Proactive Assessment of Obesity Risk during Infancy (ProAsk): a qualitative study of parents' and professionals' perspectives on an mHealth intervention.

BACKGROUND: Prevention of childhood obesity is a public health priority. Interventions that establish healthy growth trajectories early in life promise lifelong benefits to health and wellbeing. Proactive Assessment of Obesity Risk during Infancy (ProAsk) is a novel mHealth intervention designed to enable health professionals to assess an infant's risk of future overweight and motivate parental behaviour change to prevent childhood overweight and obesity. The aim of this study was to explore parents' and health professionals' experiences of the overweight risk communication and behaviour change aspects of this mHealth intervention. METHODS: The study was conducted in four economically deprived localities in the UK. Parents (N = 66) were recruited to the ProAsk feasibility study when their infant was 6-8 weeks old. Twenty two health visitors (HVs) used a hand-held tablet device to deliver ProAsk to parents when their infants were 3 months old. Parents (N = 12) and HVs (N = 15) were interviewed when infants in the study were 6 months old. Interview data were transcribed and analysed thematically using an inductive, interpretative approach. RESULTS: Four key themes were identified across both parent and health visitor data: Engaging and empowering with digital technology; Unfamiliar technology presents challenges and opportunity; Trust in the risk score; Resistance to targeting. Most participants found the interactivity and visual presentation of information on ProAsk engaging. Health visitors who were unfamiliar with mobile technology drew support from parents who were more confident using tablet devices. There was evidence of resistance to targeting infants at greatest risk of future overweight and obesity, and both parents and health visitors drew on a number of reasons why a higher than average overweight risk score might not apply to a particular infant. CONCLUSIONS: An mHealth intervention actively engaged parents, enabling them to take ownership of the process of seeking strategies to reduce infant risk of overweight. However, cognitive and motivational biases that prevent effective overweight risk communication are barriers to targeting an intervention at those infants most at risk. TRIAL REGISTRATION: NCT02314494 . Date registered 11th December 2014.

Digital technology to facilitate Proactive Assessment of Obesity Risk during Infancy (ProAsk): a feasibility study.

OBJECTIVE: To assess the feasibility and acceptability of using digital technology for Proactive Assessment of Obesity Risk during Infancy (ProAsk) with the UK health visitors (HVs) and parents. DESIGN: Multicentre, pre- and post-intervention feasibility study with process evaluation. SETTING: Rural and urban deprived settings, UK community care. PARTICIPANTS: 66 parents of infants and 22 HVs. INTERVENTION: ProAsk was delivered on a tablet device. It comprises a validated risk prediction tool to quantify overweight risk status and a therapeutic wheel detailing motivational strategies for preventive parental behaviour. Parents were encouraged to agree goals for behaviour change with HVs who received motivational interviewing training. OUTCOME MEASURES: We assessed recruitment, response and attrition rates. Demographic details were collected, and overweight risk status. The proposed primary outcome measure was weight-for-age z-score. The proposed secondary outcomes were parenting self-efficacy, maternal feeding style, infant diet and exposure to physical activity/sedentary behaviour. Qualitative interviews ascertained the acceptability of study processes and intervention fidelity. RESULTS: HVs screened 324/589 infants for inclusion in the study and 66/226 (29%) eligible infants were recruited. Assessment of overweight risk was completed on 53 infants and 40% of these were identified as above population risk. Weight-for-age z-score (SD) between the infants at population risk and those above population risk differed significantly at baseline (-0.67 SD vs 0.32 SD). HVs were able to collect data and calculate overweight risk for the infants. Protocol adherence and intervention fidelity was a challenge. HVs and parents found the information provided in the therapeutic wheel appropriate and acceptable. CONCLUSION: Study recruitment and protocol adherence were problematic. ProAsk was acceptable to most parents and HVs, but intervention fidelity was low. There was limited evidence to support the feasibility of implementing ProAsk without significant additional resources. A future study could evaluate ProAsk as a HV-supported, parent-led intervention. TRIAL REGISTRATION NUMBER: NCT02314494 (Feasibility Study Results).

"I would rather be told than not know" - A qualitative study exploring parental views on identifying the future risk of childhood overweight and obesity during infancy.

BACKGROUND: Risk assessment tools provide an opportunity to prevent childhood overweight and obesity through early identification and intervention to influence infant feeding practices. Engaging parents of infants is paramount for success however; the literature suggests there is uncertainty surrounding the use of such tools with concerns about stigmatisation, labelling and expressions of parental guilt. This study explores parents' views on identifying future risk of childhood overweight and obesity during infancy and communicating risk to parents. METHODS: Semi-structured qualitative interviews were conducted with 23 parents and inductive, interpretive and thematic analysis performed. RESULTS: Three main themes emerged from the data: 1) Identification of infant overweight and obesity risk. Parents were hesitant about health professionals identifying infant overweight as believed they would recognise this for themselves, in addition parents feared judgement from health professionals. Identification of future obesity risk during infancy was viewed positively however the use of a non-judgemental communication style was viewed as imperative. 2) Consequences of infant overweight. Parents expressed immediate anxieties about the impact of excess weight on infant ability to start walking. Parents were aware of the progressive nature of childhood obesity however, did not view overweight as a significant problem until the infant could walk as viewed this as a point when any excess weight would be lost due to increased energy expenditure. 3) Parental attributions of causality, responsibility, and control. Parents articulated a high level of personal responsibility for preventing and controlling overweight during infancy, which translated into self-blame. Parents attributed infant overweight to overfeeding however articulated a reluctance to modify infant feeding practices prior to weaning. CONCLUSION: This is the first study to explore the use of obesity risk tools in clinical practice, the findings suggest that identification, and communication of future overweight and obesity risk is acceptable to parents of infants. Despite this positive response, findings suggest that parents' acceptance to identification of risk and implementation of behaviour change is time specific. The apparent level of parental responsibility, fear of judgement and self-blame also highlights the importance of health professionals approach to personalised risk communication so feelings of self-blame are negated and stigmatisation avoided.

Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood.

The risk factors for childhood overweight and obesity are known and can be identified antenatally or during infancy, however, the majority of effective interventions are designed for older children. This review identified interventions designed to reduce the risk of overweight/obesity that were delivered antenatally or during the first 2 years of life, with outcomes reported from birth to 7 years of age. Six electronic databases were searched for papers reporting randomised controlled trials of interventions published from January 1990 to September 2013. A total of 35 eligible studies were identified, describing 27 unique trials of which 24 were behavioural and three were non-behavioural. The 24 behavioural trials were categorised by type of intervention: (1) nutritional and/or responsive feeding interventions targeted at parents of infants, which improved feeding practices and had some impact on child weight (n = 12); (2) breastfeeding promotion and lactation support for mothers, which had a positive effect on breastfeeding but not child weight (n = 5); (3) parenting and family lifestyle (n = 4); and (4) maternal health (n = 3) interventions that had some impact on feeding practices but not child weight. The non-behavioural trials comprised interventions manipulating formula milk composition (n = 3). Of these, lower/hydrolysed protein formula milk had a positive effect on weight outcomes. Interventions that aim to improve diet and parental responsiveness to infant cues showed most promise in terms of self-reported behavioural change. Despite the known risk factors, there were very few intervention studies for pregnant women that continue during infancy which should be a priority for future research.

Are anti-stigma films a useful strategy for reducing weight bias among trainee healthcare professionals? Results of a pilot randomized control trial.

BACKGROUND: Weight bias is an important clinical issue that the educators of tomorrow's healthcare professionals cannot afford to ignore. This study, therefore, aimed to pilot a randomized controlled trial of the effects of educational films designed to reduce weight stigmatization toward obese patients on trainee dietitians' and doctors' attitudes. METHODS: A pre-post experimental design with a 6-week follow-up, which consisted of an intervention group (n = 22) and a control group (n = 21), was conducted to assess the efficacy of brief anti-stigma films in reducing weight bias, and to test whether future, larger-scale studies among trainee healthcare professionals are feasible. RESULTS: Participants at baseline demonstrated weight bias, on both implicit and explicit attitude measures, as well as strong beliefs that obesity is under a person's control. The intervention films significantly improved explicit attitudes and beliefs toward obese people, and participant evaluation was very positive. The intervention did not significantly improve implicit anti-fat bias. CONCLUSION: The current study suggests both that it is possible to conduct a substantive trial of the effects of educational films designed to reduce weight stigma on a larger cohort of trainee healthcare professionals, and that brief educational interventions may be effective in reducing stigmatizing attitudes in this population.

The assessment of weight status in children and young people attending a spina bifida outpatient clinic: a retrospective medical record review.

PURPOSE: Children with disabilities are two to three times more likely to become overweight or obese than typically developing children. Children with spina bifida (SB) are at particular risk, yet obesity prevalence and weight management with this population are under-researched. This retrospective chart review explored how weight is assessed and discussed in a children's SB outpatient clinic. METHOD: Height/weight data were extracted from records of children aged 2-18 with a diagnosis of SB attending an outpatient clinic at least once between June 2009-2011. Body mass index was calculated and classified using Centers for Disease Control and Prevention cut-offs. Notes around weight, diet and physical/sedentary activities were transcribed verbatim and analysed using descriptive thematic analysis. RESULTS: Of 180 eligible patients identified, only 63 records had sufficient data to calculate BMI; 15 patients were overweight (23.81%) and 11 obese (17.46%). Weight and physical activity discussions were typically related to function (e.g. mobility, pain). Diet discussions focused on bowel and bladder function and dietary challenges. CONCLUSIONS: Anthropometrics were infrequently recorded, leaving an incomplete picture of weight status in children with SB and suggesting that weight is not prioritised. Bowel/bladder function was highlighted over other benefits of a healthy body weight, indicating that health promotion opportunities are being missed. Implications for Rehabilitation It is important to assess, categorise and record anthropometric data for children and youth with spina bifida as they may be at particular risk of excess weight. Information around weight categorisation should be discussed openly and non-judgmentally with children and their families. Health promotion opportunities may be missed by focusing solely on symptom management or function. Healthcare professionals should emphasise the broad benefits of healthy eating and physical activity, offering strategies to enable the child to incorporate healthy lifestyle behaviours appropriate to their level of ability.

Social participation and maintaining recommended waist circumference: prospective evidence from the English Longitudinal Study of Aging.

OBJECTIVE: To investigate whether older adults participating in social activities are more likely to maintain or achieve recommended waist circumference (WC) levels. METHOD: A total of 4,280 older adults who participated in Wave 2 (baseline) and Wave 4 (follow-up) of the English Longitudinal Study of Ageing. WC was measured by a nurse in both study waves. RESULTS: Participation in education, arts, music groups, evening classes, and in charitable associations was associated with maintaining recommended WC only in those men whose WC was in the recommended range at baseline. Participation in social activities was not associated with achieving recommended WC in women or men with initially large waist. DISCUSSION: Participation in cultural and charitable activities may help in maintaining a recommended level of WC in older men with WC originally in the recommended range.

Obesity-related knowledge and beliefs in obese adults attending a specialist weight-management service: implications for weight loss over 1 year.

OBJECTIVE: Cognitive approaches to obesity management assume that weight loss is more likely to occur if individuals perceive many benefits and few costs. Research to-date has been limited by the lack of prospective studies. METHODS: A longitudinal study design. At baseline, obese patients attending weight-management clinics (n=104) completed a questionnaire that assessed knowledge and beliefs regarding obesity's health and social/aesthetic consequences (Obesity Risk Knowledge (ORK-10) scale and the Obesity Beliefs scale), self-reported weight/height, goal weight, health-related quality of life, and sociodemographic characteristics. Medical records were also reviewed. At the 12-month follow-up, a second questionnaire assessed self-reported weight/height. RESULTS: At baseline, average ORK-10 scale scores were 4/10. At follow-up, 32 out of the 66 participants retained on the study did not gain weight (48.5%). For these participants, weight loss was associated with endorsement of the health (r(s)=0.40) and the social/aesthetic (r(s)=0.31) costs of obesity (p<0.05). CONCLUSION: Despite their high-risk status, participants demonstrated low levels of knowledge regarding obesity's health risks. Weight loss was associated with greater awareness of the health and social/aesthetic costs of obesity. PRACTICE IMPLICATIONS: This study suggests that health education is required to facilitate informed choices and supports the use of cognitive approaches which promote both the health and social/aesthetic consequences of obesity.

Beliefs regarding the consequences of obesity and ideal weight: an instrument development study.

OBJECTIVE: To address the current lack of psychometrically sound measures of beliefs regarding the consequences of obesity and ideal weight that has limited research to-date. METHODS: In phase one, interviews with 22 healthy-weight, overweight and obese individuals were conducted, subjected to theme analysis and used to develop 40 items. In phase two, unsound items were removed following item and principal components analyses of data from a community sample of 188 participants. In phase three, the items selected in phase two were administered to a second workforce population (n=302) to ensure their excellent psychometric properties were stable. In phase four, data were collected from 104 obese clinic attendees to establish the subscales' construct validity. RESULTS: The resultant Obesity Beliefs Scale (OBS) is comprised of three short, reliable, unidimensional and valid subscales written in language suitable for individuals aged 12 years and above. CONCLUSION: The OBS is a psychometrically sound measure of beliefs regarding the consequences obesity and ideal weight. PRACTICE IMPLICATIONS: The OBS has the potential to play a key role in prospective research designed to fully determine the role of beliefs in weight control behaviour. It can also be used to target and assess health education interventions.