than ethnicity or deprivation appeared to contribute to lower HRQOL scores. This study highlights the importance of psychologist involvement in obesity intervention programmes.

TRIAL REGISTRATION NUMBER

Australian NZ Clinical Trials Registry ANZCTR 12611000862943; Pre-results.

Physical activity is low in obese New Zealand children and adolescents

We aimed to describe physical activity and sedentary behaviour of obese children and adolescents in Taranaki, New Zealand, and to determine how these differ in Māori (indigenous) versus non-indigenous children. Participants (n = 239; 45% Māori, 45% New Zealand European [NZE], 10% other ethnicities) aged 4.8–16.8 years enrolled in a community-based obesity programme from January 2012 to August 2014 who had a body mass index (BMI) ≥ 98^th percentile (n = 233) or >91^st–98^th percentile with weight-related comorbidities (n = 6) were assessed. Baseline activity levels were assessed using the children’s physical activity questionnaire (C-PAQ), a fitness test, and ≥3 days of accelerometer wear. Average BMI standard deviation score was 3.09 (SD = 0.60, range 1.52–5.34 SDS). Reported median daily activity was 80 minutes (IQR = 88). Although 44% of the cohort met the national recommended screen time of <2 hours per day, the mean screen time was longer at 165 minutes (SD = 135). Accelerometer data (n = 130) showed low physical activity time (median 34 minutes [IQR = 29]). Only 18.5% of the total cohort met national recommended physical activity guidelines of 60 minutes per day. There were minimal ethnic differences. In conclusion, obese children/adolescents in this cohort had low levels of physical activity. The vast majority are not meeting national physical activity recommendations.

Prevalence of comorbidities in obese New Zealand children and adolescents at enrolment in a community-based obesity programme

AIM

The aim of this study was to describe the characteristics at enrolment of children and adolescents referred to an obesity programme and to determine how the prevalence of comorbidities differed in Indigenous versus non-Indigenous children.

METHODS

Participants were residents of a semi-rural region of New Zealand (NZ). Eligibility was defined by a body mass index (BMI) of ≥98th percentile or >91st centile with weight-related comorbidities. Fasting blood, medical and physical assessments were obtained.

RESULTS

During the recruitment period from January 2012 to August 2014, 239 participants, aged 4.8-16.8 years, undertook assessment. Average BMI standard deviation score was 3.09 (standard deviation (SD) = 0.60, range 1.52-5.34 SD). The majority of participants were of either Maori (NZ's indigenous people (45%)) or NZ European (45%) ethnicity; 29% of participants were from the most deprived quintile of household deprivation. Maori participants were more likely than NZ Europeans to have a mother who smoked during pregnancy (52% vs. 28%, P = 0.001), a family history of type 2 diabetes (66% vs. 53%, P = 0.04), acanthosis nigricans on examination (58% vs. 20%, P < 0.0001), a low serum high-density lipoprotein cholesterol (27% vs. 14%, P = 0.03) or high serum triglyceride (38% vs. 24%, P = 0.03) concentration.

CONCLUSION

The unique aspect of this study was the ability to recruit high levels of Maori participants and those from most deprived areas, indicating a high level of acceptability for these target groups. Comorbidities were prevalent in this cohort of overweight/obese school-aged children. While there were some differences in comorbidity prevalence between Maori and NZ Europeans, the overall clinical picture in our cohort, irrespective of ethnicity, was of concern.

Dietary Intake and Eating Behaviours of Obese New Zealand Children and Adolescents Enrolled in a Community-Based Intervention Programme

Objectives

The aim of this study was to describe dietary intake and eating behaviours of obese children and adolescents, and also to determine how these differ in Indigenous versus non-Indigenous children at enrolment in an obesity programme.

Methods

Baseline dietary intake and eating behaviour records were assessed from those enrolled in a clinical unblinded randomised controlled trial of a multi-disciplinary intervention. The setting was a community-based obesity programme in Taranaki, New Zealand. Children or adolescents who were enrolled from January 2012 to August 2014, with a BMI ≥98^th percentile or >91^st centile with weight-related comorbidities were eligible.

Results

239 participants (45% Māori, 45% NZ Europeans, 10% other ethnicities), aged 5–17 years were assessed. Two-thirds of participants experienced hyperphagia and half were not satiated after a meal. Comfort eating was reported by 62% of participants, and daily energy intake was above the recommended guidelines for 54%. Fruit and vegetable intake was suboptimal compared with the recommended 5 servings per day (mean 3.5 [SD = 1.9] servings per day), and the mean weekly breakfasts were less than the national average (5.9 vs 6.5; p<0.0001). Median sweet drink intake amongst Māori was twice that of NZ Europeans (250 vs 125 ml per day; p = 0.0002).

Conclusions

There was a concerning prevalence of abnormal eating behaviours and significant differences in dietary intake between obese participants and their national counterparts. Ethnic differences between Indigenous and non-Indigenous participants were also present, especially in relation to sweet drink consumption. Eating behaviours, especially sweet drink consumption and fruit/vegetable intake need to be addressed.