School-based obesity prevention interventions: practicalities and considerations.

Pediatric obesity continues to be a major public health concern. Once established it is difficult to treat, therefore well-designed and evaluated prevention interventions are vitally important. Schools have an important role in the prevention of childhood obesity, however, their involvement can be limited by a number of constraints and barriers, which need to be considered when designing interventions. Members of the Prevention Stream of the Australasian Child and Adolescent Obesity Research Network have extensive experience in implementing and evaluating school-based obesity prevention initiatives. Based on their collective experience and evidence from implementation research, the aim of this paper was to highlight six areas to consider when designing, implementing and evaluating obesity prevention initiatives in schools. Further, this paper aimed to provide guidance for overcoming some of the challenges and barriers faced in school-based obesity prevention research. The six key areas discussed include: design and analysis; school-community engagement; planning and recruitment; evaluation; implementation; and feedback and sustainability.

Benchmarking government action for obesity prevention--an innovative advocacy strategy.

BACKGROUND: Successful obesity prevention will require a leading role for governments, but internationally they have been slow to act. League tables of benchmark indicators of action can be a valuable advocacy and evaluation tool. OBJECTIVE: To develop a benchmarking tool for government action on obesity prevention, implement it across Australian jurisdictions and to publicly award the best and worst performers. DESIGN: A framework was developed which encompassed nine domains, reflecting best practice government action on obesity prevention: whole-of-government approaches; marketing restrictions; access to affordable, healthy food; school food and physical activity; food in public facilities; urban design and transport; leisure and local environments; health services, and; social marketing. A scoring system was used by non-government key informants to rate the performance of their government. National rankings were generated and the results were communicated to all Premiers/Chief Ministers, the media and the national obesity research and practice community. RESULTS: Evaluation of the initial tool in 2010 showed it to be feasible to implement and able to discriminate the better and worse performing governments. Evaluation of the rubric in 2011 confirmed this to be a robust and useful method. In relation to government action, the best performing governments were those with whole-of-government approaches, had extended common initiatives and demonstrated innovation and strong political will. CONCLUSION: This new benchmarking tool, the Obesity Action Award, has enabled identification of leading government action on obesity prevention and the key characteristics associated with their success. We recommend this tool for other multi-state/country comparisons.

The importance of family functioning, mental health and social and emotional well-being on child oral health.

OBJECTIVE: To examine the strength of associations between child oral health and aspects of the home environment (child behaviour, parental psychological distress and family functioning) in a large sample of 1- to 12-year-old Australian children. METHODS: The current study used data from the 2006 Victorian Child Health and Wellbeing Study. Data were obtained on 4590 primary carers. Measures of the family environment included the level of family functioning, parental psychological distress, child's emotion and behavioural problems and the family structure. RESULTS: The odds of children having good oral health status were lower with increasing parental psychological distress and poor family functioning across all age groups, and lower with increasing child mental health or conduct problems among children aged 4 years or older. Socioeconomic factors were also related to child oral health status, but this was significant only among children aged 4-7 years, with the odds of children having good oral health status 68% higher in households with a yearly income ≥AUD$ 60 000 compared with households with income <$20 000 (P < 0.05). CONCLUSION: In order to address inequities in the experience of poor oral health, solutions that encompass social, economic and psychosocial dimensions will be required. Integrating intervention strategies that promote oral, healthy family functioning and the mental health of parents and children into existing systems reaching vulnerable community members may improve child oral health outcomes and reduce the unequal distribution of oral disease across the social gradient.

Large reductions in child overweight and obesity in intervention and comparison communities 3 years after a community project.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Childhood obesity has been increasing over decades and scalable, population-wide solutions are urgently needed to reverse this trend. Evidence is emerging that community-based approaches can reduce unhealthy weight gain in children. In some countries, such as Australia, the prevalence of childhood obesity appears to be flattening, suggesting that some population-wide changes may be underway. WHAT THIS STUDY ADDS: A community-based intervention project for obesity prevention in a rural town appears to have increasing effects 3 years after the end of the project, substantially reducing overweight and obesity by 6% points in new cohorts of children, 6 years after the original baseline. An apparent and unanticipated 'spillover' of effects into the surrounding region appeared to have occurred with 10%-point reductions in childhood overweight and obesity over the same time period. A 'viral-like' spread of obesity prevention efforts may be becoming possible and an increase in endogenous community activities appears to be surprisingly successful in reducing childhood obesity prevalence. BACKGROUND: The long-term evaluations of community-based childhood obesity prevention interventions are needed to determine their sustainability and scalability. OBJECTIVES: To measure the impacts of the successful Be Active Eat Well (BAEW) programme in Victoria, Australia (2003-2006), 3 years after the programme finished (2009). METHODS: A serial cross-sectional study of children in six intervention and 10 comparison primary schools in 2003 (n = 1674, response rate 47%) and 2009 (n = 1281, response rate 37%). Height, weight, lunch box audits, self-reported behaviours and economic investment in obesity prevention were measured. RESULTS: Compared with 2003, the 2009 prevalence of overweight/obesity (World Health Organization criteria) was significantly lower (P < 0.001) in both intervention (39.2% vs. 32.8%) and comparison (39.6% vs. 29.1%) areas, as was the mean standardized body mass index (0.79 vs. 0.65, 0.77 vs. 0.57, respectively) with no significant differences between areas. Some behaviours improved and a few deteriorated with any group differences favouring the comparison area. In 2009, the investment in obesity prevention in intervention schools was about 30 000 Australian dollars (AUD) per school per year, less than half the amount during BAEW. By contrast, the comparison schools increased from a very low base to over 66 000 AUD per school per year in 2009. CONCLUSIONS: The 8%-point reduction in overweight/obesity in both areas over 6 years from baseline to 3 years post-intervention was substantial. While the benefits of BAEW increased in the intervention community in the long term, the surrounding communities appeared to have more than caught up in programme investments and health gains, suggesting a possible 'viral spread' of obesity prevention actions across the wider region.

Inconsistent associations between sweet drink intake and 2-year change in BMI among Victorian children and adolescents.

OBJECTIVE: The aim of this study was to examine whether baseline (T1) or 2-year change in sweet drink intake in children and adolescents was associated with age- and gender-standardized body mass index (BMIz) at time two (T2), 2 years later. METHODS: Data on 1465 children and adolescents from the comparison groups of two quasi-experimental intervention studies from Victoria, Australia were analysed. At two time points between 2003 and 2008 (mean interval: 2.2 years) height and weight were measured and sweet drink consumption (soft drink and fruit juice/cordial) was assessed. RESULTS: No association was observed between T1 sweet drink intake and BMIz at T2 among children or adolescents. Children from higher socioeconomic status families who reported an increased intake of sweet drinks at T2 compared with T1 had higher mean BMIz at T2 (ß: 0.13, P = 0.05). There was no evidence of a dose-response relationship between sweet drink intake and BMIz. In supplementary analyses, we observed that more frequent usual consumption of fruit juice/cordial was associated with a higher BMIz at T2 among children. CONCLUSION: This study showed limited evidence of an association between sweet drink intake and BMIz. However, the association is complex and may be confounded by both dietary and activity behaviours.

The appropriateness of opt-out consent for monitoring childhood obesity in Australia.

Childhood obesity monitoring is a fundamental component of obesity prevention but is poorly done in Australia. Monitoring obesity prevalence in children provides important population health data that can be used to track trends over time, identify areas at greatest risk of obesity, determine the effectiveness of interventions and policies, raise awareness and stimulate action. High participation rates are essential for effective monitoring because these provide more representative data. Passive ('opt-out') consent has been shown to provide high participation rates in international childhood obesity monitoring programs and in a recent Australian federal initiative monitoring early child development. A federal initiative structured like existing child development monitoring programs, but with the authority to collect height and weight measurements using opt-out consent, is recommended to monitor rates of childhood obesity in Australia.

Multilevel analysis of the Be Active Eat Well intervention: environmental and behavioural influences on reductions in child obesity risk.

BACKGROUND: The Be Active Eat Well (BAEW) community-based child obesity prevention intervention was successful in modestly reducing unhealthy weight gain in primary school children using a multi-strategy and multi-setting approach. OBJECTIVE: To (1) examine the relationship between changes in obesity-related individual, household and school factors and changes in standardised child body mass index (zBMI), and (2) determine if the BAEW intervention moderated these effects. METHODS: The longitudinal relationships between changes in individual, household and school variables and changes in zBMI were explored using multilevel modelling, with measurement time (baseline and follow-up) at level 1, individual (behaviours, n = 1812) at level 2 and households (n = 1318) and schools (n = 18) as higher levels (environments). The effect of the intervention was tested while controlling for child age, gender and maternal education level. RESULTS: This study confirmed that the BAEW intervention lowered child zBMI compared with the comparison group (-0.085 units, P = 0.03). The variation between household environments was found to be a large contributor to the percentage of unexplained change in child zBMI (59%), compared with contributions from the individual (23%) and school levels (1%). Across both groups, screen time (P = 0.03), sweet drink consumption (P = 0.03) and lack of household rules for television (TV) viewing (P = 0.05) were associated with increased zBMI, whereas there was a non-significant association with the frequency the TV was on during evening meals (P = 0.07). The moderating effect of the intervention was only evident for the relationship between the frequency of TV on during meals and zBMI, however, this effect was modest (P = 0.04). CONCLUSIONS: The development of childhood obesity involves multi-factorial and multi-level influences, some of which are amenable to change. Obesity prevention strategies should not only target individual behaviours but also the household environment and family practices. Although zBMI changes were modest, these findings are encouraging as small reductions can have population level impacts on childhood obesity levels.

Reduction in overweight and obesity from a 3-year community-based intervention in Australia: the 'It's Your Move!' project.

'It's Your Move!' was a 3-year intervention study implemented in secondary schools in Australia as part of the Pacific Obesity Prevention In Communities Project. This paper reports the outcome results of anthropometric indices and relevant obesity-related behaviours. The interventions focused on building the capacity of families, schools and communities to promote healthy eating and physical activity. Baseline response rates and follow-up rates were 53% and 69% respectively for the intervention group (n=5 schools) and 47% and 66% respectively for the comparison group (n=7 schools). Statistically significant relative reductions in the intervention versus comparison group were observed: weight (-0.74 kg, P < 0.04), and standardized body mass index (-0.07, P<0.03), and non-significant reductions in prevalence of overweight and obesity (0.75 odds ratio, P=0.12) and body mass index (-0.22, P=0.06). Obesity-related behavioural variables showed mixed results with no pattern of positive intervention outcomes. In conclusion, this is the first study to show that long-term, community-based interventions using a capacity-building approach can prevent unhealthy weight gain in adolescents. Obesity prevention efforts in this important transitional stage of life can be successful and these findings need to be translated to scale for a national effort to reverse the epidemic in children and adolescents.

Obesity prevention in the family day care setting: impact of the Romp & Chomp intervention on opportunities for children's physical activity and healthy eating.

BACKGROUND: The Romp & Chomp intervention reduced the prevalence of overweight/obesity in pre-school children in Geelong, Victoria, Australia through an intervention promoting healthy eating and active play in early childhood settings. This study aims to determine if the intervention successfully created more health promoting family day care (FDC) environments. METHODS: The evaluation had a cross-sectional, quasi-experimental design with the intervention FDC service in Geelong and a comparison sample from 17 FDC services across Victoria. A 45-item questionnaire capturing nutrition- and physical activity-related aspects of the policy, socio-cultural and physical environments of the FDC service was completed by FDC care providers (in 2008) in the intervention (n= 28) and comparison (n= 223) samples. RESULTS: Select results showed intervention children spent less time in screen-based activities (P= 0.03), organized active play (P < 0.001) and free inside play (P= 0.03) than comparison children. There were more rules related to healthy eating (P < 0.001), more care provider practices that supported children's positive meal experiences (P < 0.001), fewer unhealthy food items allowed (P= 0.05), higher odds of staff being trained in nutrition (P= 0.04) and physical activity (P < 0.001), lower odds of having set minimum times for outside (P < 0.001) and organized (P= 0.01) active play, and of rewarding children with food (P < 0.001). CONCLUSIONS: Romp & Chomp improved the FDC service to one that discourages sedentary behaviours and promotes opportunities for children to eat nutritious foods. Ongoing investment to increase children's physical activity within the setting and improving the capacity and health literacy of care providers is required to extend and sustain the improvements.