Prevention of obesity :exploring strategies for intervention in preschool

PhD ThesisThe proportion of overweight and obese children in England has increased considerably since 1995. One in five children starting reception class is now overweight or obese. Proposed reasons for this are numerous and indeterminate. They include infant feeding methods, genetics, change in eating habits and patterns, and increased sedentary behaviours. The preschool years are considered to be an optimal time to intervene in an attempt to reverse this trend. However, interventions to prevent or treat overweight in preschool-age children in the UK are scarce, with most research being conducted in the US and Australia. Previous research has demonstrated some positive results in changing some health behaviours, however, positive trends in overall obesity rates are lacking. Further research to determine which prevention strategies and methods are acceptable and operational in a ‘real world’ setting is required. Ninety-eight per cent of UK preschool-aged children now attend some form of childcare. Preschool settings may provide valuable opportunities to access children and their families not only for promoting healthy lifestyles, but also to develop and evaluate behaviour-change interventions. This thesis presents a feasibility study of a behaviour-change nursery practitioner-led intervention conducted in four preschool centres in the North East of England. The study is underpinned by the MRC Framework: Developing and Evaluating Complex Interventions. The research was conducted in four phases: a preliminary qualitative study with parents of preschool children and nursery practitioners; development of a behavioural-change intervention; implementation of the intervention; and intervention evaluation. Qualitative data revealed underlying complex communication issues between practitioners and parents regarding food provision, and roles and responsibilities. Preschool centres appeared to have difficulties with enforcing school health policies. ‘Gatekeeper’ permission and lower-hierarchal compliance were on-going problems throughout the study. The majority of nursery practitioners and parents stated ‘liking’ and ‘finding’ the intervention methods and activities acceptable and positive changes in family health behaviours were reported. This study shows that a preschool centre behaviour-change intervention is feasible, however, as demonstrated, further work with nursery practitioners is required to determine how personal attitudes and school policy application can be enhanced to progress such an intervention. iii Feasibility studies of this type are important to inform further obesity prevention strategies research. The findings from this study are likely to have policy relevance and contribute to the body of literature

A feasibility study with process evaluation of a preschool intervention to improve child and family lifestyle behaviours

Background - Around a fifth of children starting school in England are now overweight/obese. There is a paucity of interventions with the aim of obesity prevention in preschool-age children in the UK. Previous research has demonstrated some positive results in changing specific health behaviours, however, positive trends in overall obesity rates are lacking. Preschool settings may provide valuable opportunities to access children and their families not only for promoting healthy lifestyles, but also to develop and evaluate behaviour-change interventions. Methods - This paper presents a cluster randomised feasibility study of a theory based behaviour-change preschool practitioner-led intervention tested in four preschool centres in the North East of England. The primary outcome measures were to test the acceptability and feasibility of the data collection measures and intervention. Secondary measures were collected and reported for extra information. At baseline and post intervention, children’s anthropometric, dietary and physical activity measures as well as family ‘active’ time data were collected. The preschool practitioner-led intervention included family intervention tasks such as ‘family goal-setting activities’ and ‘cooking challenges’. Preschool activities included increasing physical activity and providing activities with the potential to change behaviour with increased knowledge of and acceptance of healthy eating. The process evaluation was an on-going monthly process and was collected in multiple forms such as questionnaires, photographs and verbal feedback. Results - ‘Gatekeeper’ permission and lower-hierarchal adherence were initially a problem for recruitment and methods acceptance. However, at intervention end the preschool teachers and parents stated they found most intervention methods and activities acceptable, and some positive changes in family health behaviours were reported. However, the preschool centres appeared to have difficulties with enforcing everyday school healthy eating policies. Conclusions - The findings from the current study may have implications for nursery practitioners, nursery settings, Local Educational Authorities and policy makers, and contributes to the body of literature. However, further work with preschool practitioners is required to determine how personal attitudes and school policy application can be supported to implement successfully such an intervention

Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA) : a multicentre, open-label, randomised controlled trial

This study was funded by the NIHR Health Technology Assessment programme (12/146/06).Background Tonsillectomy is regularly performed in adults with acute tonsillitis, but with scarce evidence. A reduction in tonsillectomies has coincided with an increase in acute adult hospitalisation for tonsillitis complications. We aimed to assess the clinical effectiveness and cost-effectiveness of conservative management versus tonsillectomy in patients with recurrent acute tonsillitis. Methods This pragmatic multicentre, open-label, randomised controlled trial was conducted in 27 hospitals in the UK. Participants were adults aged 16 years or older who were newly referred to secondary care otolaryngology clinics with recurrent acute tonsillitis. Patients were randomly assigned (1:1) to receive tonsillectomy or conservative management using random permuted blocks of variable length. Stratification by recruiting centre and baseline symptom severity was assessed using the Tonsil Outcome Inventory-14 score (categories defined as mild 0–35, moderate 36–48, or severe 49–70). Participants in the tonsillectomy group received elective surgery to dissect the palatine tonsils within 8 weeks after random assignment and those in the conservative management group received standard non-surgical care during 24 months. The primary outcome was the number of sore throat days collected during 24 months after random assignment, reported once per week with a text message. The primary analysis was done in the intention-to-treat (ITT) population. This study is registered with the ISRCTN registry, 55284102. Findings Between May 11, 2015, and April 30, 2018, 4165 participants with recurrent acute tonsillitis were assessed for eligibility and 3712 were excluded. 453 eligible participants were randomly assigned (233 in the immediate tonsillectomy group vs 220 in the conservative management group). 429 (95%) patients were included in the primary ITT analysis (224 vs 205). The median age of participants was 23 years (IQR 19–30), with 355 (78%) females and 97 (21%) males. Most participants were White (407 [90%]). Participants in the immediate tonsillectomy group had fewer days of sore throat during 24 months than those in the conservative management group (median 23 days [IQR 11–46] vs 30 days [14–65]). After adjustment for site and baseline severity, the incident rate ratio of total sore throat days in the immediate tonsillectomy group (n=224) compared with the conservative management group (n=205) was 0·53 (95% CI 0·43 to 0·65;Publisher PDFPeer reviewe

Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat:the NATTINA RCT and economic evaluation

BACKGROUND: The place of tonsillectomy in the management of sore throat in adults remains uncertain.OBJECTIVES: To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways.DESIGN: This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation.SETTING: The study took place at 27 NHS secondary care hospitals in Great Britain.PARTICIPANTS: A total of 453 eligible participants with recurrent sore throats were recruited to the main trial.INTERVENTIONS: Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity.MAIN OUTCOME MEASURES: The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms.RESULTS: There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it.LIMITATIONS: The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial.CONCLUSIONS: The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective.TRIAL REGISTRATION: This trial is registered as ISRCTN55284102.FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information. </p

Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trial.

BACKGROUND Tonsillectomy is regularly performed in adults with acute tonsillitis, but with scarce evidence. A reduction in tonsillectomies has coincided with an increase in acute adult hospitalisation for tonsillitis complications. We aimed to assess the clinical effectiveness and cost-effectiveness of conservative management versus tonsillectomy in patients with recurrent acute tonsillitis. METHODS This pragmatic multicentre, open-label, randomised controlled trial was conducted in 27 hospitals in the UK. Participants were adults aged 16 years or older who were newly referred to secondary care otolaryngology clinics with recurrent acute tonsillitis. Patients were randomly assigned (1:1) to receive tonsillectomy or conservative management using random permuted blocks of variable length. Stratification by recruiting centre and baseline symptom severity was assessed using the Tonsil Outcome Inventory-14 score (categories defined as mild 0-35, moderate 36-48, or severe 49-70). Participants in the tonsillectomy group received elective surgery to dissect the palatine tonsils within 8 weeks after random assignment and those in the conservative management group received standard non-surgical care during 24 months. The primary outcome was the number of sore throat days collected during 24 months after random assignment, reported once per week with a text message. The primary analysis was done in the intention-to-treat (ITT) population. This study is registered with the ISRCTN registry, 55284102. FINDINGS Between May 11, 2015, and April 30, 2018, 4165 participants with recurrent acute tonsillitis were assessed for eligibility and 3712 were excluded. 453 eligible participants were randomly assigned (233 in the immediate tonsillectomy group vs 220 in the conservative management group). 429 (95%) patients were included in the primary ITT analysis (224 vs 205). The median age of participants was 23 years (IQR 19-30), with 355 (78%) females and 97 (21%) males. Most participants were White (407 [90%]). Participants in the immediate tonsillectomy group had fewer days of sore throat during 24 months than those in the conservative management group (median 23 days [IQR 11-46] vs 30 days [14-65]). After adjustment for site and baseline severity, the incident rate ratio of total sore throat days in the immediate tonsillectomy group (n=224) compared with the conservative management group (n=205) was 0·53 (95% CI 0·43 to 0·65; <0·0001). 191 adverse events in 90 (39%) of 231 participants were deemed related to tonsillectomy. The most common adverse event was bleeding (54 events in 44 [19%] participants). No deaths occurred during the study. INTERPRETATION Compared with conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis. FUNDING National Institute for Health Research

Is Scottish Intercollegiate Guidelines Network guidance for GP management of tonsillitis suitable? A qualitative study

Background - The Scottish Intercollegiate Guidelines Network developed guidelines for the management of sore throat and indications for tonsillectomy in 1999 to address concerns of unnecessary surgery. Emergency admissions to hospital for tonsillitis have since increased. Adults experience an average of 27 episodes of tonsillitis before undergoing tonsillectomy. We wished to explore the appropriateness of the guidance and/or its implementation in primary care Aim - To explore the attitudes of GPs to the referral criteria they use when managing adults presenting with acute tonsillitis. Design - Secondary analysis of qualitative data from the NAtional Trial of Tonsillectomy in Adults (NATTINA) feasibility and process evaluation. Participants and setting - Twenty-one GPs from practices throughout the UK. Method - In-depth interviews GPs concerning both the feasibility and process evaluation phases of NATTINA. Analysis was conducted using the Framework method. Results - General practitioners felt it was rarely necessary to refer patients. They were aware of guidelines and would refer if requested by a patient who fulfilled the guidelines criteria and/or who were missing considerable amounts of work. Conclusion - The introduction of the guidelines appears to coincide with what some may have hoped to be a desired effect of reducing adult sore throat referrals and subsequent tonsillectomies by increasing the number of episodes a patient must suffer before the referral threshold is met. GPs may find equipoise for tonsillectomy referral challenging as many patients, express a strong preference for surgery. We believe this paper reinforces GP professionalism, patient-centred consultations and challenges the role of clinical guidelines

Parental Perceptions of Onsite Hospital Food Outlets in a Large Hospital in the North East of England: A Qualitative Interview Study Protocol

The need to address the increasing obesity rates of children living in the United Kingdom has become a Government priority. It has been recognized that a public health level approach as opposed to an individual approach is potentially one way forward. The wider food environment should be designed so that the 'healthier choice' is the easiest choice; this includes public sector settings such as hospitals. Due to Private Finance Initiative deals many hospitals do not own their premises and therefore do not have control over the types of shops and outlets permitted to operate on site. Many of these outlets sell and promote food and drinks high in sugar, fat and salt undermining health messages developed by the UK National Health Service. Financial incentives have been provided to encourage hospitals to promote healthier food choices; however few outlets have complied with all the set targets. The aim of this qualitative interview study is to determine the dietary perceptions and needs of parents whose children attend a large children's hospital in the North East of England. A purposive sample of parents whose children attend the hospital as an in- or out-patient will be invited to participate in a one-to-one in-depth interview to share their views of the wider hospital food environment. Interviews will be conducted until data saturation is reached and Framework Analysis will be adopted for interview analysis. These findings will inform a larger study to pilot-test an intervention to facilitate healthier food choice in hospital settings

Parental perceptions of onsite hospital food outlets in a large hospital in the North East of England: A qualitative interview study

Background - Addressing the increasing obesity rates in children living in the United Kingdom has become a priority. A public health level approach as opposed to an individual approach is potentially one way forward. The wider food environment should be designed so that the ‘healthier choice’ is the easiest choice; this includes public sector settings such as hospitals. Many hospital outlets sell and promote food and drinks high in sugar, fat and salt undermining health messages developed by the UK National Health Service. Financial incentives have been provided to encourage hospitals to promote healthier food choices; however, few outlets have complied with the targets. The aim of this qualitative interview study was to determine the dietary perceptions and needs of parents whose children attend a large children’s hospital in the North East of England and to identify potential barriers and facilitators to eating healthily in a hospital setting. Methods - Eighteen parents whose children attended the hospital as an in- or out-patient were recruited through either ward research nurses, information posters or a parent hospital Facebook page to participate in a one-to-one in-depth interview. Results - Parents reported a lack of affordable healthy options for sale both for themselves and visiting children. Although parents wanted to see more healthy options available for sale they did not feel it was appropriate to ban or restrict sales of any food types. Parents of frequent or long-term in-patients found it difficult to adequately feed themselves. Conclusions - The ways in which visitors and staff can be encouraged to choose the healthier option in an NHS hospital setting warrants further investigation. The use of ‘nudge theory’, which has gained particular momentum in areas such as health promotion, may be a tool which can be utilised by hospitals to facilitate the promotion of healthy eating

Availability of Healthy Food and Beverages in Hospital Outlets and Interventions in the UK and USA to Improve the Hospital Food Environment: A Systematic Narrative Literature Review

The aims of this systematic review are to determine the availability of healthy food and beverages in hospitals and identify interventions that positively influence the hospital food environment, thereby improving the dietary intake of employees and visitors. Embase, Medline, APA PsycInfo, Scopus, Google Scholar and Google were used to identify publications. Publications relating to the wider hospital food environment in the UK and USA were considered eligible, while those regarding food available to in-patients were excluded. Eligible publications (n = 40) were explored using a narrative synthesis. Risk of bias and research quality were assessed using the Quality Criteria Checklist for Primary Research. Although limited by the heterogeneity of study designs, this review concludes that the overall quality of hospital food environments varies. Educational, labelling, financial and choice architecture interventions were shown to improve the hospital food environment and/or dietary intake of consumers. Implementing pre-existing initiatives improved food environments, but multi-component interventions had some undesirable effects, such as reduced fruit and vegetable intake

The ‘Voice’ of Key Stakeholders in a School Food and Drink Intervention in Two Secondary Schools in NE England: Findings from a Feasibility Study

Background: Overweight/obesity affects one-third of UK 11&ndash;15-year olds. Individually focussed interventions alone have limited effectiveness. Food choice architecture approaches increase the visibility and convenience of foods to facilitate the choice of &lsquo;healthier&rsquo; foods and reduce &lsquo;unhealthy&rsquo; foods. This qualitative component of a School Food Architecture (SFA) study aimed to determine the perceptions of pupils and staff in relation to school food provision and their perceptions of the intervention. Methods: Pupil focus groups and staff one-to-one interviews. Topic guides were developed from literature and in consultation with a Young Person&rsquo;s Advisory Group. Thematic analysis was applied. Results: Focus group (n = 4) themes included: dining hall practices, determinants of choice, and aspects of health. Interview themes (n = 8) included: catering practices, health awareness, education, and knowledge of intervention. Pupils liked to purchase hand-held, quick to purchase foods potentially limiting the access to fruits and vegetables. Pupils were aware of &lsquo;healthier&rsquo; food choices but would choose other options if available. Conclusions: Schools provide a daily school meal for large numbers of pupils, with time and dining environment constraints. Pupils consume 35&ndash;40% of their daily energy intake at school, therefore interventions enabling healthier eating in school are essential, including making healthier choices readily available and accessible