Systematic review of the effectiveness and cost-effectiveness of weight management schemes for the under fives: a short report

Family-centred interventions for Indigenous early childhood well-being by primary healthcare services

BACKGROUND

Primary healthcare, particularly Indigenous-led services, are well placed to deliver services that reflect the needs of Indigenous children and their families. Important characteristics identified by families for primary health care include services that support families, accommodate sociocultural needs, recognise extended family child-rearing practices, and Indigenous ways of knowing and doing business. Indigenous family-centred care interventions have been developed and implemented within primary healthcare services to plan, implement, and support the care of children, immediate and extended family and the home environment. The delivery of family-centred interventions can be through environmental, communication, educational, counselling, and family support approaches.

OBJECTIVES

To evaluate the benefits and harms of family-centred interventions delivered by primary healthcare services in Canada, Australia, New Zealand, and the USA on a range of physical, psychosocial, and behavioural outcomes of Indigenous children (aged from conception to less than five years), parents, and families.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 22 September 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, controlled before-after studies, and interrupted time series of family-centred care interventions that included Indigenous children aged less than five years from Canada, Australia, New Zealand, and the USA. Interventions were included if they met the assessment criteria for family-centred interventions and were delivered in primary health care. Comparison interventions could include usual maternal and child health care or one form of family-centred intervention versus another.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. overall health and well-being, 2. psychological health and emotional behaviour of children, 3. physical health and developmental health outcomes of children, 4. family health-enhancing lifestyle or behaviour outcomes, 5. psychological health of parent/carer. 6. adverse events or harms. Our secondary outcomes were 7. parenting knowledge and awareness, 8. family evaluation of care, 9. service access and utilisation, 10. family-centredness of consultation processes, and 11. economic costs and outcomes associated with the interventions. We used GRADE to assess the certainty of the evidence for our primary outcomes.

MAIN RESULTS

We included nine RCTs and two cluster-RCTs that investigated the effect of family-centred care interventions delivered by primary healthcare services for Indigenous early child well-being. There were 1270 mother-child dyads and 1924 children aged less than five years recruited. Seven studies were from the USA, two from New Zealand, one from Canada, and one delivered in both Australia and New Zealand. The focus of interventions varied and included three studies focused on early childhood caries; three on childhood obesity; two on child behavioural problems; and one each on negative parenting patterns, child acute respiratory illness, and sudden unexpected death in infancy. Family-centred education was the most common type of intervention delivered. Three studies compared family-centred care to usual care and seven studies provided some 'minimal' intervention to families such as education in the form of pamphlets or newsletters. One study provided a minimal intervention during the child's first 24 months and then the family-centred care intervention for one year. No studies had low or unclear risk of bias across all domains. All studies had a high risk of bias for the blinding of participants and personnel domain. Family-centred care may improve overall health and well-being of Indigenous children and their families, but the evidence was very uncertain. The pooled effect estimate from 11 studies suggests that family-centred care improved the overall health and well-being of Indigenous children and their families compared no family-centred care (standardised mean difference (SMD) 0.14, 95% confidence interval (CI) 0.03 to 0.24; 2386 participants). We are very uncertain whether family-centred care compared to no family-centred care improves the psychological health and emotional behaviour of children as measured by the Infant Toddler Social Emotional Assessment (ITSEA) (Competence domain) (mean difference (MD) 0.04, 95% CI -0.03 to 0.11; 2 studies, 384 participants). We assessed the evidence as being very uncertain about the effect of family-centred care on physical health and developmental health outcomes of children. Pooled data from eight trials on physical health and developmental outcomes found there was little to no difference between the intervention and the control groups (SMD 0.13, 95% CI -0.00 to 0.26; 1961 participants). The evidence is also very unclear whether family-centred care improved family-enhancing lifestyle and behaviours outcomes. Nine studies measured family health-enhancing lifestyle and behaviours and pooled analysis found there was little to no difference between groups (SMD 0.16, 95% CI -0.06 to 0.39; 1969 participants; very low-certainty evidence). There was very low-certainty evidence of little to no difference for the psychological health of parents and carers when they participated in family-centred care compared to any control group (SMD 0.10, 95% CI -0.03 to 0.22; 5 studies, 975 parents/carers). Two studies stated that there were no adverse events as a result of the intervention. No additional data were provided. No studies reported from the health service providers perspective or on outcomes for family's evaluation of care or family-centredness of consultation processes.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that family-centred care delivered by primary healthcare services improves the overall health and well-being of Indigenous children, parents, and families. However, due to lack of data, there was not enough evidence to determine whether specific outcomes such as child health and development improved as a result of family-centred interventions. Seven of the 11 studies delivered family-centred education interventions. Seven studies were from the USA and centred on two particular trials, the 'Healthy Children, Strong Families' and 'Family Spirit' trials. As the evidence is very low certainty for all outcomes, further high-quality trials are needed to provide robust evidence for the use of family-centred care interventions for Indigenous children aged less than five years.

Aspiring to Reasonableness in Accelerated Approval: Anticipating and Avoiding the Next Aducanumab

The US Food and Drug Administration's decisions about drug approval-though guided by science, as well as relevant statutes, regulations, and guidance documents-reflect normative judgments about how the agency should exercise its discretion. This is particularly true in the context of the "accelerated approval" pathway, where the agency must balance speeding to market drugs for patients with unmet needs before they have been proven to work and ensuring confidence about the benefits and risks of those drugs. A key challenge in evaluating normative judgments such as these is that reasonable people can disagree, rendering it difficult to proclaim with certainty that a particular decision is right or wrong. Therefore, we propose that it is preferable to ask whether a decision is reasonable. A decision is reasonable when it transparently, comprehensively, and fairly balances the interests of affected parties, within the parameters of the decision maker's legal authority. If a decision achieves these three qualities, it can be viewed as legitimate and worthy of trust and confidence, regardless of whether one agrees with the particular outcome. We recommend that the Food and Drug Administration adopt procedural protections to promote reasonableness in four domains affecting accelerated approval decisions: pathway gatekeeping, endpoint selection, stakeholder engagement, and deliberation. This should aid the agency in minimizing controversies, such as that surrounding the 2021 approval of aducanumab (Aduhelm; Biogen).

A systematic review of meta-analyses assessing the validity of tumour response endpoints as surrogates for progression-free or overall survival in cancer

BACKGROUND

Tumour response endpoints, such as overall response rate (ORR) and complete response (CR), are increasingly used in cancer trials. However, the validity of response-based surrogates is unclear. This systematic review summarises meta-analyses assessing the association between response-based outcomes and overall survival (OS), progression-free survival (PFS) or time-to-progression (TTP).

METHODS

Five databases were searched to March 2019. Meta-analyses reporting correlation or regression between response-based outcomes and OS, PFS or TTP were summarised.

RESULTS

The systematic review included 63 studies across 20 cancer types, most commonly non-small cell lung cancer (NSCLC), colorectal cancer (CRC) and breast cancer. The strength of association between ORR or CR and either PFS or OS varied widely between and within studies, with no clear pattern by cancer type. The association between ORR and OS appeared weaker and more variable than that between ORR and PFS, both for associations between absolute endpoints and associations between treatment effects.

CONCLUSIONS

This systematic review suggests that response-based endpoints, such as ORR and CR, may not be reliable surrogates for PFS or OS. Where it is necessary to use tumour response to predict treatment effects on survival outcomes, it is important to fully reflect all statistical uncertainty in the surrogate relationship.

Physical activity interventions in early life aimed at reducing later risk of obesity and related non-communicable diseases: A rapid review of systematic reviews

To identify useful components of interventions aimed at prevention of childhood obesity and related non-communicable diseases (NCDs), which included physical activity and which targeted any or all of four life-course stages: peri-conception; pregnancy; infancy and toddlerhood (0 to 23 months); and early childhood (24 to 59 months). In May 2016, WHO Geneva searched the Cochrane Library and PubMed for systematic reviews of interventions including physical activity to prevent childhood obesity or risk factors for obesity-related NCDs. Using a narrative synthesis, the efficacy of randomized controlled trials (RCTs) to alter energy balance outcomes (measures of weight status or body fatness) was characterized by life-course stage, study characteristics, intervention functions (as defined in the behaviour change wheel), and level of the socio-ecological model (SEM) targeted. The quality of included systematic reviews was assessed. We retrieved 82 reviews from the World Health Organization (WHO) search, of which 23 were eligible for the present synthesis. The number of eligible studies by life-course stage was: 0 (peri-conception); 0 (pregnancy); 8 (infancy and toddlerhood, age 0 to 23 months; seven RCTs; age); and 37 (early childhood, age 24 to 59 months; 30 RCTs;). Thus, there was a lack of evidence for physical activity interventions during peri-conception and pregnancy. Almost all relevant studies in the 0- to 23- and 24- to 59-month life-course stages were multicomponent interventions (ie, targeted physical activity, dietary, and/or sedentary behaviours). Interventions with evidence of efficacy tended to target multiple levels of the SEM, with emphasis on parents, and extend over long periods. Effective intervention elements for early life obesity prevention included classes on parenting skills, alteration of the kindergarten playground, and financial incentives. Evidence from low- and middle-income countries was scarce, and evidence for intervention effect on obesity-related NCDs was missing. Future physical activity interventions in toddlerhood and early childhood aimed at prevention of obesity should adopt the characteristics typical of effective interventions identified by the present synthesis. There is an urgent need for more evidence on physical activity interventions set in low- and middle-income countries and which target the peri-conception and pregnancy periods.

How Can Physical Activity Be Promoted Among Children and Adolescents? A Systematic Review of Reviews Across Settings

Introduction: A vast majority of children and adolescents are physically inactive. As a result, high obesity rates and related diseases have made physical activity promotion a politically relevant topic. In order to form the basis for political decision making, evidence is required regarding the efficacy and effectiveness of interventions for physical activity promotion. In contrast to previous research, this systematic review of reviews targets three key settings (family and home, childcare, school), and is among the largest to have been conducted.

Methods: A systematic review of reviews was conducted as part of a large-scale project to develop national recommendations for physical activity promotion in Germany. Six electronic databases were searched and inclusion criteria were defined. Two independent reviewers screened the titles and abstracts of potentially relevant literature. 213 reviews were identified and categorised by target group. A total of 74 reviews were identified dealing with children and adolescents. Each review underwent a quality assessment.

Results: 39 reviews with the highest quality and relevance were analysed. Three reviews focused on the family and home setting, 4 on the childcare setting, 28 on the school setting and 4 on other settings. Evidence revealed the key role played by parents in promoting physical activity in children within each setting. Furthermore, evidence pointed toward the efficacy of multi-component interventions in the childcare and school setting. Several evidence-based intervention strategies were identified for childcare facilities and schools.

Discussion: The review of reviews identified a number of promising strategies for PA promotion among children and adolescents. Among reviews, multi-component interventions in childcare facilities and schools stand out prominently. At the same time, the review of reviews indicated that there is still a lack of studies on the efficacy of interventions that go beyond the individual level. We recommend that future research should also target community and policy level interventions and interventions other than the school setting. In order to make more specific recommendations regarding the scale-up of promising intervention strategies, further knowledge about the effectiveness, health equity and cost effectiveness of interventions is needed.

A New Model for Evaluation of Interventions to Prevent Obesity in Early Childhood

Background: Childhood obesity is a serious public health issue. In Australia, 1 in 4 children is already affected by overweight or obesity at the time of school entry. Governments around the world have recognized this problem through investment in the prevention of pediatric obesity, yet few interventions in early childhood have been subjected to economic evaluation. Information on cost-effectiveness is vital to decisions about program implementation. A challenge in evaluating preventive interventions in early childhood is to capture long-term costs and outcomes beyond the duration of an intervention, as the benefits of early obesity prevention will not be realized until some years into the future. However, decisions need to be made in the present, and modeling is one way to inform such decisions. Objective: To describe the conceptual structure of a new health economic model (the Early Prevention of Obesity in CHildhood (EPOCH) model) for evaluating childhood obesity interventions; and to validate the epidemiologic predictions. Methods and Results: We use an individual-level (micro-simulation) method to model BMI trajectories and the progression of obesity from early childhood to adolescence. The equations predicting individual BMI change underpinning our model were derived from data from the population-representative study, the Longitudinal Study of Australian Children (LSAC). Our approach is novel because it will account for costs and benefits accrued throughout childhood and adolescence. As a first step to validate the epidemiological predictions of the model, we used input data representing over 250,000 children aged 4/5 years, and simulated BMI and obesity trajectories until adolescence. Simulated mean BMI and obesity prevalence for boys and girls were verified by nationally-representative data on children at 14/15 years of age. Discussion: The EPOCH model is epidemiologically sound in its prediction of both BMI trajectories and prevalence of obesity for boys and girls. Future developments of the model will include socio-economic position and will incorporate the impacts of obesity on healthcare costs. The EPOCH model will help answer: when is it best to intervene in childhood; what are the most cost-effective approaches and which population groups will benefit most from interventions.

Sensitivity of EQ-5D-3L, HUI2, HUI3, and SF-6D to changes in speech reception and tinnitus associated with cochlear implantation

Purpose

There is concern that some generic preference-based measures (GPMs) of health-related quality of life may be insensitive to interventions that improve hearing. Establishing where sensitivity arises could contribute to the design of improved measures. Accordingly, we compared the sensitivity of four widely used GPMs to a clinically effective treatment—cochlear implantation—which restores material degrees of hearing to adults with little or no functional hearing.

Methods

Participants (N = 147) received implants in any of 13 hospitals in the UK. One month before implantation and 9 months after, they completed the HUI2, HUI3, EQ5D3L, and SF-6D questionnaires, together with the EuroQoL visual-analogue scale as a direct measure of health, a performance test of speech reception, and a self-report measure of annoyance due to tinnitus.

Results

Implantation was associated with a large improvement in speech reception and a small improvement in tinnitus. HUI2 and HUI3 were sensitive to the improvement in speech reception through their Sensation and Hearing dimensions; EQ5D3L was sensitive to the improvement in tinnitus through its Anxiety/Depression dimension; SF-6D was sensitive to neither. Participants reported no overall improvement in health. Variation in health was associated with variation in tinnitus, not variation in speech reception.

Conclusions

None of the four GPMs was sensitive to the improvements in both speech reception and tinnitus that were associated with cochlear implantation. To capture fully the benefits of interventions for auditory disorders, developments of current GPMs would need to be sensitive to both the health-related and non-health-related aspects of auditory dysfunction.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-2070-6) contains supplementary material, which is available to authorised users.

Systematic review of control groups in nutrition education intervention research

Background

Well-designed research trials are critical for determining the efficacy and effectiveness of nutrition education interventions. To determine whether behavioral and/or cognition changes can be attributed to an intervention, the experimental design must include a control or comparison condition against which outcomes from the experimental group can be compared. Despite the impact different types of control groups can have on study outcomes, the treatment provided to participants in the control condition has received limited attention in the literature.

Methods

A systematic review of control groups in nutrition education interventions was conducted to better understand how control conditions are described in peer-reviewed journal articles compared with experimental conditions. To be included in the systematic review, articles had to be indexed in CINAHL, PubMed, PsycINFO, WoS, and/or ERIC and report primary research findings of controlled nutrition education intervention trials conducted in the United States with free-living consumer populations and published in English between January 2005 and December 2015. Key elements extracted during data collection included treatment provided to the experimental and control groups (e.g., overall intervention content, tailoring methods, delivery mode, format, duration, setting, and session descriptions, and procedures for standardizing, fidelity of implementation, and blinding); rationale for control group type selected; sample size and attrition; and theoretical foundation.

Results

The search yielded 43 publications; about one-third of these had an inactive control condition, which is considered a weak study design. Nearly two-thirds of reviewed studies had an active control condition considered a stronger research design; however, many failed to report one or more key elements of the intervention, especially for the control condition. None of the experimental and control group treatments were sufficiently detailed to permit replication of the nutrition education interventions studied.

Conclusions

Findings advocate for improved intervention study design and more complete reporting of nutrition education interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0546-3) contains supplementary material, which is available to authorized users.

Diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years

BACKGROUND

Child overweight and obesity has increased globally, and can be associated with short- and long-term health consequences.

OBJECTIVES

To assess the effects of diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years.

SEARCH METHODS

We performed a systematic literature search in the databases Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, and LILACS, as well as in the trial registers ClinicalTrials.gov and ICTRP Search Portal. We also checked references of identified trials and systematic reviews. We applied no language restrictions. The date of the last search was March 2015 for all databases.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions for treating overweight or obesity in preschool children aged 0 to 6 years.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias, evaluated the overall quality of the evidence using the GRADE instrument, and extracted data following the Cochrane Handbook for Systematic Reviews of Interventions. We contacted trial authors for additional information.

MAIN RESULTS

We included 7 RCTs with a total of 923 participants: 529 randomised to an intervention and 394 to a comparator. The number of participants per trial ranged from 18 to 475. Six trials were parallel RCTs, and one was a cluster RCT. Two trials were three-arm trials, each comparing two interventions with a control group. The interventions and comparators in the trials varied. We categorised the comparisons into two groups: multicomponent interventions and dietary interventions. The overall quality of the evidence was low or very low, and six trials had a high risk of bias on individual 'Risk of bias' criteria. The children in the included trials were followed up for between six months and three years.In trials comparing a multicomponent intervention with usual care, enhanced usual care, or information control, we found a greater reduction in body mass index (BMI) z score in the intervention groups at the end of the intervention (6 to 12 months): mean difference (MD) -0.3 units (95% confidence interval (CI) -0.4 to -0.2); P < 0.00001; 210 participants; 4 trials; low-quality evidence, at 12 to 18 months' follow-up: MD -0.4 units (95% CI -0.6 to -0.2); P = 0.0001; 202 participants; 4 trials; low-quality evidence, and at 2 years' follow-up: MD -0.3 units (95% CI -0.4 to -0.1); 96 participants; 1 trial; low-quality evidence.One trial stated that no adverse events were reported; the other trials did not report on adverse events. Three trials reported health-related quality of life and found improvements in some, but not all, aspects. Other outcomes, such as behaviour change and parent-child relationship, were inconsistently measured.One three-arm trial of very low-quality evidence comparing two types of diet with control found that both the dairy-rich diet (BMI z score change MD -0.1 units (95% CI -0.11 to -0.09); P < 0.0001; 59 participants) and energy-restricted diet (BMI z score change MD -0.1 units (95% CI -0.11 to -0.09); P < 0.0001; 57 participants) resulted in greater reduction in BMI than the comparator at the end of the intervention period, but only the dairy-rich diet maintained this at 36 months' follow-up (BMI z score change in MD -0.7 units (95% CI -0.71 to -0.69); P < 0.0001; 52 participants). The energy-restricted diet had a worse BMI outcome than control at this follow-up (BMI z score change MD 0.1 units (95% CI 0.09 to 0.11); P < 0.0001; 47 participants). There was no substantial difference in mean daily energy expenditure between groups. Health-related quality of life, adverse effects, participant views, and parenting were not measured.No trial reported on all-cause mortality, morbidity, or socioeconomic effects.All results should be interpreted cautiously due to their low quality and heterogeneous interventions and comparators.

AUTHORS' CONCLUSIONS

Muticomponent interventions appear to be an effective treatment option for overweight or obese preschool children up to the age of 6 years. However, the current evidence is limited, and most trials had a high risk of bias. Most trials did not measure adverse events. We have identified four ongoing trials that we will include in future updates of this review.The role of dietary interventions is more equivocal, with one trial suggesting that dairy interventions may be effective in the longer term, but not energy-restricted diets. This trial also had a high risk of bias.

Interventions aimed at reducing obesity in early childhood: a meta-analysis of programs that involve parents

BACKGROUND

Obesity is a growing problem even in very young childhood, resulting in high costs for individuals and society. As a response, numerous obesity prevention and intervention programs have been developed. Previous research has shown that early intervention programs are more effective when parents are involved, but the effectiveness of specific aspects of programs with parental involvement has not been investigated. This meta-analysis aims to investigate the features related to the effectiveness of different types of obesity intervention programs involving parents and targeting young children (0-6-year-olds).

METHODS

The Web of Science, PubMed, PsycInfo, CINAHL, and ERIC databases were searched for childhood obesity prevention and intervention programs involving parents. Data were analyzed using the Comprehensive Meta-analysis (CMA) software.

RESULTS

Fifty studies with effect sizes measured at short-term follow-up (within 3 months from the end of the intervention) and 26 studies with effect sizes measured at long-term follow-up (all reported in a total of 49 publications) were identified. The combined effect size of interventions was small but significant at short-term follow-up (d = .08, p < .01). The results suggested the presence of a potential publication bias in studies providing results at long-term follow-up, with a nonsignificant adjusted effect size (d = .02), which indicated that obesity interventions were not effective at long-term follow-up. Multivariate meta-regression analyses showed that interventions were more effective when including either interactive sessions or educational materials as opposed to those including both interactive sessions and noninteractive educational materials. No other moderators regarding sample characteristics, study design, or methodological quality were significant.

CONCLUSION

Interventions targeting young children that require parental involvement are effective at short-term follow-up, specifically when interventions include one mode of intervention rather than two. However, results were not retained in the long run.

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background

This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.

Aims

The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.

Methods

We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.

Findings

Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.

Future Research

Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Combating child obesity: impact of HENRY on parenting and family lifestyle

BACKGROUND

One-quarter of children in England are overweight/obese at school entry. We investigated the impact of a programme designed to provide parents of infants and preschool children with the skills required for a healthier family lifestyle.

METHOD

A cohort of families was followed across the 8-week HENRY (Health Exercise Nutrition for the Really Young) parent course at nine locations in England. Seventy-seven parents enrolled on the course, of which 71 agreed to complete questionnaires addressing eating behaviours, dietary intake and parental self-efficacy. Pre- and post-course data was available from 60 (84.5%) parents (8-week follow-up data from 58 parents) and was analysed using repeated measures analyses.

RESULTS

Significant changes were observed, with most sustained at follow-up. Parents reported increased self-efficacy and ability to encourage good behaviour (P < 0.001). Increased consumption of fruits and vegetables was reported in both children and adults, together with reduced consumption of sweets, cakes and fizzy drinks in adults (all P < 0.01). There were also positive changes in eating behaviours (e.g., frequency of family mealtimes and eating while watching television or in response to negative emotion [P < 0.01] ) and reduced screen time in adults (P < 0.001).

DISCUSSION

The results build upon earlier evaluation, indicating that the HENRY intervention has a beneficial impact upon the families of infants and preschool children. Furthermore, the findings suggest that positive changes inspired by the programme can be maintained beyond its completion. Such changes may serve to protect against later obesity.

The preliminary effects of a primary care-based randomized treatment trial with overweight and obese young children and their parents

INTRODUCTION

Twenty-three percent of preschoolers are overweight/obese, which puts these children at risk for the development of chronic health comorbidities. The purpose of this randomized control pilot study was to determine the feasibility and preliminary effects of a theoretically based, primary care intervention on the physical outcomes of 60 overweight/obese preschool/early school-aged 4- to 8-year-old children.

METHODS

After recruitment and baseline assessment, parent-child dyads were randomly assigned to either the treatment or the control condition. Four intervention sessions were conducted with the parents in their child's primary health care office. The impact of the intervention was evaluated by assessing child anthropometric measures (e.g., waist, waist-by-height ratio, and body mass index [BMI]) immediately, 3 months, and 6 months after the intervention period.

RESULTS

Analysis of variance models suggested that children in the experimental group were found to have reduced waist circumference and waist-by-height ratio immediately after the intervention that persisted for 3 and 6 months (f = 0.33, 0.35, respectively). BMI and BMI percentile were not differentially affected.

DISCUSSION

These promising findings suggest that a primary care-based, parent-focused overweight/obesity treatment program is feasible and demonstrated positive preliminary effects, improving the children's overall health trajectory.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

"Eat Healthy, Stay Active!": a coordinated intervention to improve nutrition and physical activity among Head Start parents, staff, and children

PURPOSE

Examine the effectiveness of the "Eat Healthy, Stay Active!" pilot program, a multisite, 6-month educational intervention to promote healthy nutrition and physical activity among Head Start staff, parents, and children.

DESIGN

Comparison of within-group preintervention and postintervention knowledge and behavior, along with anthropomorphic measurements.

SETTING

The study was conducted in a convenience sample of six large Head Start agencies in five states.

SUBJECTS

Participants included 496 staff, 438 parents, and 112 preschool children.

INTERVENTION

The 6-month intervention consisted of core trainings and reinforcing activities for staff and parents that aligned with children's curricula.

MEASURES

Pre-post questionnaires and anthropometric measurements examined changes in body mass index (BMI), knowledge, and behaviors related to nutrition and physical activity.

ANALYSIS

Paired t-tests to compare preintervention and postintervention weights and BMI; multiple regression analyses to examine associations between weight changes and other covariates, including knowledge and behavior changes, controlling for sociodemographic variables.

RESULTS

Each group of participants demonstrated significant reductions in BMI (mean  =  30.1 to 29.2; p < .001 in adults and 17.0 to 16.6; p < 0.001 in children) and in the proportion of obese children (30% to 21%; p < .001) and adults (45% to 40%; p < .001). Child weight changes correlated with parent weight changes.

CONCLUSION

This intervention showed promising initial results, with potential effectiveness as an intervention to promote healthier behaviors among adults and children in Head Start settings.

Protocol for systematic reviews of determinants/correlates of obesity-related dietary and physical activity behaviors in young children (preschool 0 to 6 years): evidence mapping and syntheses

BACKGROUND

The aim of these reviews is to inform the design and content of interventions to reduce obesity in young children. The behaviors that are associated with obesity/overweight have been studied extensively; however, the factors associated with these behaviors in young children (0 to 6 years) have not been systematically reviewed. Over the past few years the focus of obesity prevention has shifted to preschool children because of the high prevalence of obesity at school entry and recognition that habits formed in early life could track into adulthood. In order to develop effective interventions and change behavior, it is important to understand the factors that are associated with those behaviors. For example, we need to understand whether it would be more important to target the family, childcare settings or the wider environment and identify the most effective way of changing these energy balance related behaviors.

METHODS/DESIGN

Quantitative (intervention and observational) and qualitative literature on determinants/correlates of fruit and vegetable intake, sugar sweetened beverage and other unhealthy diet intake, and physical activity and sedentary behaviors in young children will be systematically identified, mapped and reviewed. A common search strategy (no language or period restrictions) will be used to identify papers from eight electronic databases and this will be supplemented by hand-searching. Next, studies in developed countries that examine the factors associated with these behaviors in children aged 0 to 6 years (at baseline) will be screened and mapped descriptively followed by in-depth data extraction, quality assessment and synthesis. Data from quantitative studies will be summarized using either forest plots or harvest plots and narrative synthesis, and qualitative studies using thematic analysis. Qualitative evidence will be integrated with the quantitative evidence, using a parallel synthesis approach, to provide a deeper understanding of effective strategies to influence these energy balance related behaviors.

DISCUSSION

In addition to updating and mapping current research, these reviews will be the first to comprehensively synthesize and integrate both the quantitative and qualitative evidence pertaining to determinants/correlates/barriers/facilitators of obesity related behaviors in this young age group (0 to 6 years) with the aim of informing future interventions.

TRIAL REGISTRATION

International Prospective Register for Systematic Reviews (PROSPERO) Registration number: CRD42012002881.

The genetics of childhood obesity and interaction with dietary macronutrients

The genes contributing to childhood obesity are categorized into three different types based on distinct genetic and phenotypic characteristics. These types of childhood obesity are represented by rare monogenic forms of syndromic or non-syndromic childhood obesity, and common polygenic childhood obesity. In some cases, genetic susceptibility to these forms of childhood obesity may result from different variations of the same gene. Although the prevalence for rare monogenic forms of childhood obesity has not increased in recent times, the prevalence of common childhood obesity has increased in the United States and developing countries throughout the world during the past few decades. A number of recent genome-wide association studies and mouse model studies have established the identification of susceptibility genes contributing to common childhood obesity. Accumulating evidence suggests that this type of childhood obesity represents a complex metabolic disease resulting from an interaction with environmental factors, including dietary macronutrients. The objective of this article is to provide a review on the origins, mechanisms, and health consequences of obesity susceptibility genes and interaction with dietary macronutrients that predispose to childhood obesity. It is proposed that increased knowledge of these obesity susceptibility genes and interaction with dietary macronutrients will provide valuable insight for individual, family, and community preventative lifestyle intervention, and eventually targeted nutritional and medicinal therapies.

A family-based intervention targeting parents of preschool children with overweight and obesity: conceptual framework and study design of LOOPS- Lund overweight and obesity preschool study

Background

As the rate of overweight among children is rising there is a need for evidence-based research that will clarify what the best interventional strategies to normalize weight development are. The overall aim of the Lund Overweight and Obesity Preschool Study (LOOPS) is to evaluate if a family-based intervention, targeting parents of preschool children with overweight and obesity, has a long-term positive effect on weight development of the children. The hypothesis is that preschool children with overweight and obesity, whose parents participate in a one-year intervention, both at completion of the one-year intervention and at long term follow up (2-, 3- and 5-years) will have reduced their BMI-for-age z-score.

Methods/Design

The study is a randomized controlled trial, including overweight (n=160) and obese (n=80) children 4-6-years-old. The intervention is targeting the parents, who get general information about nutrition and exercise recommendations through a website and are invited to participate in a group intervention with the purpose of supporting them to accomplish preferred lifestyle changes, both in the short and long term. To evaluate the effect of various supports, the parents are randomized to different interventions with the main focus of: 1) supporting the parents in limit setting by emphasizing the importance of positive interactions between parents and children and 2) influencing the patterns of daily activities to induce alterations of everyday life that will lead to healthier lifestyle. The primary outcome variable, child BMI-for-age z-score will be measured at referral, inclusion, after 6 months, at the end of intervention and at 2-, 3- and 5-years post intervention. Secondary outcome variables, measured at inclusion and at the end of intervention, are child activity pattern, eating habits and biochemical markers as well as parent BMI, exercise habits, perception of health, experience of parenthood and level of parental stress.

Discussion

The LOOPS project will provide valuable information on how to build effective interventions to influence an unhealthy weight development to prevent the negative long-term effects of childhood obesity.

Trial registration

ClinicalTrials.gov NCT00916318

Childhood obesity

Childhood obesity has important consequences for health and wellbeing both during childhood and also in later adult life. The rising prevalence of childhood obesity poses a major public health challenge in both developed and developing countries by increasing the burden of chronic non-communicable diseases. Despite the urgent need for effective preventative strategies, there remains disagreement over its definition due to a lack of evidence on the optimal cut-offs linking childhood BMI to disease risks, and limited evidence on the most effective components of interventions to prevent childhood obesity. This article reviews the trends in childhood obesity, its genetic, nutritional and other risk factors, and preventative and treatment strategies. Particular emphasis is given to early-onset obesity in pre-school children, which, as a precursor to later childhood and adult obesity, provides insights into the developmental and genetic origins of obesity and also offers the potential for early preventative approaches with long-lasting benefits.

An economic perspective on childhood obesity: recent findings on cost of illness and cost effectiveness of interventions

OBJECTIVE

This review aims to put an economic perspective on childhood and adolescent obesity by providing an overview on the latest literature on obesity-related costs and the cost effectiveness of interventions to prevent or manage the problem.

METHODS

The review is based on a comprehensive PubMed/Medline search performed in October 2011.

RESULTS

Findings on the economic burden of childhood obesity are inconclusive. Considering the different cost components and age groups, most but not all studies found excess health care costs for obese compared with normal-weight peers. The main limitations relate to short study periods and the strong focus on health care costs, neglecting other components of the economic burden of childhood obesity. The results of the economic evaluations of childhood and adolescent obesity programs support the expectation that preventive and management interventions with acceptable cost effectiveness do exist. Some interventions may even be cost saving. However, owing to the differences in various methodologic aspects, it is difficult to compare preventive and treatment approaches in their cost effectiveness or to determine the most cost-effective timing of preventive interventions during infancy and adolescence.

CONCLUSION

To design effective public policies against the obesity epidemic, a better understanding and a more precise assessment of the health care costs and the broader economic burden are necessary but, critically, depend on the collection of additional longitudinal data. The economic evaluation of childhood obesity interventions poses various methodologic challenges, which should be addressed in future research to fully use the potential of economic evaluation as an aid to decision making.

HENRY: development, pilot and long-term evaluation of a programme to help practitioners work more effectively with parents of babies and pre-school children to prevent childhood obesity

BACKGROUND

Despite epidemic numbers of obese and overweight pre-school children, professionals report a lack of confidence and self-efficacy in working with parents around lifestyle change. HENRY--Health Exercise Nutrition for the Really Young--trains health and community practitioners to work more sensitively and effectively with parents of babies and pre-school children around obesity and lifestyle concerns. Underpinned by the Family Partnership Model, reflective practice and solution-focused techniques, it offers face-to-face training and e-learning. This paper describes the development, pilot and evaluation of HENRY Sure Start Children's Centres.

METHODS

Twelve Children's Centres in Oxfordshire took part in the pilot involving 137 staff. Questionnaires were administered at the end of training courses. Self-reported confidence ratings were obtained before and after training. Postal questionnaires were sent to Centre managers 2-6 months later to ascertain long-term effects. Nine managers participated in in-depth interviews. A further 535 learners completed the e-learning course and online feedback.

RESULTS

One hundred and thirty-one staff (96%) completed the training course and valued it as a way of enhancing skills and knowledge. Mean (±SD) self-reported confidence ratings increased (4.1 ± 0.7 to 7.2 ± 0.7; P < 0.00001). An influence on personal as well as professional lives was apparent. Long-term follow-up indicated ongoing impact attributed to HENRY on both Centres and staff. All 535 e-learners successfully completed: 98% would recommend HENRY; 94% thought it enhanced their skills as well as knowledge.

CONCLUSIONS

HENRY is an innovative approach that offers some promise in tackling obesity through training community and health practitioners to work more effectively with parents of very young children. It appears to have an effect on participants' personal lives as well as professional work. A large-scale long-term study would be required to ascertain if there is the desired impact on young children's lifestyles and risk of obesity.