Bridging the gap: SHINE – a Tier 3 service for severely obese children and young people

In March 2014, the consultation document Joined up Clinical Pathways for Obesity was published, exploring options for the future commissioning responsibilities of Tier 3 and 4 weight management services. What became apparent was the lack of reference to childhood weight management services (more so at Tier 3), which mirrors the scarcity of evidence-based research in this area. This article asks a number of key questions: who should provide Tier 3 services for children and young people (CYP), what does such a service look like and who should fund these services for CYP? Greater commitment is needed from the Department of Health to provide clarity for Tier 3 service providers. SHINE (Self-Help, Independence, Nutrition and Exercise), an established Tier 3 service for CYP with severe obesity, is an example of what a Tier 3 programme can look like. Finally, it is proposed that funding is better distributed across the Obesity Care Pathway to ensure that CYP with severe obesity can access appropriate treatment

A Qualitative Exploration of Key Stakeholders Views towards Designing Health Promotion Interventions for Looked After Children

Introduction: Looked After Children (LAC) are some of the most vulnerable and socially excluded in society (Golding, 2008). Hearty Lives (HL) is £1.2 million British Heart Foundation project designed to reduce health inequalities by supporting those at greatest risk of cardiovascular disease. Two of the six sites focussed on addressing inequalities specifically in children in the social care context. Objectives: The research aimed to gather stakeholders’ views in the design, development and refinement of the HL, health promotion intervention (HP based interventions) to ensure they were acceptable and feasible for LAC and/or carers. Method: 14 qualitative semi-structured interviews were conducted with stakeholders. Interviews explored views towards the HL intervention and what they felt were the key factors to consider in designing HP interventions in the social care context. Results: Stakeholder views revealed two approaches to working with LAC. One approach was to develop an in-house intervention that targeted LAC and care home workers in a safe, familiar environment. Stakeholders believed the key to this approach was taking time to build trust and rapport with the children which increased the likelihood of children engaging and adhering to the HP intervention. Stakeholders suggested a second, more cost and time effective, approach was to target LAC carers and home workers directly. The carers could then filter and transfer the healthy lifestyle/educational messages to LAC. This removed barriers to accessing LAC. Conclusions: Stakeholders views suggest that both in-house interventions and interventions targeted at LAC workers are acceptable and feasible approaches to working with LAC. Their views suggest that targeting LAC workers could be a more sustainable method of delivering HP interventions. Further research is needed to establish the effectiveness of different approaches to engaging LAC in health promotion

Addressing Health Disparities: Action Research in the Design and Development of Health Promotion Programmes for Young People

Introduction: Hearty Lives (HL) is a £1.2 million programme established by the British Heart Foundation which aims to reduce health inequalities, particularly by supporting those ‘at greatest risk’ of Cardiovascular Disease (CVD). Six programmes have been set up (Adur, Glasgow, Liverpool, Manchester, Renfrewshire & Wolverhampton) to reduce the incidence of CVD risk factors in children and young people (aged 11-18 years old). Leeds Beckett University (LBU) is conducting the national three-year evaluation of the HL programmes. Objectives: The national evaluation aims to extract key learnings and provide recommendations for working with vulnerable populations (at greater risk of CVD). This is done through an action research methodology. Methods: Within this action research approach, a case study methodology has been used to recognise the uniqueness of each HL project. Impact and process outcomes are being collected to assess HL intervention effectiveness and to establish what processes led to the success or shortcomings of each approach. Key stakeholders views towards HL interventions were captured. Results: The evidence produced from the first year fed into the refinement and development of each of the six HL interventions in the second year. The 6 HL interventions have considered stakeholders views in order to develop tailored and flexible HP interventions. This is considered key when addressing health disparities (Jacobs et al., 2012). All HL interventions recognise the importance of planning for sustainability and putting strategies in place to ensure that they can be continued beyond the three year funding. Developing links with partners, delivering training to multiple stakeholders and accessing other sources of funding are key to consider in the sustainability of such HP interventions. Conclusion: This research highlights the benefits of a collaborative action research approach. It identifies the value of evaluation teams working alongside stakeholders to refine and develop feasible, acceptable and efficacious HP interventions

Psychosocial Interventions in the Management of Severe Adolescent Obesity

Purpose: Psychosocial Interventions (PSI) are commonly utilised in mental health management, and to our knowledge, have not been explicitly used in weight management. PSI are characterised by three distinct phases: 1) an initial in-depth assessment; 2) an intensive group intervention to stabilise the condition (in this instance weight gain); and 3) an intensive group maintenance programme. PSI focus on the psychosocial elements of obesity, including: stress management, body dysmorphia and self-esteem. As such, the PSI approach is more holistic than traditional weight management approaches. This paper evaluated the outcomes of a PSI when delivered under service level conditions. Methods: SHINE (Self-Help, Independence, Nutrition, and Exercise) is a community-based weight management programme that implements a PSI approach. The programme is located in Sheffield, UK. Adolescents (n = 393) with severe obesity signed onto the programme between 2011 and 2013. The programme spans 12-15 months and participants attend three phases of the PSI. Phase One is undertaken before the programme, Phase Two is a 12-week intervention and Phase Three is split into three 12-week maintenance interventions. Anthropometric measurements (BMI and WC) were collected at baseline, 3-, 6-, 9- and 12-months. Psychosocial measures (self-esteem, anxiety and depression) were collected at baseline and 3-months. Participant retention was also assessed. Results: 304 participants started the programme and 289 were retained at 3 months. At 3 months BMI z-score reduced by 0.21 (95% CI: 0.19, 0.24) and WC by 7.8cm (95% CI: 7.2, 8.5). Almost 25% of participants reduced their BMI classification (e.g. severely obese to obese). Anxiety and self-esteem improved by 63% and 50% respectively. 89 participants continued to attend the programme after 12 months, obtaining a BMI z-score reduction of 0.46 (95% CI: 0.35, 0.58) and a WC reduction of 10.5cm (95% CI: 7.8, 13.1). Conclusions: Obesity is a highly complex condition to manage and requires intensive and prolonged support to produce meaningful and lasting behavioural and anthropometric changes. The SHINE PSI approach has shown promise and demonstrated encouraging results - suggesting that it may be beneficial for interventions to consider wider determinants of health and wellbeing beyond simply diet and physical activity

Engaging Families in Weight Management

Purpose: Approximately 50% of families who initiate a weight management programme (WMP) will not complete. It is fundamental to understand why participants initiate and complete a programme, and to ensure that programmes are effectively designed and delivered. This study examined the reasoning for family (young person and parent) engagement in three different and diverse WMPs. Methods: A multiple instrumental case study approach was employed. Three community-based WMPs participated: MoreLife, SHINE, and Weigh to Go. Clear design and implementation differences existed between WMPs. Multiple WMPs were recruited to examine the generalisability of research findings, and extract key features associated with participant engagement. Thirty families took part (~10 per programme). Data were collected early in the programme (0-2 weeks) and immediately after completion or dropout (within two weeks). Young people took part in a Participatory Action Research (PAR) session (interactive activities to generate meaningful information), and parents completed semi-structured interviews. A deductive line of inquiry was used; questions were based upon participant characteristics, environmental interactions, psychological processes and programme interactions. Interview data was transcribed verbatim and analysed alongside the PAR data using content and thematic analysis (themes presented in italics). Results: Preliminary findings indicate that families often engage in a WMP for non-weight related reasons. Such reasons include: management of mental health, to improve self -esteem, and to create friendships. Families remain in a WMP when: the programme suits their needs, they fit in amongst other participants, strong relationships are fostered with staff, and have strong support networks. Numerous families completing programmes prioritised WMP attendance above other leisure activities, and had plans in place to ensure they could attend each session. Low engagement was due to situational factors (e.g. logistic barriers [transport, timing…]) rather than programme dissatisfaction. Conclusions: Families attend community-based WMPs for reasons beyond weight management. Additionally, the families identified unique WMP features (e.g. maintenance programmes and non-clinical staff) which encourage programme attendance. Such features can be replicated in multiple, diverse settings. Understanding participant engagement is critical to designing and implementing efficacious WMPs

The Engagement Pathway: A Conceptual Framework of Engagement-Related Terms in Weight Management

Engagement denotes the extent to which, and how, individuals participate in weight management (WM) services. Effective WM services should generate meaningful outcomes and promote high participant engagement; however, research is predominantly focused on the former. Given that engagement is a poorly understood phenomenon, and that engagement-related concepts are often used synonymously (e.g., dropout and attrition), the engagement pathway is hereby introduced. This pathway defines key concepts (e.g., recruitment, adherence, attrition) and their relationships in the enrolment, intervention, and maintenance stages of treatment. The pathway will help researchers and practitioners better understand engagement-related concepts whilst encouraging greater conceptual consistency between studies

Action Research in the Design, Development and Delivery of a Sustainable, School-based, Health Promotion Intervention for Children and Young People

Introduction: Interventions are often developed without the guidance of the target group to be worked with. Action research (programme development with the input of researchers and clients) has been highlighted as a useful method for increasing programme engagement and achieving programme outcomes [1]. Hearty Lives Renfrewshire (HLR), is a British Heart Foundation a community-based intervention aiming to increase knowledge and awareness of CVD risk factors in young people, adopted an action research methodology. HLR delivers a school-based intervention to young people aged 13-16; this intervention was developed by the young people, with elements of the intervention delivered by the young people. Objectives: To evaluate the use of an action research approach to designing, developing and delivering HLR. Method: Semi-structured interviews with stakeholders (n = 5, 22-56 minutes), and focus groups interviews with participants [attending the HLR intervention] (n = 9, 15 minutes). Interviews were recorded and transcribed verbatim. Thematic analysis was used to analyse the data. Results: Students suggested they felt empowered when consulted with about improving and refining the programme. The HLR delivery team were responsive to participant ideas and facilitated the implementation of ideas. Intervention content was also refined to become more engaging – this was a product of participant feedback. To increase programme reach, a Parkour (acrobatic free running) club was set up which had health messages embedded in its design. All participants cited an improved knowledge, yet behaviour change was less apparent. Conclusion: HLR successfully engaged with participants in all stages of the intervention. Moreover, the programme expanded using alternate modes of delivery (e.g. Parkour) to engage a traditionally hard-to-engage demographic. Action Research should be considered when designing, developing and refining an intervention rather than a traditional problem-solution orientated approach

Do parent and child outcome expectations align when attending a weight management programme?

Background: Childhood weight management programmes (WMP) are used within the UK to stem the rising prevalence of pediatric obesity. These WMPs often provide children and young people (CYP) and their family’s with methods of stabilising and reducing the severity of the weight issue. That said, low engagement in WMPs is often encountered but the reasoning is not well known. Misaligned and unrealistic outcome expectations have been hypothesised as a reason for low engagement. This paper explores 1) the parent and CYP outcome expectations of a WMP, and 2) the qualitative level of agreement between parent and CYP expectations. Methods: 30 families were recruited from three, UK-based WMPs (10 families per programme). Qualitative research methods were used to examine both the parent and CYP outcome expectations. Participatory research methods were used with CYP and semi-structured interviews with parents. Data were collected from parents and CYP independently, and notably, were collected from participants within two weeks of starting a WMP. Data were analysed using thematic analysis. In separate analyses, the alignment between parent and CYP responses were examined. Results: Preliminary findings indicate that parents reported 24 different outcome expectations (varying from ‘anger management’ to ‘weight management [not loss]’ to ‘understanding consequences of obesity’), whilst CYP reported 25 expectations (ranging from ‘aesthetic improvement’ to ‘physical activity opportunities’ to ‘not wanting to attend’). Weight loss was the most cited outcome expectation amongst parents and CYP, however friendship, CYP confidence, dietary education, and the reinforcement of parent messages were also strongly cited. Of note, weight loss was not always cited as the primary outcome expectation. The qualitative level of agreement between CYP and parents shall be reported. Conclusions: Families do not always initiate a WMP for the sole purpose of weight loss and management. Practitioners would benefit from understanding what families hope to achieve during their attendance, and subsequently tailor the programme, comments and feedback to reflect this. By tailoring messages and feedback directly to the family expectations, families may see a greater benefit in WMP attendance and therefore be encouraged to persist in treatment. Attendance and weight-related outcomes are strongly correlated

The Glycosyltransferase Repertoire of the Spikemoss Selaginella moellendorffii and a Comparative Study of Its Cell Wall

Spike mosses are among the most basal vascular plants, and one species, Selaginella moellendorffii, was recently selected for full genome sequencing by the Joint Genome Institute (JGI). Glycosyltransferases (GTs) are involved in many aspects of a plant life, including cell wall biosynthesis, protein glycosylation, primary and secondary metabolism. Here, we present a comparative study of the S. moellendorffii genome across 92 GT families and an additional family (DUF266) likely to include GTs. The study encompasses the moss Physcomitrella patens, a non-vascular land plant, while rice and Arabidopsis represent commelinid and non-commelinid seed plants. Analysis of the subset of GT-families particularly relevant to cell wall polysaccharide biosynthesis was complemented by a detailed analysis of S. moellendorffii cell walls. The S. moellendorffii cell wall contains many of the same components as seed plant cell walls, but appears to differ somewhat in its detailed architecture. The S. moellendorffii genome encodes fewer GTs (287 GTs including DUF266s) than the reference genomes. In a few families, notably GT51 and GT78, S. moellendorffii GTs have no higher plant orthologs, but in most families S. moellendorffii GTs have clear orthologies with Arabidopsis and rice. A gene naming convention of GTs is proposed which takes orthologies and GT-family membership into account. The evolutionary significance of apparently modern and ancient traits in S. moellendorffii is discussed, as is its use as a reference organism for functional annotation of GTs