Cost-effectiveness of a community-delivered multicomponent intervention compared with enhanced standard care of obese adolescents: cost-utility analysis alongside a randomised controlled trial (the HELP trial).

OBJECTIVE: To undertake a cost-utility analysis of a motivational multicomponent lifestyle-modification intervention in a community setting (the Healthy Eating Lifestyle Programme (HELP)) compared with enhanced standard care. DESIGN: Cost-utility analysis alongside a randomised controlled trial. SETTING: Community settings in Greater London, England. PARTICIPANTS: 174 young people with obesity aged 12-19 years. INTERVENTIONS: Intervention participants received 12 one-to-one sessions across 6 months, addressing lifestyle behaviours and focusing on motivation to change and self-esteem rather than weight change, delivered by trained graduate health workers in community settings. Control participants received a single 1-hour one-to-one nurse-delivered session providing didactic weight-management advice. MAIN OUTCOME MEASURES: Mean costs and quality-adjusted life years (QALYs) per participant over a 1-year period using resource use data and utility values collected during the trial. Incremental cost-effectiveness ratio (ICER) was calculated and non-parametric bootstrapping was conducted to generate a cost-effectiveness acceptability curve (CEAC). RESULTS: Mean intervention costs per participant were £918 for HELP and £68 for enhanced standard care. There were no significant differences between the two groups in mean resource use per participant for any type of healthcare contact. Adjusted costs were significantly higher in the intervention group (mean incremental costs for HELP vs enhanced standard care £1003 (95% CI £837 to £1168)). There were no differences in adjusted QALYs between groups (mean QALYs gained 0.008 (95% CI -0.031 to 0.046)). The ICER of the HELP versus enhanced standard care was £120 630 per QALY gained. The CEAC shows that the probability that HELP was cost-effective relative to the enhanced standard care was 0.002 or 0.046, at a threshold of £20 000 or £30 000 per QALY gained. CONCLUSIONS: We did not find evidence that HELP was more effective than a single educational session in improving quality of life in a sample of adolescents with obesity. HELP was associated with higher costs, mainly due to the extra costs of delivering the intervention and therefore is not cost-effective. TRIAL REGISTRATION NUMBER: ISRCTN9984011.

A community-based motivational personalised lifestyle intervention to reduce BMI in obese adolescents: results from the Healthy Eating and Lifestyle Programme (HELP) randomised controlled trial.

OBJECTIVE: Approximately 7% of children and young people aged 5-15 years in the UK have obesity at a level likely to be associated with comorbidities. The majority of multicomponent lifestyle programmes have limited applicability and generalisability for British adolescents.The Healthy Eating and Lifestyle Programme (HELP) was a specific adolescent-focused intervention, designed for obese 12 to 18-year-olds seeking help to manage their weight. Participants were randomised to the 12-session HELP intervention or standard care. The primary outcome was difference in mean body mass index (BMI) (kg/m2) between groups at week 26 adjusted for baseline BMI, age and sex. SUBJECTS: 174 subjects were randomised (87 in each arm), of whom 145 (83%) provided primary outcome data at week 26. RESULTS: At week 26 there were no significant effects of the intervention on BMI (mean change in BMI 0.18 kg/m2 for the intervention arm, 0.25 kg/m2 for the control arm; adjusted difference between groups: -0.11 kg/m2 (95% CI -0.62 to 0.40), p=0.7). At weeks 26 and 52 there were no significant differences between groups in any secondary outcomes. CONCLUSION: At minimum this study reinforces the need for higher level, structured interventions to tackle the growing public health burden of obesity in the UK and internationally.The HELP intervention was no more effective than a single educational session for reducing BMI in a community sample of obese adolescents.Further work is needed to understand how weight management programmes can be delivered effectively to young people from diverse and deprived backgrounds in which childhood obesity is common. The study has significant implications in terms of informing public health interventions to tackle childhood obesity. TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN99840111.

Adiposity and carotid-intima media thickness in children and adolescents: a systematic review.

BACKGROUND: Adiposity in childhood is associated with later cardiovascular disease (CVD), but it is unclear whether this relationship is independent of other risk factors experienced in later life, such as smoking and hypertension. Carotid-intima media thickness (cIMT) is a measure of subclinical atherosclerosis that may be used to assess CVD risk in young people. The aim of this study was to examine the relationship between adiposity and cIMT in children and adolescents. METHODS: We searched Medline, Embase, Global Health, and CINAHL Plus electronic databases (1980-2014). Population-based observational studies that reported a measure of association between objectively-measured adiposity and cIMT in childhood were included in this review. RESULTS: Twenty-two cross-sectional studies were included (n = 7,366 children and adolescents). Thirteen of nineteen studies conducted in adolescent populations (mean age ≥ 12 years, n = 5,986) reported positive associations between cIMT and adiposity measures (correlation coefficients 0.13 to 0.59). Three studies of pre-adolescent populations (n = 1,380) reported mixed evidence, two studies finding no evidence of a correlation, and one an inverse relationship between skinfolds and cIMT. Included studies did not report an adiposity threshold for subclinical atherosclerosis. CONCLUSIONS: Based on studies conducted mostly in Western Europe and the US, adiposity does not appear to be associated with cIMT in pre-adolescents, but may be associated in adolescents. If further studies confirm these findings, a focus on cardiovascular disease prevention efforts in pre-adolescence, before arterial changes have emerged, may be justified.

Development and evaluation of an online tool for management of overweight children in primary care: a pilot study.

OBJECTIVE: To explore the acceptability of implementing an online tool for the assessment and management of childhood obesity (Computer-Assisted Treatment of CHildren, CATCH) in primary care. DESIGN AND SETTING: An uncontrolled pilot study with integral process evaluation conducted at three general practices in northwest London, UK (November 2012-April 2013). PARTICIPANTS: Families with concerns about excess weight in a child aged 5-18 years (n=14 children). INTERVENTION: Families had a consultation with a doctor or nurse using CATCH, which assessed child weight status, cardiometabolic risk and risk of emotional and behavioural difficulties and provided personalised lifestyle advice. Families and practitioners completed questionnaires to assess the acceptability and usefulness of the consultation, and participated in semistructured interviews which explored user experiences. OUTCOME MEASURES: The primary outcome was family satisfaction with the tool-assisted consultation. Secondary outcomes were practitioners' satisfaction, and acceptability and usefulness of the intervention to families and practitioners. RESULTS: The majority of families (86%, n=12) and all practitioners (n=4) were satisfied with the consultation. Participants reported that the tool was easy to use, the personalised lifestyle advice useful and the use of visual aids beneficial. Families and practitioners identified a need for practical, structured support for weight management following the consultation. CONCLUSIONS: The results of this pilot study indicate that an online tool for assessment and management of childhood obesity can be implemented in primary care, and is acceptable to patients, families and practitioners. Further development and evaluation of the tool is warranted.

Child obesity cut-offs as derived from parental perceptions: cross-sectional questionnaire.

BACKGROUND: Overweight children are at an increased risk of premature mortality and disease in adulthood. Parental perceptions and clinical definitions of child obesity differ, which may lessen the effectiveness of interventions to address obesity in the home setting. The extent to which parental and objective weight status cut-offs diverge has not been documented. AIM: To compare parental perceived and objectively derived assessment of underweight, healthy weight, and overweight in English children, and to identify sociodemographic characteristics that predict parental under- or overestimation of a child's weight status. DESIGN AND SETTING: Cross-sectional questionnaire completed by parents linked with objective measurement of height and weight by school nurses, in English children from five regions aged 4-5 and 10-11 years old. METHOD: Parental derived cut-offs for under- and overweight were derived from a multinomial model of parental classification of their own child's weight status against school nurse measured body mass index (BMI) centile. RESULTS: Measured BMI centile was matched with parent classification of weight status in 2976 children. Parents become more likely to classify their children as underweight when they are at the 0.8th centile or below, and overweight at the 99.7th centile or above. Parents were more likely to underestimate a child's weight if the child was black or South Asian, male, more deprived, or the child was older. These values differ greatly from the BMI centile cut-offs for underweight (2nd centile) and overweight (85th). CONCLUSION: Clinical and parental classifications of obesity are divergent at extremes of the weight spectrum.

The benefits and harms of providing parents with weight feedback as part of the national child measurement programme: a prospective cohort study.

BACKGROUND: Small-scale evaluations suggest that the provision of feedback to parents about their child's weight status may improve recognition of overweight, but the effects on lifestyle behaviour are unclear and there are concerns that informing parents that their child is overweight may have harmful effects. The aims of this study were to describe the benefits and harms of providing weight feedback to parents as part of a national school-based weight-screening programme in England. METHODS: We conducted a pre-post survey of 1,844 parents of children aged 4-5 and 10-11 years who received weight feedback as part of the 2010-2011 National Child Measurement Programme. Questionnaires assessed general knowledge about the health risks associated with child overweight, parental recognition of overweight and the associated health risks in their child, child lifestyle behaviour, child self-esteem and weight-related teasing, parental experience of the feedback, and parental help-seeking behaviour. Differences in the pre-post proportions of parents reporting each outcome were assessed using a McNemar's test. RESULTS: General knowledge about child overweight as a health issue was high at baseline and increased further after weight feedback. After feedback, the proportion of parents that correctly recognised their child was overweight increased from 21.9% to 37.7%, and more than a third of parents of overweight children sought further information regarding their child's weight. However, parent-reported changes in lifestyle behaviours among children were minimal, and limited to increases in physical activity in the obese children only. There was some suggestion that weight feedback had a greater impact upon changing parental recognition of the health risks associated with child overweight in non-white ethnic groups. CONCLUSIONS: In this population-based sample of parents of children participating in the National Child Measurement Programme, provision of weight feedback increased recognition of child overweight and encouraged some parents to seek help, without causing obvious unfavourable effects. The impact of weight feedback on behaviour change was limited; suggesting that further work is needed to identify ways to more effectively communicate health information to parents and to identify what information and support may encourage parents in making and maintaining lifestyle changes for their child.

Predictors of health-related behaviour change in parents of overweight children in England.

OBJECTIVE: Providing parents with information about their child's overweight status (feedback) could prompt them to make lifestyle changes for their children. We assessed whether parents of overweight children intend to or change behaviours following feedback, and examined predictors of these transitions. METHODS: We analysed data from a cohort of parents of children aged 4-5 and 10-11 years participating in the National Child Measurement Programme in five areas of England, 2010-2011. Parents of overweight children (body mass index ≥91st centile) with data at one or six months after feedback were included (n=285). The outcomes of interest were intention to change health-related behaviours and positive behaviour change at follow-up. Associations between respondent characteristics and outcomes were assessed using logistic regression analysis. RESULTS: After feedback, 72.1% of parents reported an intention to change; 54.7% reported positive behaviour change. Intention was associated with recognition of child overweight status (OR 11.20, 95% CI 4.49, 27.93). Parents of older and non-white children were more likely to report behaviour changes than parents of younger or white children. Intention did not predict behaviour change. CONCLUSIONS: Parental recognition of child overweight predicts behavioural intentions. However, intentions do not necessarily translate into behaviours; interventions that aim to change intentions may have limited benefits.

Can the relationship between ethnicity and obesity-related behaviours among school-aged children be explained by deprivation? A cross-sectional study.

OBJECTIVES: It is unclear whether cultural differences or material disadvantage explain the ethnic patterning of obesogenic behaviours. The aim of this study was to examine ethnicity as a predictor of obesity-related behaviours among children in England, and to assess whether the effects of ethnicity could be explained by deprivation. SETTING: Five primary care trusts in England, 2010-2011. PARTICIPANTS: Parents of white, black and South Asian children aged 4-5 and 10-11 years participating in the National Child Measurement Programme (n=2773). PRIMARY OUTCOME MEASURES: Parent-reported measures of child behaviour: low level of physical activity, excessive screen time, unhealthy dietary behaviours and obesogenic lifestyle (combination of all three obesity-related behaviours). Associations between these behaviours and ethnicity were assessed using logistic regression analyses. RESULTS: South Asian ethnic groups made up 22% of the sample, black ethnic groups made up 8%. Compared with white children, higher proportions of Asian and black children were overweight or obese (21-27% vs16% of white children), lived in the most deprived areas (24-47% vs 14%) and reported obesity-related behaviours (38% with obesogenic lifestyle vs 16%). After adjusting for deprivation and other sociodemographic characteristics, black and Asian children were three times more likely to have an obesogenic lifestyle than white children (OR 3.0, 95% CI 2.1 to 4.2 for Asian children; OR 3.4, 95% CI 2.7 to 4.3 for black children). CONCLUSIONS: Children from Asian and black ethnic groups are more likely to have obesogenic lifestyles than their white peers. These differences are not explained by deprivation. Culturally specific lifestyle interventions may be required to reduce obesity-related health inequalities.

Perceptions of health risk among parents of overweight children: a cross-sectional study within a cohort.

OBJECTIVE: To identify the socio-demographic and behavioural characteristics associated with perceptions of weight-related health risk among the parents of overweight children. METHODS: Baseline data from a cohort of parents of children aged 4-11 years in five areas in England in 2010-2011 were analysed; the sample was restricted to parents of overweight children (body mass index ≥ 91(st) centile of UK 1990 reference; n=579). Associations between respondent characteristics and parental perception of health risk associated with their child's weight were examined using logistic regression analyses. RESULTS: Most parents (79%) did not perceive their child's weight to be a health risk. Perception of a health risk was associated with recognition of the child's overweight status (OR 10.59, 95% CI 5.51 to 20.34), having an obese child (OR 4.21, 95% CI 2.28 to 7.77), and having an older child (OR 2.67, 95% CI 1.32 to 5.41). However, 41% of parents who considered their child to be overweight did not perceive a health risk. CONCLUSIONS: Parents that recognise their child's overweight status, and the parents of obese and older children, are more likely to perceive a risk. However, many parents that acknowledge their child is overweight do not perceive a related health risk.

The ethics of unlinked anonymous testing of blood: views from in-depth interviews with key informants in four countries.

OBJECTIVES: In this study we explore the ethical issues around unlinked anonymous testing (UAT) of blood, a method of seroprevalence surveillance for infectious diseases. Our study focused on UAT for HIV, although UAT can be used for other infectious diseases. The objectives of the research were to gain a better understanding of the views of key informants in countries adopting different UAT testing strategies, and to use the findings of the research to inform health policy. DESIGN: Qualitative study using in-depth interviews and ethical analysis. SETTING: Four countries using different strategies around UAT of blood for HIV (the UK, the USA, the Netherlands and Norway). PARTICIPANTS: Twenty-three key informants in the four countries. RESULTS: Participants from the four countries have different views on UAT of blood, and the approaches and policies on UAT adopted by different countries have been historically and culturally determined. We use our findings to explore the relationship between public health policy and ethics, framing our discussion in relation to two important contemporary debates: informed consent for participation in medical and public health research; and the balance between the individual good and the public good. CONCLUSIONS: Qualitative research and ethical analysis of UAT of blood in different countries has yielded important findings for consideration by policy makers. The policy of UAT of blood for HIV and other diseases in the UK needs reconsideration in the light of these findings.

Public health ethics: teaching survey and critical review.

The last decade has witnessed development of the new field of public health ethics, as well as growing emphasis on the importance of ethics education to both students and graduates of the health care professions. Using a topic-based interpretation of public health ethics this paper presents a questionnaire survey of the nature and content of teaching of public health ethics to medical undergraduates and public health postgraduate students in the United Kingdom. Completed questionnaires were returned by 76.9% (20/26) of medical schools and 76.7% (23/30) of institutions teaching postgraduate public health courses. Public health ethics was described as being taught in 75% of medical schools and 52% of institutions providing postgraduate education. However, in both types of location the content and nature of teaching was patchy and often minimal. If medical schools and postgraduate institutions are serious about improving the discussion and teaching of ethical issues in public health, there will need to be considerable investment and commitment, accompanied by creativity and imagination. In parallel, the debate about the meaning of, and approaches to, public health ethics needs to be broadened and enriched. The topic-based interpretation of public health ethics has limitations. Alternatives are explored and critically reviewed.