Shared care obesity management in 3-10 year old children: 12 month outcomes of HopSCOTCH randomised trial

Objective: To determine whether general practice surveillance for childhood obesity, followed by obesity management across primary and tertiary care settings using a shared care model, improves body mass index and related outcomes in obese children aged 3-10 years. Design: Randomised controlled trial. Setting: 22 family practices (35 participating general practitioners) and a tertiary weight management service (three paediatricians, two dietitians) in Melbourne, Australia. Participants: Children aged 3-10 years with body mass index above the 95th centile recruited through their general practice between July 2009 and April 2010. Intervention: Children were randomly allocated to one tertiary appointment followed by up to 11 general practice consultations over one year, supported by shared care, web based software (intervention) or “usual care” (control). Researchers collecting outcome measurements, but not participants, were blinded to group assignment. Main outcome measures: Children’s body mass index z score (primary outcome), body fat percentage, waist circumference, physical activity, quality of diet, health related quality of life, self esteem, and body dissatisfaction and parents’ body mass index (all 15 months post-enrolment). Results: 118 (60 intervention, 56 control) children were recruited and 107 (91%) were retained and analysed (56 intervention, 51 control). All retained intervention children attended the tertiary appointment and their general practitioner for at least one (mean 3.5 (SD 2.5, range 1-11)) weight management consultation. At outcome, children in the two trial arms had similar body mass index (adjusted mean difference −0.1 (95% confidence interval −0.7 to 0.5; P=0.7)) and body mass index z score (−0.05 (−0.14 to 0.03); P=0.2). Similarly, no evidence was found of benefit or harm on any secondary outcome. Outcomes varied widely in the combined cohort (mean change in body mass index z score −0.20 (SD 0.25, range −0.97-0.47); 26% of children resolved from obese to overweight and 2% to normal weight. Conclusions: Although feasible, not harmful, and highly rated by both families and general practitioners, the shared care model of primary and tertiary care management did not lead to better body mass index or other outcomes for the intervention group compared with the control group. Improvements in body mass index in both groups highlight the value of untreated controls when determining efficacy.Melissa Wake, Kate Lycett, Susan A Clifford, Matthew A Sabin, Jane Gunn, Kay Gibbons, Cathy Hutton, Zoë McCallum, Sarah J Arnup, Gary Witter

The quality of reporting in cluster randomised crossover trials: proposal for reporting items and an assessment of reporting quality

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.SA was supported in part by a Monash University Graduate Scholarship and a National Health and Medical Research Council of Australia Centre of Research Excellence grant (1035261) to the Victorian Centre for Biostatistics (ViCBiostat). Funding was provided to KM through a National Institute for Health Research (NIHR) research methods fellowship (MET-12-16). JM was supported by a National Health and Medical Research Council (NHMRC) Australian Public Health Fellowship (1072366)

Shifting identities: social and cultural factors that shape decision making around sustaining breastfeeding

In the UK, women’s beliefs, attitudes and behaviours around breastfeeding are shaped by myriad influences and by changing social and structural factors and cultural mores. Whilst public health discourse equates breastfeeding with ‘good mothering’ and health professionals emphasise ‘breast as best’, these normative values compete with other standards or criteria of ‘good mothering’ held by others within women’s social networks that exert influence on them. Moreover, cultural and structural factors affecting the pattern of women’s labour market participation, specifically public policy emphasis on return to paid work aligned with policies directed at reconciling work and family act as constraints on sustaining optimal breastfeeding i.e. exclusive breastfeeding for six months as advised by the World Health Organisation (2003). For women in this study, initiating and sustaining breastfeeding was subject of a complex process that contributed to multiple valued outcomes: nurturing thriving and healthy babies, experiencing themselves as ‘competent’ mothers, successfully managing shifting identities and negotiating competing pressures in the real life context of their daily lives and relationships with ‘significant others’. Even as women struggled to present and see themselves as ‘good mothers’, they were active agents and not just acted upon. They sought to reconcile the value they placed on breastfeeding with seeing themselves and being seen by others as ‘good mothers’. Thus, they sought out situations where breastfeeding was highly valued (such as support groups), and developed strategies to counter or avoid threats to their sense of themselves as nurturing and competent mothers that was related to, but not synonymous with sustaining breastfeeding. Midwives and health visitors in this study encouraged women to breastfeed but not in the way that this is generally portrayed in much of the current literature. Analysis of observed interactions between women who had chosen to breastfeed and midwives and health visitors suggests more of a negotiated encounter in which these health professional considered the whole situation of the woman and her struggle to be a ‘good mother’

Exposure to adversity and inflammatory outcomes in mid and late childhood

Background: We aimed to estimate the association between exposure to adversity and inflammatory markers in mid (4 years) and late (11–12 years) childhood, and whether effects differ by type and timing of exposure. Methods: Data sources: Barwon Infant Study (BIS; N = 510 analyzed) and Longitudinal Study of Australian Children (LSAC; N = 1156 analyzed). Exposures: Adversity indicators assessed from 0 to 4 (BIS) and 0–11 years (LSAC): parent legal problems, mental illness and substance abuse, anger in parenting responses, separation/divorce, unsafe neighborhood, and family member death; a count of adversities; and, in LSAC only, early (0–3), middle (4–7), or later (10–11) initial exposure. Outcomes: Inflammation quantified by high sensitivity C-reactive protein (hsCRP, Log (ug/ml)) and glycoprotein acetyls (GlycA, Log (umol/L)). Analyses: Linear regression was used to estimate relative change in inflammatory markers, adjusted for sociodemographic characteristics, with exposure to adversity. Outcomes were log-transformed. Results: Evidence of an association between adversity and hsCRP was weak and inconsistent (e.g., 3+ versus no adversity: BIS: 12% higher, 95%CI -49.4, 147.8; LSAC 4.6% lower, 95%CI: −36.6, 48.3). A small positive association between adversity and GlycA levels was observed at both 4 years (e.g., 3+ versus no adversity: 3.3% higher, 95%CI -3.0, 9.9) and 11–12 years (3.2% higher, 95%CI 0.8, 5.8). In LSAC, we did not find evidence that inflammatory outcomes differed by initial timing of adversity exposure. Conclusions: Small positive associations between adversity and inflammation were consistently observed for GlycA, across two cohorts with differing ages. Further work is needed to understand mechanisms, clinical relevance, and to identify opportunities for early intervention