Reducing social inequalities in access to overweight and obesity care management for adolescents: The PRALIMAP-INÈS trial protocol and inclusion data analysis

Ten-year postintervention follow-up of adolescents participating in the management of overweight and social inequalities (PRALIMAP-INÈS intervention): the PRALIMAP-CINeCO survey protocol

INTRODUCTION

The short-term effectiveness of the PRomotion de l'ALIMentation et de l'Activité Physique-INÈgalités de Santé' (PRALIMAP-INÈS) intervention to reduce social inequalities in overweight and obesity management among adolescents between 2012 and 2015 was demonstrated. This longitudinal mixed-methods study is a 10-year postintervention follow-up of the PRALIMAP-INÈS intervention with the aim of investigating social, economic, educational and health (especially weight) trajectories from adolescence to young adulthood.

METHODS AND ANALYSIS

Among adolescents enrolled in PRALIMAP-INÈS (n=1419), we estimate the number of participants to be 852. Adolescents who were included in the PRALIMAP-INÈS intervention will be contacted 10 years later and invited to participate in a follow-up visit. Participants will self-report their sociodemographic characteristics, body image perceptions, overweight/obesity care pathway, lifestyle and dietary behaviours and attitudes, psychological health and experience of the PRALIMAP-INÈS intervention. A check-up visit will be scheduled by a clinical research nurse to record waist circumference and weight and height for body mass index calculation and to construct the healthcare pathway from adolescence to young adulthood. 40 participants will be invited to participate in a semistructured interview conducted by a sociologist to deepen the understanding of trajectories regarding social aspects that are likely to influence health behaviours in participants.

ETHICS AND DISSEMINATION

The PRALIMAP-CINeCO trial was approved by French Persons Protection Committee (no. 2021-A00949-32) and a conformity declaration was made with French National Commission for Data Protection and Liberties. Results will be presented at conferences and published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05386017; Pre-results.

Lifestyle Behaviors and Psychological Health in Adolescents with Overweight or Obesity: Cross-sectional Associations with Weight Underestimation

BACKGROUND

Encouraging adolescents with overweight/obesity to accurately perceive their weight in the belief that this will improve their lifestyle behaviors (physical activity (PA), sedentary behavior (SB), eating behavior (EB)) may be detrimental to their psychological health. This study aimed to investigate associations between weight underestimation and lifestyle behaviors along with psychological health in French adolescents with overweight or obesity.

METHOD

Baseline data from adolescents who participated in a school-based trial were used. Lifestyle behaviors and psychological health (anxiety, depression, eating disorders, quality of life (QoL)) were self-reported. Weight underestimation was measured by matching objective and perceived weight status. Multilevel models were computed to investigate associations between weight underestimation and lifestyle behaviors and psychological health, by gender.

RESULTS

Of the 1245 adolescents included (15.3 ± 0.7 years), 15.8% underestimated their objective weight (boys 24.2%; girls 8.2%). Boys with underestimation had higher vigorous PA energy expenditure (β = 372.7 MET-min/week, 95%CI [25.1;720.4]), and lower daily sugar-sweetened beverages and foods consumption (β =  - 0.3 points, 95%CI [- 0.7; - 0.0]) than those with accurate perception. Girls with weight underestimation had lower eating disorder (β =  - 6.0 points, 95%CI [- 9.6; - 2.5]), anxiety (β =  - 7.8 points, 95%CI [- 13.8; - 1.9]), and higher QoL (β = 3.3 points, 95%CI [0.0; 6.5]) scores than girls with accurate perception.

CONCLUSION

Weight underestimation among adolescents with overweight or obesity was associated with healthier lifestyle behaviors in boys, and better psychological health (eating disorder, anxiety and QoL) in girls. Accurate perception of weight status may not be a relevant lever to improve lifestyle behaviors and psychological health.

Role of dietary intake and physical activity in reducing weight social inequalities among adolescents: an application of G-formula to PRALIMAP-INÈS trial

Interventions aiming to reduce social inequalities of weight status in adolescents usually focus on lifestyle behaviours, but their effectiveness is limited. This study analysed the effect of achieving levels of dietary intake (DI) and/or physical activity (PA) guidelines on reducing social inequalities in weight status among adolescents. We included adolescents from the PRomotion de l'ALIMentation et de l'Activité Physique - INÉgalité de Santé (PRALIMAP-INÈS) trial with weight status data available at baseline and 1-year follow-up (n 1130). PA and DI were measured using the International Physical Activity Questionnaire and a validated FFQ, respectively. We estimated the likelihood of a 1-year reduction in BMI z-score (BMIz) and population risk difference (PRD) under hypothetical DI and PA levels and socio-economic status using the parametric G-formula. When advantaged and less advantaged adolescents maintained their baseline DI and PA, we found social inequalities in weight status, with a PRD of a 1-year reduction in BMIz of -1·6 % (-3·0 %, -0·5 %). These inequalities were not observed when less advantaged adolescents increased their proportion of achieving DI guidelines by 30 % (PRD = 2·2 % (-0·5 %, 5·0 %)) unlike the same increase in PA (PRD = -3·9 % (-6·8 %, -1·3 %)). Finally, social inequalities of weight status were not observed when levels of achievement of both PA and DI guidelines increased by 30 % (PRD = 2·2 % (-0·5 %, 4·0 %)). Enhancing DI rather than PA could be effective in reducing social inequalities in weight status among adolescents. Future interventions aiming to reduce these inequalities should mostly target DI to be effective.

Proportionate universalism intervention is effective for tackling nutritional social gradient in adolescents: the PRALIMAP-INÈS mixed randomised trial

OBJECTIVE

This study aimed to investigate the effectiveness of proportionate universalism intervention to reduce the slope of the nutritional social gradient in adolescents.

STUDY DESIGN

A mixed (experimental and quasi-experimental) multicentre trial.

METHODS

Data from 985 adolescents of the PRALIMAP-INÈS trial (North-eastern France, 2012-2015) were analysed. For this, adolescents were split into five social classes according to the Family Affluence Scale: Highly Less Advantaged (H.L.Ad; n = 33), Less Advantaged (L.Ad; n = 155), Intermediate (Int; n = 404), Advantaged (Ad; n = 324) and Highly Advantaged (H.Ad; n = 69). The overweight care management was a standard care for all and a strengthened one adapted to the social class of adolescents. The main outcome was the 1-year change of the body mass index z-score (BMIz) slope. Other nutritional outcomes were BMI, ΔBMI_p95 (BMI minus 95th percentile of the WHO reference), %BMI_p95 (percent of 95th percentile of the WHO reference), leisure-time sport, consumption of fruits and vegetables and consumption of sugary foods and drinks.

RESULTS

The inclusion data confirmed a weight social gradient expressed by a significant BMIz linear regression coefficient (β = -0.09 [-0.14 to -0.04], P < 0.0001). The higher the social class, the lower the BMIz. The 1-year BMIz linear regression coefficient was -0.07 [-0.12 to -0.02], corresponding to a significant weight social gradient reduction of 23.3% (β = 0.021 [0.001 to 0.041]; P = 0.04). Consistent results were found for other nutritional outcomes.

CONCLUSIONS

PRALIMAP-INÈS shows that proportionate universalism intervention is effective to reduce the adolescents' nutritional social gradient and suggests that equitable health programmes and policies are a realistic goal.

Economic evaluation of a school-based strategy to prevent overweight and obesity in French adolescents: insights from the PRALIMAP randomised trial

OBJECTIVES

This study aimed to provide cost-effectiveness and budget impact analyses of a school-based overweight/obesity screening and care prevention strategy among adolescents.

STUDY DESIGN

Cost-effectiveness and budget impact analyses.

METHODS

Data from 3538 adolescents who participated in a school-based randomised controlled trial in the Northeast of France were used. Costs (from a public payer's perspective) included screening for overweight and obesity and subsequent care. Effectiveness was measured as the change in body mass index (kilogram per square metre), prevalence of overweight/obesity, moderate physical activity energy expenditure, duration and frequency and total sitting time. The incremental cost-effectiveness ratio was calculated, and a budget impact analysis was conducted.

RESULTS

The screening and care strategy resulted in an incremental cost-effectiveness ratio of €1634.48 per averted case of overweight/obesity and €255.43 per body mass index unit decrease. The costs for increasing moderate physical activity by 1000 metabolic equivalent of task-min/week, duration by 60 min/week and frequency 1 day/week were €165.28, €39.21 and €93.66 per adolescent, respectively. Decreasing total sitting time by 60 min/week had a cost of €8.49 per adolescent. The cost of implementing the strategy nationally was estimated to be €50.1 million with a payback period from 3.6 to 7.3 years.

CONCLUSIONS

The screening and care strategy could be an efficient way to prevent overweight and obesity among adolescents. Future studies should investigate how the current results could be achieved in schools with different settings and thus justify its relevance for overweight and obesity prevention to policy-makers.

Behavioural risk patterns in adolescents with excess weight participating in the PRALIMAP-INÈS trial

OBJECTIVE

To investigate clustering of risk behaviours in adolescents with excess weight.

DESIGN

Cross-sectional analysis of baseline data from the PRALIMAP-INÈS trial. Information on food frequency consumption (fruit, vegetables, sugary products and beverages), physical activity, sedentary behaviour (week and weekend days), smoking and alcohol consumption (current frequency and intoxication episodes) and socio-demographic data was collected using self-reported questionnaires. Behavioural risk factors were entered as categorical variables in a two-step clustering procedure: multiple correspondence analysis followed by hierarchical clustering. Associations between cluster membership and socio-demographic variables were investigated using multivariable multinomial logistic regression.

SETTING

French PRALIMAP-INÈS trial.

PARTICIPANTS

Adolescents with excess weight.

RESULTS

A total of 1391 participants (13-18 years old, 58·2 % female) were included in the analysis, which resulted in the identification of four groups of participants, including, respectively, 543 (39·0 %), 373 (26·8 %), 246 (17·7 %) and 229 (16·5 %) participants. Clusters 1 and 4 showed associations of rather healthy behaviours (high physical activity and low consumption of sugary products; high consumption of fruit and vegetables, respectively), while clusters 2 and 3 showed associations of rather unhealthy behaviours (high sedentary behaviour and low consumption of fruit and vegetables; smoking and alcohol consumption, respectively). Both social status and family structure were associated with cluster membership.

CONCLUSIONS

Risk behaviour patterns in adolescents with excess weight were clustered in both healthier and less healthy ways, with a complex interplay with socio-demographic factors.

[Theoretical and practical challenges of proportionate universalism: a reviewAnálise dos desafios teóricos e práticos de universalismo proporcional]

OBJECTIVE

In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues.

METHODS

We searched for all articles published until 6th of February 2020, mentioning "Proportionate Universalism" or its synonyms "Targeted universalism" OR "Progressive Universalism" as a topic in all Web of Science databases.

RESULTS

This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs.

CONCLUSION

This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.

Sociodemographic and psychological characteristics associated with discrepancy between body satisfaction and weight change among adolescents

This study aimed to describe the discrepancy between body satisfaction change and weight change among adolescents following a 2-year school-based intervention, to identify associated sociodemographic factors, and to explore possible associations with perceived health indicators. We used data from a northeastern France representative adolescents sample (14-18 years old) who participated in the PRALIMAP (PRomotion de l'ALIMentation et de l'Activité Physique) study (2006-2009). Weight change was measured by the change in body mass index z-score from the start to the end of the study. Body satisfaction and self-perceived health (anxiety, depression, eating disorder and quality of life) changes were assessed using self-administered questionnaires. Discrepancy between body satisfaction change and weight change was described with cross-tabulations, and subdivided into optimism/pessimism (i.e. positive/negative body satisfaction change compared to weight change). Sociodemographic factors associated with discrepancy were determined by multivariate logistic regression models. Adjusted linear regression models described 2-year change in weight and self-perceived health according to discrepancy. Among the 3279 adolescents included (aged 15.1 ± 0.6 years), the proportion of discrepancy was 74.8% (pessimism = 41.6%; optimism = 33.2%). Discrepancy, especially pessimism, was higher in boys than in girls (OR = 1.44 [1.19; 1.74], p = .0002), and in socially advantaged adolescents (OR = 1.82 [1.20; 2.74], p = .004) than in disadvantage ones. Body satisfaction change was rather in line with anxiety, depression and quality of life changes than weight change. Body satisfaction change should be considered in overweight and obesity prevention interventions alongside body weight change, and could be used as indicator of long-term behavior maintenance. Clinical trials registry and number:ClinicalTrials.gov (NCT01688453).

Theoretical and practical challenges of proportionate universalism: a review

OBJECTIVE

In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it.The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues.

METHODS

We searched for all articles published until 6th of February 2020, mentioning "Proportionate Universalism" or its synonyms "Targeted universalism" OR "Progressive Universalism" as a topic in all Web of Science databases.

RESULTS

This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs.

CONCLUSION

This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.

Physical activity rather than sedentary behaviour is socially determined in French adolescents with overweight and obesity

Social differences in prevalence of overweight and obesity among adolescents, known as the weight social gradient, could be explained by differences in behaviours between social classes. This study examined the respective association of physical activity (PA), sedentary behaviour (SB) and weight status with adolescents' socioeconomic status. We used cross-sectional data for 1935 adolescents (13-18 years old) with overweight or obesity who participated in the PRALIMAP-INÉS (PRomotion de l'ALImentation et de l'Activité Physique - INÉgalités de Santé) trial conducted in northeastern France between 2012 and 2015. Adolescents completed the International Physical Activity Questionnaire for PA and SB and the Family Affluence Scale for socioeconomic status. Weight status was assessed by the body mass index (BMI) and BMI z-score. Social gradient of weight status, PA and SB were described according to the Family Affluence Scale (slopes) and evidenced by the linear trend test (p). Adolescents' socioeconomic status was positively associated with PA practice (frequency, vigorous PA and leisure-time PA), but there was no association with their SB. The results confirmed a significant weight social gradient: BMI (β = 0.37, p < .0001) and BMI z-score (β = 0.07, p = .0001). The weight social gradient in adolescents was mostly associated with PA (5.7% to 8.1%) rather than SB (2.7% to 5.7%). Nearly 14% of BMI z-scores could be related to a combined PA and SB effect. PA was found an important factor of weight social gradient in adolescence. Actions aimed at preventing weight social inequalities among adolescents could include PA promotion as lever. CLINICAL TRIALS REGISTRY AND NUMBER: ClinicalTrials.gov (NCT01688453).

Effectiveness of a socially adapted intervention in reducing social inequalities in adolescence weight. The PRALIMAP-INÈS school-based mixed trial

BACKGROUND

A high prevalence of overweight/obesity among low socioeconomic status adolescents contributes to health inequalities. However, evidence-based interventions for reducing social inequalities in adolescent weight are lacking. We aimed to investigate whether strengthened care management for adolescents with low socioeconomic status has an equivalent effect in reducing overweight as standard care management in adolescents with high status.

METHODS

PRALIMAP-INÈS was a multicentre trial including 35 state-run high and middle schools in the north-eastern France. A population-based sample of 1639 adolescents aged 13-18 years with screened and clinically confirmed overweight/obesity were proposed for inclusion and divided into two groups by the Family Affluence Scale score: advantaged (score > 5), receiving standard care management (A.S) and less-advantaged randomly assigned to two groups (1:2 ratio): standard care management (LA.S) and standard and strengthened care management (LA.S.S). Interventions were based on the proportionate universalism principle: universal standard care for all groups and proportionate care for the LA.S.S group. Main outcome was body mass index z-score (BMIz) assessed before and 1 year after inclusion.

RESULTS

A total of 1419 adolescents were included and 1143 followed up at 1 year: 649 in A.S, 158 in LA.S and 336 in LA.S.S groups. BMIz decreased significantly for boys (-0.11 [95% CI, -0.13 to -0.08]; p < 0.0001) and girls (-0.05 [-0.08 to -0.03]; p < 0.0001). No equivalence between LA.S.S and A.S groups was evidenced. For girls, the trend to superiority for LA.S.S was confirmed by the more favourable change (-0.06 [-0.11 to -0.01]; p = 0.01) observed on superiority analysis, with no differential change for boys (0.02 [-0.03 to 0.08]; p = 0.41).

CONCLUSIONS

A public health school-based intervention using the proportionate universalism principle may be effective in not worsening or even reducing overweight social inequalities in adolescents, especially for girls. Overcoming social barriers may help health professionals dealing with the burden and inequalities of overweight in adolescents.

Universal School-Based Intervention Does Not Reduce Socioeconomic Inequalities in Weight Status among Adolescents

Background: Differences in weight status by socioeconomic position occur during adolescence and is known as weight social gradient (WSG). The PRALIMAP (Promotion de l'ALIMentation et de l'Activité Physique) trial highlighted that a universal intervention was effective in reducing overweight and obesity prevalence among adolescents. However, its ability to reduce the WSG is unclear. This study aimed to evaluate the impact of the PRALIMAP intervention on the WSG among adolescents. Methods: Data were obtained from 3504 adolescents who participated in the school-based PRALIMAP trial between 2006 and 2009. The PRALIMAP study consisted of three interventional strategies: educational, environmental, screening and care. Weight status was assessed by body mass index (BMI) z-score and overweight and obesity prevalence. The "indice de position sociale des élèves" was used to measure adolescents' socioeconomic status. Linear regression and hierarchical models were used to assess the WSG and its evolution, respectively. Results: Among all adolescents (14-18 years old), significant WSG was identified at baseline: BMI z-score (β = -0.06; p < 0.0001), overweight and obesity prevalence (β = -2.86; p < 0.0001). Overall, the intervention conferred no significant reduction in the WSG: BMI z-score (β = -0.01 [-0.02 to 0.01], p = 0.48), overweight and obesity prevalence (β = -0.01 [-0.07 to 0.05], p = 0.73). Similar results were observed for adolescents whatever the interventional strategy they benefited from in the PRALIMAP trial. Conclusions: This study provided no evidence that the PRALIMAP universal intervention was effective in reducing the socioeconomic inequalities in weight status among adolescents. Different interventions that account for social differences should be considered to tackle these inequalities.

Using facilitator-receiver peer dyads matched according to socioeconomic status to promote behaviour change in overweight adolescents: a feasibility study

OBJECTIVE

To evaluate the feasibility of an innovative peer intervention promoting healthy eating and physical activity, which purposefully selected peer facilitators according to socioeconomic status to target less-advantaged overweight receivers.

SETTING

Nine high schools, two middle schools.

PARTICIPANTS

One hundred and fifty-six adolescents were approached to become facilitators, of whom 18 were trained. Thirty-two of 56 potential receivers agreed to participate.

INTERVENTION

The peer intervention was carried out in 2013-2014 and embedded in a larger trial: PRALIMAP-INÈS (Promotion de l'ALIMentation et l'Activité Physique-INEgalité de Santé). Facilitanoators were selected and trained to organise weight-control activities with specific peer receivers participating in the programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

Different types of data were collected to assess demand, acceptability, implementation and practicality of the intervention. For the facilitators, this included 6 training sessions, 11 mid-programme interviews, 4 end-of-programme sessions, telephone notes and text message exchanges. All six potential receivers in one school were also interviewed. Sociodemographic and health characteristics were also analysed.

RESULTS

Agreeing to participate was more likely when asked by a peer compared with a professional (51.2% discordant pairs; p<0.02). Twelve activities, mostly based on physical activity and implemented during weekends or holidays, were carried out. The mean age of active receivers was 16 and their body mass index was higher than other participants. For both facilitators and active receivers, there were more participating girls. Qualitative analysis reveals key implementation challenges for facilitators. Interviews with the receivers highlight social difficulties, with most feeling bad about their appearance and wanting to lose weight. Those who participated in peer activities were very positive about the experience especially social support.

CONCLUSIONS

The present study suggests the peer intervention is feasible provided organisational difficulties are addressed. Good practice recommendations are formulated, including a longer training session, organising a joint meeting with the facilitators and receivers, matching dyads on place of residence and multiplying modes of contact.

TRIAL REGISTRATION NUMBER

NCT01688453.

Reach and Acceptability of a Mobile Reminder Strategy and Facebook Group Intervention for Weight Management in Less Advantaged Adolescents: Insights From the PRALIMAP-INÈS Trial

Background

Although information and communication technology interventions appear to be a promising means of reducing the health inequality gap in overweight and obesity prevention, research on information and communication technology interventions is lacking outside the Anglo-Saxon world.

Objective

The aim of this study was to assess the reach and acceptability of 2 information and communication technology interventions delivered as part of a French nutritional program: an SMS text messaging (short message service, SMS) attendance-reminder for collective sessions strategy and a Facebook challenge group.

Methods

This study sample comprised 262 socially less advantaged overweight adolescents aged between 13 and 18 years. The information and communication technology interventions were carried out during the 2013-2014 academic year in 33 French state-run schools. For the SMS attendance-reminder for collective sessions strategy, at the start of the academic year, adolescents were asked to give their mobile number. SMS attendance-reminders were sent shortly before each of the 5 collective sessions. For the Facebook challenge group, adolescents were invited to join a closed Facebook group in which challenges on physical activity and on diet were posted weekly. Process data and 2 sets of face-to-face interviews were also used to interpret participation rates and access to Facebook. Appreciation for both interventions was evaluated by a questionnaire at the end of the academic year.

Results

Of the recruited adolescents, 79.0% (207/262) gave their mobile number, reflecting high access to a mobile phone. Giving a number was significantly more likely for girls (odds ratio [OR] 2.1, 95% CI 1.1-3.9; P=.02) and adolescents in a vocational or general high school as opposed to middle school (OR 1.0, 95% CI 0.4-2.7; OR 0.2, 95% CI 0.1-0.5; P<.001). Indicating a mobile number at the start of the year was not significantly associated with participation in collective sessions. Of the adolescents seen at the start-of-year face-to-face interviews, 78.1% (153/196) declared an interest in the Facebook challenge group, which implies having a Facebook account or being able to have access to one. However, only 21 adolescents went through the process of joining the group. Although there was satisfaction with the Facebook group among the participants, the low participation rate in the Facebook group does not allow conclusions to be drawn with confidence.

Conclusions

The results are in line with the claim that using information and communication technologies in health programs is unlikely to widen health inequalities. However, in this population of French adolescents, mobile phone strategies seem more adapted to a high school context, and caution should be exercised with a younger audience. Although there is positive appreciation of the SMS attendance-reminders and a Facebook intervention is initially highly appealing to less advantaged adolescents, no evidence of impact could be demonstrated. These results highlight the difficulty in assessing the impact of specific interventions in complex health programs.

Trial Registration

Clinicaltrials.gov NCT01688453; https://clinicaltrials.gov/ct2/show/NCT01688453 (Archived by WebCite at http://www.webcitation.org/6yy6EQ0SM)