Managing obesity in secondary care: a personal practice

Assessing the efficacy of the Healthy Eating and Lifestyle Programme (HELP) compared with enhanced standard care of the obese adolescent in the community: study protocol for a randomized controlled trial

BACKGROUND

The childhood obesity epidemic is one of the foremost UK health priorities. Childhood obesity tracks into adult life and places individuals at considerable risk for diabetes, cardiovascular disease, liver disease and other morbidities. There is widespread need for paediatric lifestyle programmes as change may be easier to accomplish in childhood than later in life.

STUDY DESIGN/METHOD

The study will evaluate the management of adolescent obesity by conducting a Medical Research Council complex intervention phase III efficacy randomised clinical trial of the Healthy Eating Lifestyle Programme within primary care. The study tests a community delivered multi-component intervention designed for adolescents developed from best practice as identified by National Institute for Health and Clinical Excellence. The hospital based pilot reduced body mass index and improved health-related quality of life.Subjects will be individually randomised to receiving either the Healthy Eating Lifestyle Programme (12 fortnightly family sessions) or enhanced standard care. Baseline and follow up assessments will be undertaken blind to allocation status. A health economic evaluation is also being conducted.200 obese young people (13-17 years, body mass index > 98th centile for age and sex) will be recruited from primary care within the greater London area.The primary hypothesis is that a motivational and solution-focused family-based weight management programme delivered over 6 months is more efficacious in reducing body mass index in obese adolescents identified in the community than enhanced standard care.The primary outcome will be body mass index at the end of the intervention, adjusted for baseline body mass index, age and sex.The secondary hypothesis is that the Healthy Eating Lifestyle Programme is more efficacious in improving quality of life and psychological function and reducing waist circumference and cardiovascular risk factors in obese adolescents than enhanced standard care assessed at 6 and 12 months post baseline assessment.Improvement in quality of life predicts on-going lifestyle change and maximises the chances of long-term weight reduction. We will explore whether improvement in QOL may be intermediate on the pathway between the intervention and body mass index change.

TRIAL REGISTRATION

ISRCTN: ISRCTN99840111.

Family-based behavioural treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial

Background

The best outcomes for treating childhood obesity have come from comprehensive family-based programmes. However there are questions over their generalisability.

Objective

To examine the acceptability and effectiveness of ‘family-based behavioural treatment’ (FBBT) for childhood obesity in an ethnically and socially diverse sample of families in a UK National Health Service (NHS) setting.

Methods

In this parallel group, randomised controlled trial, 72 obese children were randomised to FBBT or waiting list control. Primary outcomes were body mass index (BMI) and BMI standard deviation scores (SDS). Secondary outcomes were weight, weight SDS, height, height SDS, waist, waist SDS, fat mass index, fat free mass index, blood pressure, and psychosocial measures. Outcomes were assessed at baseline and post-treatment, with analyses on the 6 month data done on an intent-to-treat (ITT) basis. Follow-up anthropometric data were collected at twelve months for the treatment group.

Results

ITT analyses included all children with baseline data (n=60). There were significant BMI SDS changes (p<0.01) for the treatment and control groups of −0.11 (0.16) and −0.10 (1.6). The treatment group showed a significant reduction in systolic blood pressure (−0.24 (0.7), p<0.05) and improvements in quality of life and eating attitudes (p<0.05), with no significant changes for the control group. However the between-group treatment effects for BMI, body composition, blood pressure and psychosocial outcomes were not significant. There was no overall change in BMI or BMI SDS from 0-12 months for the treatment group. No adverse effects were reported.

Conclusions

Both treatment and control groups experienced significant reductions in level of overweight, but with no significant difference between them. There were no significant group differences for any of the secondary outcomes.

An update in prevention and treatment of pediatric obesity

BACKGROUND

Obesity prevalence is growing as well as its severity with increasing morbidity and mortality. This "globesity" also affects developing countries where under nutrition and stunting frequently coexist with overweight and obesity. One third of obese adults began to be so in the pediatric ages. There are two main types of prevention: general one representing greater actions from health authorities and the individual one carried out by the pediatrician and the patient at risk. Once the state of obesity is reached (relative body mass index, rBMI >121%) the longer lasting care becomes more complex and frequently unsuccessful. The treatment of obesity is aimed to care for the present and silent disorders and for preventing its further tracking to adulthood.

DATA SOURCES

Identification of pediatric population at risk which is the one with an rBMI of 111%-120% plus other risk factors. Specific individual actions include reduction of food intake, increase of energy expenditure, involvement of parents, and the child-adolescent himself in the prevention. Therapy is based on some principles plus the important medical and emotional approach.

RESULTS

A Cochrane study based on only 10 appropriate studies showed a predominant poor efficacy of the undergone preventive action. Treatment guides are presented after our own experience with a group of 400 kids with an average follow-up of 7 years and other individual prevention studies.

CONCLUSIONS

Involving motivated pediatricians with a minimum of time for visits and better follow-up in the frame of a general national preventive programme could be a rational outcome. Treatment of obesity should never be postponed whatever the clinical care is.

A review of local practice regarding investigations in children attending obesity clinics and a comparison of the results with other studies

BACKGROUND

Obese children are at high risk of developing co-morbidities, with a prevalence of abnormal tests ranging from 30 to 58%. Recent guidance recommends that all children with a body mass index (BMI) above the 95th centile be investigated. This study aimed to determine the prevalence of abnormal results in an urban paediatric population and to compare local practice against these recommendations.

METHODS

Patient records of children attending either a community or hospital-based obesity clinic were analysed retrospectively to obtain anthropometric data and laboratory results; from this, the frequency of investigation and the prevalence of abnormal results were calculated. Investigations considered were alanine aminotransferase, thyroid-stimulating hormone (TSH), and fasting glucose, insulin and lipid profiles.

RESULTS

One hundred thirty-six children (75 girls, 61 boys) were identified, with mean BMI z-score of 3.27 and mean age of 11.4 years (range 1.4-20.4). Children with BMI z-score >3 were more likely to be investigated, but otherwise, the frequency was similar for both sex and age. The prevalence of abnormal results was liver function tests, 14.3%; TSH, 0.0%; glucose, 0.0%; insulin, 31.6%; triglycerides, 10.0%; cholesterol, 15.6%. The sample size was small, but there did not appear to be a significant difference in the percentage abnormal results found for sex, age, or BMI z-score.

CONCLUSION

The prevalence of abnormal results was less than that identified in another UK study carried out in a tertiary centre, suggesting that the true population-based prevalence is lower than believed. This might be especially so because fewer tests were performed in these clinics than currently recommended and children at highest risk were more likely to be investigated. Therefore, further research is indicated to determine the true figure as well as to identify risk factors for co-morbidity, before costly recommendations to test all children with a BMI above the 95th centile are implemented.

Obesity in childhood and adolescence: evidence based clinical and public health perspectives

A global epidemic of paediatric obesity occurred in recent years, and prevalence of obesity is continuing to rise. In the developed world obesity is now the most common disease of childhood and adolescence. Paediatric obesity is not a cosmetic issue, being associated with a significant burden of ill health both for obese children and for adults who were obese as children. Health professionals tend to underestimate the impact of paediatric obesity, and lack the skills, knowledge, and time to treat it effectively. This short review aims to summarise recent systematic reviews on the origins, consequences, prevention, and treatment of paediatric obesity.

Definitions of childhood obesity: current practice

OBJECTIVE

To review current practice in the definition of childhood obesity based on body mass index (BMI), in order to understand why the recommendations of the International Task Force on Obesity (IOTF) have not been fully adopted.

DESIGN

Literature search using MEDLINE to identify papers on childhood obesity published in the first 4 months of 2005, and a cited reference search on the recommendations of the IOTF.

RESULTS

Citations of the IOTF definition have increased since publication, but less than half of papers on childhood obesity published in the period used the definition. Most used the 95th centile of a national distribution to define obesity.

CONCLUSIONS

Reasons for using centiles of a national distribution included the need for z-scores or centiles to define underweight or extreme obesity, not available in conjunction with the IOTF definition, inclusion of children under 2 years, and concerns about over- or underestimation of the prevalence of obesity. None of these preclude use of the principle underlying the IOTF definition, that of continuity with the adult definition of BMI of 30 kg/m2 or more. Adoption of either the IOTF definition or corresponding centiles of a national distribution would enable comparisons of prevalence between countries and over time.