Effectiveness of a socially adapted intervention in reducing social inequalities in adolescence weight. The PRALIMAP-INÈS school-based mixed trial.

BACKGROUND: A high prevalence of overweight/obesity among low socioeconomic status adolescents contributes to health inequalities. However, evidence-based interventions for reducing social inequalities in adolescent weight are lacking. We aimed to investigate whether strengthened care management for adolescents with low socioeconomic status has an equivalent effect in reducing overweight as standard care management in adolescents with high status. METHODS: PRALIMAP-INÈS was a multicentre trial including 35 state-run high and middle schools in the north-eastern France. A population-based sample of 1639 adolescents aged 13-18 years with screened and clinically confirmed overweight/obesity were proposed for inclusion and divided into two groups by the Family Affluence Scale score: advantaged (score > 5), receiving standard care management (A.S) and less-advantaged randomly assigned to two groups (1:2 ratio): standard care management (LA.S) and standard and strengthened care management (LA.S.S). Interventions were based on the proportionate universalism principle: universal standard care for all groups and proportionate care for the LA.S.S group. Main outcome was body mass index z-score (BMIz) assessed before and 1 year after inclusion. RESULTS: A total of 1419 adolescents were included and 1143 followed up at 1 year: 649 in A.S, 158 in LA.S and 336 in LA.S.S groups. BMIz decreased significantly for boys (-0.11 [95% CI, -0.13 to -0.08]; p < 0.0001) and girls (-0.05 [-0.08 to -0.03]; p < 0.0001). No equivalence between LA.S.S and A.S groups was evidenced. For girls, the trend to superiority for LA.S.S was confirmed by the more favourable change (-0.06 [-0.11 to -0.01]; p = 0.01) observed on superiority analysis, with no differential change for boys (0.02 [-0.03 to 0.08]; p = 0.41). CONCLUSIONS: A public health school-based intervention using the proportionate universalism principle may be effective in not worsening or even reducing overweight social inequalities in adolescents, especially for girls. Overcoming social barriers may help health professionals dealing with the burden and inequalities of overweight in adolescents.

Measuring adolescents' weight socioeconomic gradient using parental socioeconomic position.

Background: There is an evidence of social inequalities in weight status in adolescence but the diversity of family socioeconomic status (SES) indicators can lead to discrepant findings. We aimed to identify how combination of family SES indicators can help measuring weight socioeconomic gradient (WSG) among adolescents. Methods: Cross-sectional data from 2113 adolescents (13-18 years old) of the PRALIMAP-INÈS trial were used. Multiple SES indicators and assessment of weight status including body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR) and self-perception of overweight were used. We used principal component analysis (PCA) followed by structural equation models to identify SES dimensions. A dimension normalized score was calculated ranging from 1 to 10 (a high score corresponding to high SES). Linear regression models (linear trend test) were used to assess the WSG. Results: Three SES dimensions were identified: (i) 'Family social status', (ii) 'Family education level' and (iii) 'Family income level'. BMI was significantly lower in highly advantaged compared with highly less advantaged [-1.64 (-2.39; -0.89) for family social dimension, -0.86 (-1.37; -0.36) for family education level and -2.35 (-3.65; -1.05) for family income level]. Similar results were observed for all weight indicators excepted for self-perception of overweight status. Socially less advantaged adolescents perceived themselves less fat than they were. Conclusion: Although WSG was evident in adolescence, association between SES and weight status differed according to objective or perceived weight indicators. The proposed SES dimension can be applied in other field and future studies are needed to confirm our findings.

Reach and Acceptability of a Mobile Reminder Strategy and Facebook Group Intervention for Weight Management in Less Advantaged Adolescents: Insights From the PRALIMAP-INÈS Trial.

BACKGROUND: Although information and communication technology interventions appear to be a promising means of reducing the health inequality gap in overweight and obesity prevention, research on information and communication technology interventions is lacking outside the Anglo-Saxon world. OBJECTIVE: The aim of this study was to assess the reach and acceptability of 2 information and communication technology interventions delivered as part of a French nutritional program: an SMS text messaging (short message service, SMS) attendance-reminder for collective sessions strategy and a Facebook challenge group. METHODS: This study sample comprised 262 socially less advantaged overweight adolescents aged between 13 and 18 years. The information and communication technology interventions were carried out during the 2013-2014 academic year in 33 French state-run schools. For the SMS attendance-reminder for collective sessions strategy, at the start of the academic year, adolescents were asked to give their mobile number. SMS attendance-reminders were sent shortly before each of the 5 collective sessions. For the Facebook challenge group, adolescents were invited to join a closed Facebook group in which challenges on physical activity and on diet were posted weekly. Process data and 2 sets of face-to-face interviews were also used to interpret participation rates and access to Facebook. Appreciation for both interventions was evaluated by a questionnaire at the end of the academic year. RESULTS: Of the recruited adolescents, 79.0% (207/262) gave their mobile number, reflecting high access to a mobile phone. Giving a number was significantly more likely for girls (odds ratio [OR] 2.1, 95% CI 1.1-3.9; P=.02) and adolescents in a vocational or general high school as opposed to middle school (OR 1.0, 95% CI 0.4-2.7; OR 0.2, 95% CI 0.1-0.5; P<.001). Indicating a mobile number at the start of the year was not significantly associated with participation in collective sessions. Of the adolescents seen at the start-of-year face-to-face interviews, 78.1% (153/196) declared an interest in the Facebook challenge group, which implies having a Facebook account or being able to have access to one. However, only 21 adolescents went through the process of joining the group. Although there was satisfaction with the Facebook group among the participants, the low participation rate in the Facebook group does not allow conclusions to be drawn with confidence. CONCLUSIONS: The results are in line with the claim that using information and communication technologies in health programs is unlikely to widen health inequalities. However, in this population of French adolescents, mobile phone strategies seem more adapted to a high school context, and caution should be exercised with a younger audience. Although there is positive appreciation of the SMS attendance-reminders and a Facebook intervention is initially highly appealing to less advantaged adolescents, no evidence of impact could be demonstrated. These results highlight the difficulty in assessing the impact of specific interventions in complex health programs. TRIAL REGISTRATION: Clinicaltrials.gov NCT01688453; https://clinicaltrials.gov/ct2/show/NCT01688453 (Archived by WebCite at http://www.webcitation.org/6yy6EQ0SM).

Reducing social inequalities in access to overweight and obesity care management for adolescents: The PRALIMAP-INÈS trial protocol and inclusion data analysis.

BACKGROUND: Despite social inequalities in overweight/obesity prevalence, evidence-based public health interventions to reduce them are scarce. The PRALIMAP-INÈS trial aimed to investigate whether a strengthened-care management for adolescents with low socioeconomic status has an equivalent effect in preventing and reducing overweight as a standard-care management for high socioeconomic status adolescents. METHODS: PRALIMAP-INÈS was a mixed, prospective and multicenter trial including 35 state-run schools. It admitted overweight or obese adolescents, age 13-18 years old, for 3 consecutive academic years. One-year interventions were implemented. Data were collected before (T0), after (T1) and post (T2) intervention. Among 2113 eligible adolescents who completed questionnaires, 1639 were proposed for inclusion and 1419 were included (220 parental refusals). Two groups were constituted according to the Family Affluence Scale (FAS) score: the less advantaged (FAS≤5) were randomly assigned to 2 groups in a 2/1 ratio. The 3 intervention groups were: advantaged with standard-care management (A.S, n = 808), less advantaged with standard-care management (LA.S, n = 196), and less advantaged with standard and strengthened-care management (LA.S.S, n = 415). The standard-care management was based on the patient education principle and consisted of 5 collective sessions. The strengthened-care management was based on the proportionate universalism principle and consisted of activities adapted to needs. INCLUSION RESULTS: The written parental refusal was less frequent among less advantaged and more overweight adolescents. A dramatic linear social gradient in overweight was evidenced. DISCUSSION: The PRALIMAP-INÈS outcomes should inform how effectively a socially adapted public health program can avoid worsening social inequalities in overweight adolescents attending school. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01688453).