Today, 3.24 million Australians are estimated to be obese. Without effective preventative programs, particularly among young children, this figure could rise to 7.2 million by 2025. This review provides practical information on successful and/or promising interventions that strengthen the primary health care response, through the promotion of healthy weight among young children aged two to six years. It reviews the policy implications of implementing these in different settings.The research reported in this paper is a project of the Australian Primary Health Care Research Institute, which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research, Evaluation and Development Strategy

Campbell-Pope, Renee

Hearn, Lydia

Miller, Margaret

Waters, Stacey

The Australian National University

Preventing Overweight and Obesity in Young ChildrenPREVENTING OVERWEIGHT AND OBESITY IN YOUNG CHILDREN: SYNTHESISING THE EVIDENCE FOR MANAGEMENT AND POLICY MAKINGAustralian Primary Health Care Research Institute(APHCRI)- Stream Four -Preventing Overweight and Obesity in Young ChildrenRationale for Study:ß Australia has one of the highest proportions of overweight children in the developed world and this is increasing steadilyß Serious long term physical, emotional and social consequences, eg. low self-esteem, isolation, school absenteeism, & bullyingß Overweight at 6 years is a good indicator of overweight in adulthood yet few interventions focus on young childrenß Of those interventions that do focus on children, most are aimed at school aged children which does not adequately acknowledge that food preferences & lifestyles are already likely to be well established by the time they reach school agePreventing Overweight and Obesity in Young ChildrenRationale cont…ß Previous efforts have focused “what” types of interventions work best (with emphasis on single component, behavioural models based on diet and exercise), rather than on “who” are the primary care providers and “how” can they best be engaged in multi-component interventions to ensure long-term results ß Parents play a critical role in developing children’s attitudes and habits regarding food and exercise, but barriers between PHC providers and parents have discouraged programs from systematically involving parentsß Interventions that focus on shared goals between PHC and parents are needed, rather than activities that label their children as overweight    Preventing Overweight and Obesity in Young ChildrenInitial research questions:ß What are the key causal pathways for overweight and obesity in primary school children?ß What are some of the ‘mediators’ and outcomes of overweight and obesity in primary school children?ß What empirically tested interventions & strategies exist to address overweight and obesity and their mediators in both school and out of school programs?ß To what extent have these interventions & strategies engaged parents?Revised research questions:ß To what extent is overweight and obesity a problem among children aged 2-6 years in Australia?ß Who are the key ‘moderators’ in preventing/reducing overweight & obesity in children aged 2-6 years?ß What ‘successful’ or ‘promising’ interventions exist to strengthen the capacity of PHC providers to work with parents to prevent overweight & obesity among children 2-6 years?ß How applicable are these interventions to different PHC settings and what do they imply Commonwealth/state relationships, organisational linkages, costs, etc.?Research Question 1: To what extent is overweight and obesity a problem among young children (2-6 years) in Australia?ßTo what extent is it perceived as a problem by national/state governments in Australia?-How is it reflected in government policies?-How significant is it compared with other issues?-What actions have been taken to deal with the situation?-What government organisations exist to address the issue?-What barriers exist in translating policies into practice?  ßTo what extent is it a real problem among young children in Australia-Prevalence (Overall, SES, CALD)-Long term impact (physical, social, emotional, financial costs)-Changes over timeßHow and why has the problem come about and what frameworks have been used to address the problem? Preventing Overweight and Obesity in Young ChildrenPreventing Overweight and Obesity in Young ChildrenReview of literature on:ß National, state & peak body strategies, policies, action plans & guidelines on overweight and obesity in young children:- Tabled these to chronicle the historic development of international, national, state & peak body policies, action plans and guidelines - Australia was 1st country to develop national strategy – 1997- Set up national sub-committees (SIGNAL & SIGPAH) – 1998/9- Initial emphasis very much divided into nutrition/diet & physical activity, school based, not targeted- As emphasis swung to multi-causal pathways developed NOTF in 2002- Healthy Weight Australia and National Agenda of Action for Young People and their Families which emphasised healthy life styles/environmental factors- National Agenda on Early Childhood focus on children aged 0-5 yearsPreventing Overweight and Obesity in Young Childrenß How and why have these problems come about and what frameworks are being used to address them?- Despite national policies outlining the urgency of problem and emphasising the need for multi-component, population focused aimed at strengthening of the capacity of parents, teachers, child care workers, and PHC providers, emphasis is still on the individual;- Major gap in the development of interventions aimed at children aged 2-6 years;- Emphasis has been on mediating variables:Intervention Categories Selected Examples Physical activity Actual engagement in physical activities Diet Intervention focus on dietary intake Psychosocial Focus on self-esteem, body image, and peer support Health education Education on healthy eating and active living Environmental Environmental modification for greater accessibility and safe use of public transport, recreational facilities, cafeteria menus  Behaviour modification Motivational reinforcement Legislative Advertising, marketing, food pricing and labelling Promotional incentives and rewards Money, sports equipment and stickers  Preventing Overweight and Obesity in Young ChildrenBy placing emphasis on “what” to do:ß Reinforced notion of overweight as a ‘problem’ – resulting in victim blaming and apportioning of guilt/blame on children and parentsß Ignored the profound impact of micro environment – Parents/family attitudes, lifestyle, food preferenceß Failed to address balance between upstream macro level changes (legislation, environment), meso level changes (communities  & families), and micro level changes (to meet individual needs)ß Not been tailored to particular sub-groupsQUESTION: Should the emphasis be on ‘who’ are the key primary health care providers, and ‘how’ can we strengthen their capacity to work with parents and families to prevent and reduce overweight? Preventing Overweight and Obesity in Young ChildrenResearch Question 2: Who are the key ‘primary health care providers’ in preventing overweight and obesity in children aged 2-6 years?ßWhat role are they presently playing?ßWhat role should they be playing?ß To what extent are they engaging parents in the prevention of overweight and obesity of young children?ßWhat are the key ‘enablers’ and ‘barriers’ in strengthening the capacity of PHC providers to work with parents?PHC Providers- Clinical/medical providers (GP’s, practice nurses, child health nurses, paediatricians)- Allied health care providers (Multicultural and indigenous health workers, health promotion/education workers, nutritionists)→Settings-Family clinics-Schools/ Preschools-Day care centres-Out of school care centres-Communities→ Parents andFamiliesPreventing Overweight and Obesity in Young ChildrenRole of Primary Health Care Providers:Population oriented Individually orientedPolicy & AdvocacyEducation &FacilitationTreatment Preventing Overweight and Obesity in Young ChildrenUpstream DownstreamSource: Adapted from Kumanyika, 2005Preventing Overweight and Obesity in Young ChildrenBarriers to engaging parents:ß Definitions of overweight and obesityß Physical, social, emotional impact of overweight on children’s  health and well-beingß Locus of controlBarriers to engaging PHC providers:ß Prevention of weight gain not perceived as their core business and given low priorityß PHC providers under supervision of different government departments, and are funded at state levelß Child care sector is fragmented & decentralised and therefore requires different interventions, formats and approachesß Nature of general practice disparate and limited tools for reaching independent practices and to do so is labour intensiveß Lack of empirical evidence has entrenched childhood obesity to the policy level and has limited allocation of funds for interventionsResearch Question 3: What successful or ”promising” interventions exist to strengthen the capacity of PHC providers to work with parents to prevent overweight & obesity among children 2-6 years?Preventing Overweight and Obesity in Young ChildrenSTAGE 4: Analysis of findingsInclusion: if scored within top tertile of any four criteria Analysis: according to  relevance for PHC providers & site/settingsReview: of promising models from other public health areasSTAGE 3: Secondary appraisal- Capture ‘Promising’ Interventions -∑Level of parental participation∑Extent of engagement by PHC care providers∑Methodological rigour∑Program impact and generalisability∑Level of upstream involvement∑Multi-dimensional approach∑Integration of population focused healthy living strategiesSTAGE 1: Search and Identification of Reports– Wide and Comprehensive -Covering 13 databases of black literature, 18, grey literature databases, policy papers, hand searches, contacted peak bodies, Internet search, bibliographies of published & unpublished reports.N= ? thousandsFORMULATION OF FINDINGS & RECOMMEDATIONSSTAGE 2: Initial appraisal– Broad and Inclusive –Any interventions that addressed the interventions:∑Systematic Reviews (n=23)∑Non-systematic reviews (n=26)∑Total interventions (n=975)∑Primary preventive interventions (n=77)∑Involving parents and PHC providers (n=55)Adapted from Flynn et al, 2006Intervention Target group Settings PHC Providers Intervention Strategy Country Intervention Findings & Conclusions Strengths Limitations  Good Food  for Children – Food from Home  Sangster et al, 2003   0-5 year old children & their parents  (no descript of children)  N= 15 centres                                                                                                                                                                  Child care: Long day care centres  Parents & Child Care staff  1. Primary, universal prevention2. Pre-test post-test comparison, Ix group only3. Improve nutrition prepared from home4. Needs assessment conducted feedback to centre director; workshops with staff including communication with parents; resources given to staff and parents; lunchbox, food safety and policy checklists provided5. Frequency & duration of workshop not provided, outcome evaluation conducted 3months post-intervention  AUS  Improvements in the nutrition score of the food provided in lunchboxes, especially in the provision of foods containing iron and calcium, and appropriate drinks and snacks; improved handling of food and content of policies; no change in the levels of staff know ledge of nutrition and food handling practices; power analysis and participation rate not discussed.Conclusions: The intervention was effective in improving food provided to children and food handling practices in this settingMeasurement tools &  psychometric information: Food in lunchboxes assessed using a food checklist based on the Caring for Children Checklist; observation of staff food handling practices using a checklist based on current recommendations for child care centres; policies collected and assessed with a checklist based on current recommendations; food safety and nutrition know ledge assessed in a face-to-face interview; process evaluation questionnaires to assess the workshops; all assessments based on assessments used in previous child care studies.   MR: t-tests and McNemar tests  conducted, formative, process & impact evaluation conducted, which provided a solid groundwork for improved communication betw een staff and parents, measurement tools (pre-piloted) used for evaluation, outcome evaluation demonstrated improved nutritional lunches brought from home (3 months post-intervention) & improved food handling policies in the child care centre.         UI: briefly discussed the policy development, inter-sectoral involvement to improve primarily nutrition, w hich involved developing personal skills and building public policy.                                                                                                                                                                                   MA: multiple components  MR: study design: no control group, poor demographic description of sample group, poor psychometric description of measures, no theoretical framew ork discussed, no long term evaluation (only 3 months), pow er analysis and participation rate not discussed                                                                                                                                                                                                  Frequency & duration of workshop not provided, outcome evaluation conducted 3 months post-intervention w ith poor increase of know ledge among staff about nutritional needs and the actual food handling practices did not improve.    UI: article did not discuss details of developing public policy or in referenced article  PP & PHCP:  not a signif icantly long duration or intensity      IPHLS: focus primarily on nutrition   Preventing Overweight and Obesity in Young ChildrenSUMMARY OF APPRAISAL CRITERIAName of Programme __________________________________________COMPONENTS FOR ASSESSING CRITERIA(each factor per criteria was scored)LevelsLow Mid High Methodological rigour (quantitative and qualitative): Design level; selection bias; information bias; confoundingTheoretical framework; sampling; data collection; analysis approachLevel of Primary Health Provider participation:Duration, intensity, type of participation, and level of involvement.Level of parental/carer participation: Duration, intensity, type of participation, and level of involvement.Multi-dimensional approach: Single component, diet & exercise counted, multiple componentsProgram Impact & Transferability:Size, scope, process, outcome, generalisability, targetLevel of upstream involvement: Policy, education, facilitation, treatmentPopulation focus:Individual, family, community, environmental, legal(Adapted from Flynn et al., 2006, p.21-23)Preventing Overweight and Obesity in Young Children051015202530354045Total Number of Interventions (N=55)Assessment CriteriaPreliminary Results of Interventions Preventing Obesity among Children Low 34 31 27 41 32 29Medium 21 20 26 13 19 24High 0 4 2 3 4 2Methodological rigourLevel of upstream involvementMulti-dimensional approachLevel of parent participationLevel of PHCP participationPopulation focused approachPreventing Overweight and Obesity in Young ChildrenPreventing Overweight and Obesity in Young ChildrenResearch question 4: How applicable are these to different PHC settings and what do they imply for Commonwealth/state relationships, organisational linkages, cots, etc.?• Started pulling out some the ‘promising’ interventions and reviewed these with our steering committee to see if they agreed with scored outcomes• Looked at gaps in our data – what interventions we haven’t included especially international ones• Incorporated findings from other public health care sectors• Reviewed the relevance and likely acceptability of these ‘promising’ interventions within different Australian contextsPreventing Overweight and Obesity in Young ChildrenAPHCRI Stream Five Proposal:ß Develop and pilot a portfolio of interventions for children 2-5 yrs- Convening decision-making group to establish context, goals and criteria for selection of interventions- Initial appraisal of potential interventions by PHC- Detailed appraisal of selected interventions to assess applicability, costs, staff training needs, etc.- Triangulation of results into settings-based actions ß Design a portfolio selection guide:- Introduce a spectrum of settings-based actions and PHC intervention points, highlighting strengths and difficulties- Outline promising or candidate interventions incorporating specific information on relevance to community, costs, capacity building needs, required level of engagement- Review process policy makers could use to select optimal mix of interventions (build intensity and breadth)

Preventing overweight and obesity in young children: synthesising the evidence for management and policy making

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