Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Improvements over time for patients following liver trauma: A 17-year observational study

Background

Centralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre.

Methods

All patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V).

Results

There were 600 patients; the median age was 33 (IQR 22-52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively).

Conclusions

Outcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.

Injuries among children attributed to violence and social funding: a 10-year observational study

BACKGROUND

Mechanisms and patterns of injury in children are changing, with violent mechanisms becoming more prevalent over time. Government funding of services for children and young people has reduced nationally over the last decade. We aimed to investigate the trends in admissions of injured children to a Major Trauma Centre (MTC) and examine the relationship between injuries sustained by violent mechanisms and local authority funding of children and youth services within the same catchment area.

METHODS

A 10-year observational study included all patients aged<18 years treated at a regional MTC between April 2012 and April 2022. Number of admissions with violent trauma, mechanism of injury, requirement for operative intervention and mortality were compared with published annual local authority expenditure reports.

RESULTS

1126 children were included; 71.3% were boys, with median age 11 years (IQR 3-16). There were 154/1126 (14%) children who were victims of violent trauma; they were more likely to be boys than children injured by non-violent mechanisms (84% vs 69%). The proportion of injuries attributed to violence increased over the study period at the same time as reductions in local authority funding of services for the early years, families and youth services. However, there were insufficient data to formally assess the interdependency between these factors.

CONCLUSIONS

The proportion of injuries attributed to violence has increased over time, and government spending on specific children and young people's services has decreased over the same time period. Further work is needed to examine the interdependency between spending and violent injuries in children, and public health interventions to target violence-related injuries should take into account youth service funding.

Injury by knife crime amongst children is associated with socioeconomic deprivation: an observational study

PURPOSE

Children who live in areas of socioeconomic deprivation may be at higher risk of being victims of violent crime such as knife wounds. The current study investigated whether socioeconomic disparity was associated with higher risk of knife crime.

METHODS

An observational study included patients aged ≤ 17 years at a UK Major Trauma Centre injured by knife trauma from 2016 to 2022. Indices of deprivation were recorded according to the zip code of residence and compared with those of all of England. These included Index of Multiple Deprivation (IMD); income; employment; education and skills; health and disability; crime; barriers to housing and services; living environment; and Income Deprivation Affecting Children Index (IDACI).

RESULTS

There were 139 patients (96% male) with median age of 16 years. When compared with the whole of England, patients had worse indices of IMD (p = 0.021); income (p < 0.001); employment (p < 0.001); education and skills (p < 0.001); health and disability; and IDACI (p < 0.001). There were no significant differences in indices of crime, barriers to housing and services or living environment.

CONCLUSIONS

Paediatric knife injury was associated with poor socioeconomic status in multiple domains. Focussed efforts to address socioeconomic disparities should be a priority as a public health measure for vulnerable children.

Nature-Based Early Childhood Education and Children's Physical Activity, Sedentary Behavior, Motor Competence, and Other Physical Health Outcomes: A Mixed-Methods Systematic Review

BACKGROUND

The purpose was to synthesize evidence on the association between nature-based Early Childhood Education (ECE) and children's physical activity (PA) and motor competence (MC).

METHODS

A literature search of 9 databases was concluded in August 2020. Studies were eligible if (1) children were aged 2-7 years old and attending ECE, (2) ECE settings integrated nature, and (3) assessed physical outcomes. Two reviewers independently screened full-text articles and assessed study quality. Synthesis was conducted using effect direction (quantitative), thematic analysis (qualitative), and combined using a results-based convergent synthesis.

RESULTS

1370 full-text articles were screened and 39 (31 quantitative and 8 qualitative) studies were eligible; 20 quantitative studies assessed PA and 6 assessed MC. Findings indicated inconsistent associations between nature-based ECE and increased moderate to vigorous PA, and improved speed/agility and object control skills. There were positive associations between nature-based ECE and reduced sedentary time and improved balance. From the qualitative analysis, nature-based ECE affords higher intensity PA and risky play, which could improve some MC domains. The quality of 28/31 studies was weak.

CONCLUSIONS

More controlled experimental designs that describe the dose and quality of nature are needed to better inform the effectiveness of nature-based ECE on PA and MC.

Patterns and mechanisms of major trauma injuries during and after the UK Covid-19 Nationwide lockdown: analysis from a UK Major Trauma Centre

PURPOSE

To compare patterns and mechanisms of injuries during and after the UK Nationwide lockdown during the COVID-19 pandemic.

METHODS

This prospective cohort study included all major trauma admissions during the 10-week period of the nationwide lockdown (09/03/2020-18/05/2020), compared with admissions in the 10-weeks following the full lifting of lockdown restrictions (04/07/20-12/09/2020). Differences in the volume, spectrum and mechanism of injuries presenting during and post-lockdown were compared using Fisher's exact and Chi-squared tests as appropriate. The associated risk of 30-day mortality was examined using univariable and multivariable logistic regression.

RESULTS

A total of 692 major trauma admissions were included in this analysis. Of these, 237 patients were admitted during the lockdown and 455 patients were admitted post-lockdown. This represented a twofold increase in trauma admission between the two periods. Characteristically, both cohorts had a higher proportion of male patients (73.84% male during lockdown and 72.5% male post-lockdown). There was a noted shift in age groups between both cohorts with an overall more elderly population during lockdown (p = 0.0292), There was a significant difference in mechanisms of injury between the two cohorts. The 3-commonest mechanisms during the lockdown period were: Road traffic accidents (RTA)-31.22%, Falls of less than 2 m-26.58%, and falls greater than 2 m causing 22.78% of major trauma admissions. However, in the post-lockdown period RTAs represented 46.15% of all trauma admissions with falls greater than 2 m causing 17.80% and falls less than 2 m causing 15.16% of major trauma injuries. With falls in the elderly associated with an increased risk of mortality. In terms of absolute numbers, there was a twofold increase in major trauma injuries due to stabbings and shootings, rising from 25 admitted patients during the lockdown to 53 admitted patients post-lockdown.

CONCLUSIONS

The lifting of lockdown restrictions resulted in a twofold increase in major trauma admissions that was also associated with significant changes in both the demographic and patterns of injuries with RTA's contributing almost half of all injury presentations.

TRIAL REGISTRATION

This study was classed as a service evaluation and registered with the local audit department, registration number: 20-177C.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

664 The ICON Trauma Study: The Impact of the COVID-19 Lockdown on Major Trauma Workload in the UK

Introduction

Anecdotal evidence suggest a direct impact of the SARS-COV-2-pandemic on presentation and severity of major trauma.

Method

This observational study from a UK Major Trauma Centre matched a cohort of patients admitted during a 10-week period of the SARS-CoV-2-pandemic (09/03/2020 to 18/05/2020) to a historical cohort admitted during a similar time period in 2019 (11/03/2019 to 20/05/2019). Demographic differences, injury method and severity were compared using Fisher’s and Chi-squared tests. Multivariable logistic regression examined the associated factors predicting 30-day mortality.

Results

Of 642 patients, 405 and 237 were in the 2019 and 2020 cohorts respectively. 1.69%(4/237) of the 2020 cohort tested SARS-CoV-2 positive. There was a 41.5% decrease in trauma admissions in 2020. The 2020 cohort was older (median 46 vs.40 years), more comorbid and frailer (p < 0.0015). There was a significant difference in injury method with a decrease in vehicle related trauma, but an increase in falls. There was a 2-fold increased risk of mortality in the 2020 cohort that in adjusted models, was explained by higher injury severity and frailty. Positive SARS-CoV-2 status was not associated with increased mortality on multivariable analysis.

Conclusions

Patients admitted during the SARS-CoV-2-pandemic were older, frailer, more co-morbid and had an increased risk of mortality.

Evolution of non-operative management of liver trauma

The management of complex liver injury has changed during the last 30 years. Operative management has evolved into a non-operative management (NOM) approach, with surgery reserved for those who present in extremis or become hemodynamically unstable despite resuscitation. This NOM approach has been associated with improved survival rates in severe liver injury and has been the mainstay of treatment for the last 20 years. Patients that fail NOM and require emergency surgery are associated with increased morbidity and mortality. Better patient selection may have an impact not only on the rate of failure of NOM, but the mortality rate associated with it. The aim of this article is to review the evidence that helped shape the evolution of liver injury management during the last 30 years.

Factors Associated with Attrition and Performance Throughout Surgical Training: A Systematic Review and Meta-Analysis

Background

Attrition within surgical training is a challenge. In the USA, attrition rates are as high as 20–26%. The factors predicting attrition are not well known. The aim of this systematic review is to identify factors that influence attrition or performance during surgical training.

Method

The review was performed in line with PRISMA guidelines and registered with the Open Science Framework (OSF). Medline, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were searched for articles. Risk of bias was assessed using the Newcastle–Ottawa scale. Pooled estimates were calculated using random effects meta-analyses in STATA version 15 (Stata Corp Ltd). A sensitivity analysis was performed including only multi-institutional studies.

Results

The searches identified 3486 articles, of which 31 were included, comprising 17,407 residents. Fifteen studies were based on multi-institutional data and 16 on single-institutional data. Twenty-nine of the studies are based on US residents. The pooled estimate for overall attrition was 17% (95% CI 14–20%). Women had a significantly higher pooled attrition than men (24% vs 16%, p < 0.001). Some studies reported Hispanic residents had a higher attrition rate than non-Hispanic residents. There was no increased risk of attrition with age, marital or parental status. Factors reported to affect performance were non-white ethnicity and faculty assessment of clinical performance. Childrearing was not associated with performance.

Conclusion

Female gender is associated with higher attrition in general surgical residency. Longitudinal studies of contemporary surgical cohorts are needed to investigate the complex multi-factorial reasons for failing to complete surgical residency.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05844-0) contains supplementary material, which is available to authorised users.

Longitudinal study of the associations between change in sedentary behavior and change in adiposity during childhood and adolescence: Gateshead Millennium Study

BACKGROUND

Sedentary time (ST) has been reported to have a range of negative health effects in adults, however, the evidence for such effects among children and adolescents is sparse. The primary aim of the study was to examine associations between changes in sedentary behavior (time and fragmentation) and changes in adiposity across childhood and adolescence.

METHODS

Participants were recruited as part of the Gateshead Millennium Study. Measures were taken at age 7 (n=502), 9 (n=506), 12 (n=420) and 15 years (n=306). Participants wore an ActiGraph GT1M and accelerometer epochs were 'sedentary' when recorded counts were ⩽25 counts per 15 s. ST was calculated and fragmentation (SF) was assessed by calculating the number of sedentary bouts per sedentary hour. Associations of changes in ST and SF with changes in adiposity (body mass index (BMI), and fat mass index (FMI)) were examined using bivariate linear spline models.

RESULTS

Increasing ST by 1% per year was associated with an increase in BMI of 0.08 kg m-2 per year (95% CI: 0.06-0.10; P<0.001) and FMI of 0.15  kg m-2 per year (0.11-0.19; P<0.001). Change in SF was associated with BMI and FMI (P<0.001). An increase of 1 bout per sedentary hour per year (that is, sedentary time becoming more fragmented) was associated with an increase in BMI of 0.07  kg m-2 per year (0.06-0.09; P<0.001) and an increase in FMI of 0.14  kg m-2 per year (0.10-0.18; P<0.001) over the 8 years period. However, an increase in SF between 9-12 years was associated with a 0.09  kg m-2 per year decrease in BMI (-0.18-0.00; P=0.046) and 0.11  kg m-2 per year decrease in FMI (-0.22-0.00; P=0.049).

CONCLUSIONS

Increased ST and increased SF from 7-15 years were associated with increased adiposity. This is the first study to show age-specific associations between change in objectively measured sedentary behavior and adiposity after adjustment of moderate-to-vigorous-intensity physical activity in children and adolescents. The study suggests that, targeting sedentary behavior for obesity prevention may be most effective during periods in which we see large increases in ST.

Mothers' perceptions of child weight status and the subsequent weight gain of their children: a population-based longitudinal study

BACKGROUND

There is a plethora of cross-sectional work on maternal perceptions of child weight status showing that mothers typically do not classify their overweight child as being overweight according to commonly used clinical criteria. Awareness of overweight in their child is regarded as an important prerequisite for mothers to initiate appropriate action. The gap in the literature is determining whether, if mothers do classify their overweight child's weight status correctly, this is associated with a positive outcome for the child's body mass index (BMI) at a later stage.

OBJECTIVE

To explore longitudinal perceptions of child weight status from mothers of a contemporary population-based birth cohort (Gateshead Millennium Study) and relationships of these perceptions with future child weight gain.

METHODS

Data collected in the same cohort at 7, 12 and 15 years of age: mothers' responses to two items concerning their child's body size; child's and mother's BMI; pubertal maturation; demographic information.

RESULTS

Mothers' perceptions of whether their child was overweight did not change markedly over time. Child BMI was the only significant predictor of mothers' classification of overweight status, and it was only at the extreme end of the overweight range and in the obese range that mothers reliably described their child as overweight. Even when mothers did appropriately classify their child as overweight at an earlier stage, this was not related to relatively lower child BMI a few years later.

CONCLUSIONS

Mothers tend to classify their child as overweight in only more extreme cases. It is an important finding that no beneficial impact was shown on later child BMI in overweight children whose mothers classified their child's weight status as overweight at an earlier stage.

Risk factors for overweight and overfatness in rural South African children and adolescents

Background

To determine risk factors for overweight/overfatness in children and adolescents from rural KwaZulu-Natal, South Africa.

Methods

Anthropometric data were collected from a cross-sectional sample (n = 1519, ages 7, 11 and 15 years) and linked to demographic information (n = 1310 and n = 1317 in overweight and overfat analyses, respectively). Candidate risk factors for overweight/overfatness were identified and tested for associations with overweight (BMI-for-age >+1SD, WHO reference) and overfatness (>85th centile body fatness, McCarthy reference) as outcomes. Associations were examined using simple tests of proportions (χ²/Mann–Whitney U tests) and multivariable logistic regression.

Results

Sex was a consistent variable across both analyses; girls at significantly increased risk of overweight and overfatness (overweight: n = 180, 73.9 and 26.1% females and males, respectively (P < 0.0001); overfat: n = 187, 72.7 and 27.3% females and males, respectively (P < 0.0001)). In regression analyses, sex and age (defined by school grade) were consistent variables, with boys at lower risk of overweight (adjusted odds ratio (AOR) 0.40 (confidence interval (CI) -0.28–0.57)) and risk of overweight increasing with age (AOR 0.65 (CI- 0.44–0.96), 0.50 (CI-0.33–0.75) and 1.00 for school grades 1, 5 and 9, respectively). Results were similar for overfatness.

Conclusions

This study suggests that pre-adolescent/adolescent females may be the most appropriate targets of future interventions aimed at preventing obesity in rural South Africa.

Obesity impairs academic attainment in adolescence: findings from ALSPAC, a UK cohort

OBJECTIVE

While being overweight or obese in adolescence may have detrimental effects on academic attainment, the evidence base is limited by reliance on cross-sectional studies with small sample sizes, failure to take account of confounders and lack of consideration of potential mediators. The present study aimed to address these limitations and examine longitudinal associations between obesity in adolescence and academic attainment.

DESIGN

Associations between weight status at 11 years old and academic attainment assessed by national tests at 11, 13 and 16 years were examined in the Avon Longitudinal Study of Parents and Children. Healthy weight was defined as body mass index (BMI) Z-score <1.04; overweight as BMI Z-score 1.04-1.63; obesity as BMI Z-score ⩾1.64.

PARTICIPANTS

Data from 5966 participants with objectively measured weight status were examined: 71.4% were healthy weight (1935 males; 2325 females), 13.3% overweight (372 males; 420 females) and 15.3% obese (448 males; 466 females).

RESULTS

Girls obese at 11 years had lower academic attainment at 11, 13 and 16 years compared with those of a healthy weight, even after controlling for a wide range of confounders. Associations between obesity and academic attainment were less clear in boys. The potential mediating effects of depressive symptoms, intelligence quotient (IQ) and age of menarche in girls were explored, but when confounders were included, there was no strong evidence for mediation.

CONCLUSIONS

For girls, obesity in adolescence has a detrimental impact on academic attainment 5 years later. Mental health, IQ and age of menarche did not mediate this relationship, suggesting that further work is required to understand the underlying mechanisms. Parents, education and public health policy makers should consider the wide reaching detrimental impact of obesity on educational outcomes in this age group.

Longitudinal changes in objectively measured sedentary behaviour and their relationship with adiposity in children and adolescents: systematic review and evidence appraisal

This review aimed to determine longitudinal changes in objectively measured overall sedentary behaviour, and to examine their associations with adiposity in children and adolescents. A search for longitudinal studies was performed using several electronic databases. Of 161 potentially eligible papers, 10 for change in sedentary behaviour and 3 for longitudinal associations with change in adiposity were included. Weighted mean increase in daily sedentary behaviour per year was 5.7% for boys and 5.8% for girls. Only one paper included preschool children, and it showed a decrease in sedentary behaviour. Nine studies were from Western countries. Null associations were reported between sedentary behaviour and adiposity in two studies, the other found that increases in sedentary behaviour were associated with increases in adiposity, but only in those with body mass index above the 50th percentile. There was consistent evidence that sedentary behaviour increases with age in school-age children and adolescents, by approximately 30 min extra daily sedentary behaviour per year. There was little evidence on the influence of changes in sedentary behaviour on changes in adiposity. There is a need for more longitudinal research, for more evidence from outside the Western world, and for more studies that examine 'dose-response' associations between changes in sedentary behaviour and changes in adiposity.

Use of mid-upper arm circumference for determining overweight and overfatness in children and adolescents

OBJECTIVE

To assess the use of mid-upper arm circumference (MUAC) for identification of overweight and overfatness in rural South African children and adolescents.

METHODS

Anthropometric data (weight, height, MUAC and % body fat) from a cross-sectional sample of 978 black South African 5-14-year-olds were analysed. Receiver operating characteristic (ROC) curve analysis determined the validity of MUAC as a proxy for determining overweight and overfatness.

FINDINGS

Area under the curve (AUC) results were generally high. Boys and girls aged 10-14 years had ROC-AUC for overfatness classed as 'excellent', 0.97 and 0.98 respectively. Cut-points in the MUAC distribution which optimised the ROC-AUC for identification of overfatness and obesity were determined for boys and girls aged 5-9 and 10-14 years, and had high sensitivity and specificity.

CONCLUSIONS

MUAC may have potential for clinical and surveillance applications as an accurate yet simple and widely available indicator of overweight and overfatness in children and adolescents in resource-poor settings.

Associations between objectively measured physical activity and academic attainment in adolescents from a UK cohort

BACKGROUND

To test for cross-sectional (at age 11) and longitudinal associations between objectively measured free-living physical activity (PA) and academic attainment in adolescents.Method Data from 4755 participants (45% male) with valid measurement of PA (total volume and intensity) by accelerometry at age 11 from the Avon Longitudinal Study of Parents and Children (ALSPAC) was examined. Data linkage was performed with nationally administered school assessments in English, Maths and Science at ages 11, 13 and 16.

RESULTS

In unadjusted models, total volume of PA predicted decreased academic attainment. After controlling for total volume of PA, percentage of time spent in moderate-vigorous intensity PA (MVPA) predicted increased performance in English assessments in both sexes, taking into account confounding variables. In Maths at 16 years, percentage of time in MVPA predicted increased performance for males (standardised β=0.11, 95% CI 0.00 to 0.22) and females (β=0.08, 95% CI 0.00 to 0.16). For females the percentage of time spent in MVPA at 11 years predicted increased Science scores at 11 and 16 years (β=0.14 (95% CI 0.03 to 0.25) and 0.14 (0.07 to 0.21), respectively). The correction for regression dilution approximately doubled the standardised β coefficients.

CONCLUSIONS

Findings suggest a long-term positive impact of MVPA on academic attainment in adolescence.

Computed tomographic measures of airway morphology in smokers and never-smoking normals

Bronchial wall area percent (WA% = 100 × wall area/total bronchial cross sectional area) is a standard computed tomographic (CT) measure of central airway morphology utilized in smokers with chronic obstructive pulmonary disease (COPD). Although it provides significant clinical correlations, the range of reported WA% is narrow. This suggests limited macroscopic change in response to smoking or that remodeling proportionally affects the airway wall and lumen dimensions such that their ratio is preserved. The objective of this study is to assess central airway wall area (WA), lumen area (Ai), and total bronchial area (Ao) from CT scans of 5,179 smokers and 92 never smoking normal subjects. In smokers, WA, Ai, and Ao were positively correlated with forced expiratory volume in 1 s (FEV1) expressed as a percent of predicted (FEV1%), and the WA% was negatively correlated with FEV1% (P < 0.0001 for all comparisons). Importantly, smokers with lower FEV1% tended to have airways of smaller cross-sectional area with lower WA. The increases in the WA% across GOLD stages of chronic obstructive pulmonary disease (COPD) can therefore not be due to increases in WA. The data suggest two possible origins for the WA% increases: 1) central airway remodeling resulting in overall reductions in airway caliber in excess of the decreased WA or 2) those with COPD had smaller native airways before they began smoking. In both cases, these observations provide an explanation for the limited range of values of WA% across stages of COPD.

The Malaysian Childhood Obesity Treatment Trial (MASCOT)

INTRODUCTION

The present study describes a randomised controlled trial (RCT) based on a novel, generalisable intervention for childhood obesity, comparing the intervention with a no-treatment control group.

METHOD

The Malaysian Childhood Obesity Treatment Trial (MASCOT) was a single-blind RCT of a dietetic treatment for childhood obesity in children of primary school age (7 to 11 years old) in Kuala Lumpur, Malaysia. The MASCOT comprising eight sessions, of an 8-hour family-centred group treatment programme is described, based on behavioural change techniques. The study sample was characterised by BMI z-score, health related quality of life reported by participants and their parents (PedsQL questionnaire), objectively measured habitual physical activity and sedentary behaviour (Actigraph accelerometry)

RESULTS

The MASCOT sample of 107 children was characterised by a low quality of life, mean total score on PedsQL 67.7 (4.5) as reported by the children, and 66.0 (16.4) as reported by their parents. The children spent, on average, 89% of their waking day on sedentary activity, and 1% of the day in moderate-vigorous intensity physical activity, equivalent to only around 8 minutes/day.

CONCLUSION

Obese children in the MASCOT study had an impaired quality of life, high levels of sedentary behaviour and very low levels of physical activity.

Impact of methodological decisions on accelerometer outcome variables in young children

BACKGROUND

The impact of accelerometer-related methodological decisions relating to the assessment of physical activity and sedentary time has not been conclusively determined in young children.

OBJECTIVES

To determine the effects of epoch and cutoff points on the assessment of physical activity and sedentary time and to determine the accelerometer wear time required to achieve reliable accelerometer data in children.

DESIGN

Children were recruited from centres at Ghent, Glasgow, Gothenburg and Zaragoza.

METHODS

Physical activity was assessed for 1 week in 86 children (41 girls, 45 boys; mean age 7±2 years) by uniaxial accelerometry. The epoch was set at 15 s and reintegrated to 30 and 60 s. Time spent sedentary and in moderate and vigorous physical activity (MVPA) was assessed using a range of cutoff points. Number of days required to achieve 80% reliability was predicted using the Spearman-Brown Prophecy formula.

RESULTS

The Reilly cutoff points (<1100 counts per min (CPM)) indicated less sedentary time per day when comparing 15 vs 30 s and 15 vs 60 s epochs: 570±91 vs 579±93 min and 570±91 vs 579±94 min, respectively; P<0.05. Pate cutoff points (>420 counts per 15 s) reported more MVPA time per day compared with Sirard (890 counts per 15 s) and Puyau cutoff points (>3200 counts per min) using 15 s epoch: 78 (4-197) min (median (range) vs 18 (1-80) min and 24 (1-100) min, respectively; P<0.001. Compliance with guidelines of at least 60 min MVPA was 84, 78 and 73% for Pate cutoff points using 15, 30 and 60 s epochs, respectively, but 0% for Sirard and Puyau cutoff points across epochs. The number of days required to achieve 80% reliability for CPM, sedentary and MVPA time was 7.4-8.5 days.

CONCLUSION

Choice of epoch and cutoff point significantly influenced the classification of sedentary and MVPA time and observed compliance to the MVPA guidelines.

The IDEFICS validation study on field methods for assessing physical activity and body composition in children: design and data collection

OBJECTIVE

To describe the design, measurements and fieldwork of the IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) physical activity and body composition validation study, and to determine the potential and limitations of the data obtained.

DESIGN

Multicentre validation study.

SUBJECTS

A total of 98 children from four different European countries (age: 4-10 years).

METHODS

An 8-day measurement protocol was carried out in all children using a collaborative protocol. Reference methods were the doubly labelled water method for physical activity, and a three- and a four-compartment model for body composition. Investigated field methods were accelerometers, a physical activity questionnaire and various anthropometric measurements.

RESULTS

For the validation of physical activity field methods, it was possible to gather data from 83 to 89 children, laying the basis for age- and sex-specific results. The validation of body composition field methods is possible in 64-80 children and allows sex-specific analyses but has only limited statistical power in the youngest age group (<6 years). The amount of activity energy expenditure (AEE) varied between centres, sexes and age groups, with boys and older children having higher estimates of AEE. After normalisation of AEE by body weight, most group-specific differences diminished, except for country-specific differences.

CONCLUSION

The IDEFICS validation study will allow age- and sex-specific investigation of questions pertaining to the validity of several field methods of body composition and physical activity, using established reference methods in four different European countries. From the participant analyses it can be concluded that the compliance for the investigated field methods was higher than that for the reference methods used in this validation study.

Validity, practical utility and reliability of Actigraph accelerometry for the measurement of habitual physical activity in dogs

OBJECTIVES

To test the validity, practical utility, and reliability of the Actigraph GT3-X accelerometer for measurement of habitual physical activity in pet dogs.

METHODS

In the validation study, 30 dogs wore the accelerometer for 1 day while being filmed. Accelerometer and film were synchronised and 10-minute periods of the filmed records were extracted with dogs in continuous periods of sedentary behaviour, light intensity physical activity indoors, light to moderate intensity physical activity outdoors and vigorous physical activity outdoors. For the practical utility and reliability studies, 20 dogs wore the GT3-X accelerometers for 1 week: practical utility was quantified as data loss and was also assessed by owner questionnaire; reliability was determined by 2 to 7 days of monitoring using the Spearman-Brown prophecy formula.

RESULTS

In the validation study, accelerometry output differed significantly between activity intensities (Friedman test, P<0·01). In the practical utility study, no data were lost from any dogs and dog owners reported that accelerometry was well tolerated. Reliability of accelerometry output was high: for 3 days of wear, it was 91% [95% confidence interval (CI) 82 to 96] and for 7 days of wear, it was 94% (CI 88 to 97).

CLINICAL SIGNIFICANCE

The GT3-X accelerometer is valid, practical and reliable for the measurement of habitual physical activity in dogs.

Accuracy of simple clinical and epidemiological definitions of childhood obesity: systematic review and evidence appraisal

The optimum means of defining obesity in children is unclear, creating variation in practice, and hindering obesity surveillance, prevention and treatment. This study aimed to review evidence on the use of body mass index (BMI) and waist circumference for diagnosis of high body fat content and adverse cardiometabolic risk factors in children and adolescents. A systematic literature review was carried out and evidence appraised using the Quality Assessment of Studies of Diagnostic Accuracy in Systematic Reviews method. Literature searching began following the last systematic review of this topic (end 2001) and collected evidence in MEDLINE and EMBASE in 0- to 18-year-olds that compared the accuracy of BMI vs. waist circumference and compared BMI interpreted relative to national reference data vs. BMI interpreted relative to Cole/International Obesity Task Force international reference data. Ten studies compared diagnostic accuracy of BMI vs. waist circumference: they reported no improved identification of adverse cardiometabolic risk profiles from waist circumference over that provided by high BMI. Eight studies compared BMI with national reference data vs. the international approach: 5/8 found significantly poorer accuracy (lower sensitivity) using BMI with the international approach; 3/8 found similar sensitivity; in 7/7 studies that compared specificity this was similar. In conclusion, the present review provides no compelling evidence for use of either high waist circumference or BMI interpreted using the International Obesity Task Force approach in preference to the use of national BMI percentiles for the identification of children and adolescents with excess fatness and adverse cardiometabolic risk profile.

Tracking of obesity and body fatness through mid-childhood

OBJECTIVES

To explore how fat, lean and body mass index (BMI) track in childhood and how this relates to parental obesity.

DESIGN AND SETTING

Prospective population-based cohort study: Avon Longitudinal Study of Parents and Children, UK.

METHOD

Height, weight and leg-to-leg bioelectrical impedance (BIA) were collected at ages 7 and 11 years, as well as pre-pregnancy parental heights and weights. For BMI International Obesity Task Force thresholds of obesity and overweight were used. Impedance data were expressed as separate lean and fat z scores, internally standardised for gender, height and age and a child was defined as over-fat if fat z score was >85th and very over-fat if >95th internal centile.

RESULTS

Data were available for 7723 and 7252 children at ages 7 and 11 years, respectively (6066 at both time points). Of those obese at age 7, 75% were still obese at age 11, while of those who had been overweight 16% had become obese and 20% now had normal BMI. Both fat and lean z scores showed moderate levels of tracking (correlation coefficients 0.70 and 0.73, respectively). Children with one or two obese parents had higher fat z scores at age 7 and showed greater increases in fat thereafter. They were more likely to be very over-fat at age 7 and, of these, 69% remained so at age 11 compared to only 45% with non-obese parents (p <0.001).

CONCLUSIONS

Children of obese parents already have high fat levels at age 7 and are more likely to remain very over-fat.

Assessment of obesity in children and adolescents: synthesis of recent systematic reviews and clinical guidelines

This review summarises recent systematic reviews and evidence-based guidelines that deal with the issue of how best to diagnose or define obesity in children and adolescents. A recent systematic review showed that parents typically fail to recognise obesity in their children and adolescents, and a good deal of other evidence suggests that health professionals under-diagnose obesity in children and adolescents when using informal methods based on observation. There is therefore a need for practical, objective, methods that both identify the fattest children and adolescents adequately, and identify those who are at greatest risk of the 'co-morbidities' of obesity. A large body of consistent evidence shows that a high body mass index (BMI) for age and sex identifies the fattest children adequately, with low-moderate false negative rate and a low false positive rate. Furthermore, children and adolescents at high BMI for age are at much greater risk of the co-morbidities of obesity. A recent systematic review found that the use of BMI for age with national reference data and cut-off points (such as the 95th percentile to define obesity) was superior to the Cole-International Obesity Task Force international approach for defining obesity based on BMI for age. The same systematic review also found no evidence that use of waist circumference for age improved the diagnosis of obesity, or the cardio-metabolic co-morbidities of obesity, in children and adolescents. Recent systematic reviews are therefore supportive of current guidelines that recommend percentile-based cut-offs relative to national reference data to (e.g. BMI at or above the 95th or 98th percentile in the UK) to define obesity for clinical applications in children and adolescents.

High prevalence of obesity in ambulatory children and adolescents with intellectual disability

BACKGROUND

Obesity prevalence is unusually high among adults with intellectual disability (ID). There is limited and conflicting evidence on obesity prevalence among ambulatory children and adolescents with ID. The present study aimed to estimate obesity prevalence in this group and to compare with population prevalence.

METHODS

Survey of nine schools (n = 206, 150 boys) for ambulatory children and adolescents with mild-moderate ID in Scotland in 2007. Obesity was defined as measured body mass index (BMI) at or above the 95th percentile relative to UK 1990 reference data, and using the international definition based on BMI. Obesity prevalence observed was compared against Scottish population data on obesity prevalence from the most recent nationally representative survey.

RESULTS

Obesity prevalence (at or above 95th percentile for BMI) was 36%, and was significantly higher among those attending secondary schools compared with primary schools (P < 0.01). Prevalence of obesity was significantly higher than in the general paediatric population in both boys and girls (P < 0.01).

CONCLUSIONS

The present study suggests that that obesity may be very prevalent among ambulatory children and adolescents with ID, and that increased obesity risk may begin in childhood.

Objectively measured habitual physical activity in a highly obesogenic environment

BACKGROUND

While the prevalence of overweight and obesity among children continues to grow nationally, prevalence in the North-East of England is among the highest in the UK. The objective of this study was to investigate the habitual physical activity levels in a particularly obesogenic environment in the North-East of England.

METHODS

Eight primary schools were selected using a stratified random sampling frame ranking average deprivation levels. Participating children (n = 246, mean age 10 years) wore an accelerometer (Actigraph, GT-256) over five consecutive days (weekend plus three weekdays). Total daily moderate-to-vigorous intensity physical activity was calculated using thresholds by Puyau and colleagues.

RESULTS

Only 7% (17/246) of children were sufficiently active. Boys were more physically active than girls (766 +/- 268 vs. 641 +/- 202 counts/min, 95% CI for the difference 63-186 cpm.). Total physical activity was not influenced significantly by deprivation levels or weight status, and there were no significant differences in physical activity between school or weekend days.

CONCLUSIONS

The North-East of England is a recognized 'hot spot' for paediatric obesity and the present study shows that low levels of habitual physical activity are typical. Choice of accelerometry threshold affects both the apparent amount of physical activity and the ability to detect groups with particularly low levels of physical activity.

Association of duration of television viewing in early childhood with the subsequent development of asthma

OBJECTIVE

To investigate whether duration of television (TV) viewing in young children is associated with subsequent development of asthma.

METHODS

Children taking part in the Avon Longitudinal Study of Parents and Children (ALSPAC) with no wheeze up to the age of 3.5 years and follow-up data at 11.5 years of age took part in a prospective longitudinal cohort study. The main outcome measure was asthma, defined as doctor-diagnosed asthma by 7.5 years of age with symptoms and/or treatment in the previous 12 months at 11.5 years of age. Parental report of hours of TV viewing per day by the children was ascertained at 39 months.

RESULTS

In children with no symptoms of wheeze at 3.5 years of age and follow-up data at 11.5 years of age, the prevalence of asthma was 6% (185/3065). Increased TV viewing at 3.5 years was associated with increased prevalence of asthma at 11.5 years of age (p for linear trend = 0.0003). Children who watched television for >2 h/day were almost twice as likely to develop asthma by 11.5 years of age as those watching TV for 1-2 h/day (adjusted odds ratio 1.8 (95% CI 1.2 to 2.6)).

CONCLUSION

Longer duration of TV viewing in children with no symptoms of wheeze at 3.5 years of age was associated with the development of asthma in later childhood.

Surveillance of physical activity in the UK is flawed: validation of the Health Survey for England Physical Activity Questionnaire

OBJECTIVE

Public health surveillance of physical activity in children in the UK depends on a parent-reported physical activity questionnaire which has not been validated. We aimed to validate this questionnaire against measurement of physical activity using accelerometry in 6-7-year-old children.

METHODS

In 130 children aged 6-7 years (64 boys, 66 girls) we estimated habitual moderate-vigorous intensity physical activity (MVPA) using the Health Survey for England parent-report questionnaire for physical activity. For the same time period and the same children, we measured MVPA objectively using 7-day accelerometry with the Actigraph accelerometer.

RESULTS

The questionnaire over-estimated MVPA significantly (paired t test, p<0.01). Mean error (bias) when using the questionnaire was 122 min/day (95% CI 124 to 169). Mean time spent in MVPA was 146 min/day (95% CI 124 to 169) using the questionnaire and 24 min/day (95% CI 22 to 26) using the accelerometer. Rank order correlations between MVPA measured by accelerometer and estimated by the questionnaire were not statistically significant.

CONCLUSIONS

Public health surveillance of physical activity should not rely on this questionnaire. Levels of habitual physical activity in children are likely to be substantially lower than those reported in UK health surveys.

Energy intake variability in free-living young children

It has been suggested that young children regulate their daily energy intake very closely with highly stable day-to-day total energy intake. This hypothesis was developed on the basis of an experimental study of 15 children aged 26 to 62 months, which reported a within-subject coefficient of variation (CV) in daily energy intake of 10.4%. We tested the hypothesis that free-living energy intakes were highly stable on a day-to-day basis in a sample of free-living young children from Glasgow, Scotland. In 101 children (47 boys) aged 2.6-6.8 years, energy intake was measured using multiple-pass 24-h recalls. Within-subject CV was 19.2%, which was significantly higher than the 10.4% reported by previously Birch and colleagues (p<0.0001). In addition, we identified four other studies on free-living children with within-subject CVs ranging from 16.1-28.7%. This evidence indicates that young children show a wide intra-individual variation in day-to-day regulation of energy intake in a free-living environment.

Objective measurement of physical activity and sedentary behaviour: review with new data

Objective methods are being used increasingly for the quantification of the amount of physical activity, intensity of physical activity and amount of sedentary behaviour in children. The accelerometer is currently the objective method of choice. In this review we address the advantages of objective measurement compared with more traditional subjective methods, notably the avoidance of bias, greater confidence in the amount of activity and sedentary behaviour measured, and improved ability to relate variation in physical activity and sedentary behaviour to variation in health outcomes. We also consider unresolved practical issues in paediatric accelerometry by critically reviewing the existing evidence and by providing new evidence.

Polymorphic variation in surfactant protein B is associated with COPD exacerbations

Exacerbations of chronic obstructive pulmonary disease (COPD) reduce quality of life and increase mortality. Genetic variation might explain the substantial variability seen in exacerbation frequency among COPD subjects with similar lung function. Polymorphisms in five candidate genes, previously associated with COPD susceptibility, were analysed in order to determine whether they demonstrated association with COPD exacerbations. A total of 88 single nucleotide polymorphisms (SNPs) in the genes microsomal epoxide hydrolase (EPHX1), transforming growth factor, beta-1 (TGFB1), serpin peptidase inhibitor, clade E (nexin, plasminogen activator inhibitor type 1), member 2 (SERPINE2), glutathione S-transferase pi (GSTP1) and surfactant protein B (SFTPB) were genotyped in 389 non-Hispanic white participants in the National Emphysema Treatment Trial. Exacerbations were defined as COPD-related emergency room visits or hospitalisations using the Centers for Medicare and Medicaid Services claims data. One or more exacerbations were experienced by 216 (56%) subjects during the study period. An SFTPB promoter polymorphism, rs3024791, was associated with COPD exacerbations. Logistic regression models, analysing a binary outcome of presence or absence of exacerbations, confirmed the association of rs3024791 with COPD exacerbations. Negative binomial regression models demonstrated association of multiple SFTPB SNPs (rs2118177, rs2304566, rs1130866 and rs3024791) with exacerbation rates. Polymorphisms in EPHX1, GSTP1, TGFB1 and SERPINE2 did not demonstrate association with COPD exacerbations. In conclusion, genetic variation in surfactant protein B is associated with chronic obstructive pulmonary disease susceptibility and exacerbation frequency.

Parents' journey through treatment for their child's obesity: a qualitative study

BACKGROUND

Treatment for childhood obesity is characterised by patient non-attendance and drop-out, and widespread failure to achieve weight maintenance. Qualitative methods may improve our understanding of patient perceptions and so improve treatment for childhood obesity.

AIM

To provide insight into the perceptions of parents of obese children as they "journey" from pre-treatment to end of treatment.

METHODS

We used purposive sampling and studied 17 parents of children (mean (SD) age 8.4 (2.1) years) attending 6-month outpatient treatments for obesity (BMI>98th percentile). Parent's perceptions were explored by in-depth interviews, analysed using Framework methods.

RESULTS

Parents were characterised as being unaware of their child's weight, in denial or actively seeking treatment. Parents were consistently motivated to enter treatment due to perceived benefits to their child's self-esteem or quality of life, and weight outcomes appeared typically less important. During treatment parents felt there was a lack of support for lifestyle changes outside the clinic, and noted that members of the extended family often undermined or failed to support lifestyle changes. Parents generally felt that treatment should have continued beyond 6 months and that it had provided benefits to their child's well-being, self-esteem and quality of life, and this is what motivated many to remain engaged with treatment.

DISCUSSION

This study may help inform future treatments for childhood obesity by providing insights into the aspects of treatment of greatest importance to parents. Future treatments may need to consider providing greater support for lifestyle changes within the extended family, and may need to focus more on psycho-social outcomes.

Socioeconomic differences in risk factors for obesity in adolescents in Northern Ireland

OBJECTIVES. To test for socioeconomic differences in some biological and behavioral risk factors for obesity in a representative and contemporary sample of adolescents.

METHODS

Cohort study of 2 016 randomly selected 12- and 15-year-olds representative of Northern Ireland, studied in 2000. We tested for differences in obesity risk factors based on a priori hypotheses between adolescents from affluent (n=487) versus deprived (n=237) families. Potential risk factors were dietary energy and macronutrient intake, habitual physical activity, TV viewing and computer use, and physical fitness.

RESULTS

Adolescents of higher socioeconomic status reported significantly lower habitual energy intake (210 kJ/kg/d SD 80 vs. 229 kJ/kg/d SD 91, p < 0.01); significantly higher levels of habitual physical activity (physical activity score 25.9 SD 16.6 vs. 20.9 SD 16.4, p < 0.001), and had significantly higher cardiorespiratory fitness (estimated VO2 max 46.2 ml/kg/min SD 8.4 vs. 43.4 ml/kg/min SD 8.3, p < 0.001). Prevalence of overweight and obesity (BMI >85th percentile) in the cohort was 29.1% and was slightly but not significantly higher in the low (33.8%) versus the high (28.5%) socioeconomic groups.

CONCLUSIONS

Differences in some of the biological and behavioral risk factors for obesity exist between adolescents of different socioeconomic status in Northern Ireland. These may help explain the basis of established socioeconomic differences in obesity risk.

Clinical determinants of exacerbations in severe, early-onset COPD

Chronic obstructive pulmonary disease (COPD) exacerbations impair health. The present authors analysed participants in the Boston Early-Onset COPD Study for familial aggregation and propensity for COPD exacerbations. In the present study, two exacerbation outcomes, episodes of cough and phlegm, and frequent exacerbations were analysed with multivariable modelling and generalised estimating equations. In early-onset COPD probands, passive tobacco smoke exposure within the home was strongly associated with episodes of cough and phlegm. Chronic phlegm production was associated with both exacerbation phenotypes in probands. In first-degree relatives of early-onset COPD probands, chronic bronchitis, episodic wheezing, pneumonia and active smoking were associated with the episodes of cough and phlegm phenotype. In relatives, identical characteristics plus exertional dyspnoea were associated with frequent exacerbations. Exacerbation risk increased with declining lung function. Familial aggregation for episodes of cough and phlegm was observed in relatives with severe obstruction. In conclusion, passive smoke exposure increases morbidity in severe early-onset chronic obstructive pulmonary disease probands, and chronic obstructive pulmonary disease exacerbations correlate with chronic sputum production in probands and relatives. The familial aggregation of exacerbations suggests a genetic basis for susceptibility to chronic obstructive pulmonary disease exacerbations.

Development of bioelectrical impedance-derived indices of fat and fat-free mass for assessment of nutritional status in childhood

OBJECTIVES

(1) To develop a method of manipulating bioelectrical impedance (BIA) that gives indices of lean and fat adjusted for body size, using a large normative cohort of children. (2) To assess the discriminant validity of the method in a group of children likely to have abnormal body composition.

DESIGN

Two prospective cohort studies.

SETTING

Normative data: Avon Longitudinal Study of Parents and Children (ALSPAC), population based cohort; proof of concept study: tertiary feeding clinic and special needs schools.

SUBJECTS

Normative data: 7576 children measured aged between 7.25 and 8.25 (mean 7.5) (s.d.=0.2) years; proof of concept study: 29 children with either major neurodisability or receiving artificial feeding, or both, mean age 7.6 (s.d.=2) years.

MEASURES

Leg-to-leg (Z (T)) and arm-to-leg (Z (B)) BIA, weight and height. Total body water (TBW) was estimated from the resistance index (RI=height(2)/Z), and fat-free mass was linearly related to TBW. Fat mass was obtained by subtracting fat-free mass from total weight. Fat-free mass was log-transformed and the reciprocal transform was taken for fat mass to satisfy parametric model assumptions. Lean and fat mass were then adjusted for height and age using multiple linear regression models. The resulting standardized residuals gave the lean index and fat index, respectively.

RESULTS

In the normative cohort, the lean index was higher and fat index lower in boys. The lean index rose steeply to the middle of the normal range of body mass index (BMI) and then slowly for higher BMI values, whereas the fat index rose linearly through and above the normal range. In the proof of concept study, the children as a group had low lean indices (mean (s.d.) -1.5 (1.7)) with average fat indices (+0.21 (2.0)) despite relatively low BMI standard deviation scores (-0.60 (2.3)), but for any given BMI, individual children had extremely wide ranges of fat indices. The lean index proved more stable and repeatable than BMI.

CONCLUSIONS

This clinical method of handling BIA reveals important variations in nutritional status that would not be detected using anthropometry alone. BIA used in this way would allow more accurate assessment of energy sufficiency in children with neurodisability and may provide a more valid identification of children at risk of underweight or obesity in field and clinical settings.

Tackling the obesity epidemic: new approaches

Perspective on the paper by Rudolf et al (see page 736)

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.

Quality of life in a clinical sample of obese children

OBJECTIVES

To measure health-related quality of life (HRQoL) in a clinical sample of obese children by child self-report and parent-proxy report; to compare quality of life assessments provided by obese children and their parents; to assess differences in quality of life between the obese clinical sample and healthy control children.

DESIGN

Pairwise comparison of obese children matched for age, gender and socio-economic status with non-obese controls.

SUBJECTS

One hundred and twenty-six obese children (body mass index (BMI) >/=98th centile) and 71 lean control children (BMI <85th centile). Controls were matched with 71 children from the obese clinical group (mean age 8.6, standard deviation (s.d.) 1.9 years; 33 M/38 F).

MEASUREMENT

The Paediatric Quality of Life Inventory (UK) version 4 was self-administered to parents and to children aged 8-12 years and interview was administered to children aged 5-7 years. This questionnaire assessed physical, social, emotional and school functioning from which total, physical and psychosocial health summary scores were derived.

RESULTS

In the obese clinical group (n=126), parent proxy-reported quality of life was low for all domains. In the obese clinical group, parent-reported scores were significantly lower than child self-reported scores in all domains except physical health and school functioning. Parent-proxy reports were significantly higher for healthy controls than obese children in all domains (median total score 85.2 vs 64.7; 95% confidence interval (CI) 15.6, 24.1). For child self-reports, only physical health was significantly higher for healthy controls than obese children (median score 81.3 vs 75.0; 95% CI 3.1, 12.5).

CONCLUSIONS

HRQoL is impaired in clinical samples of obese children compared to lean children, but the degree of impairment is likely to be greatest when assessed using the parent perspective rather than the child perspective.

Habitual physical activity and sedentary behaviour in a clinical sample of obese children

OBJECTIVE

To objectively measure habitual physical activity and sedentary behaviour in a clinical sample of obese children and to compare with age- and sex-matched non-obese controls.

DESIGN

Pairwise comparison of obese children matched for age and gender with non-obese controls.

SUBJECTS

A total of 116 obese children (body mass index (BMI)> or =98th centile) and 53 non-obese control children (BMI<85th centile). Controls were matched with 53 of the obese children (mean age 8.6, s.d. 2.0 years; 25 M and 28 F).

MEASUREMENT

Habitual physical activity and sedentary behaviour were measured over a 7-day period using CSA accelerometers. Total physical activity (mean accelerometry count per minute (c.p.m.)), percentage of monitored time in sedentary behaviour, light and moderate to vigorous intensity physical activity (MVPA) were compared.

RESULTS

Obese children (n=116) spent on average 80.4% of their monitored time in sedentary behaviour and 2.5% of their monitored time in MVPA. Total activity (mean c.p.m.) was significantly higher in the non-obese group (n=53) than the obese group (n=53), 729 vs 648 c.p.m.; 95% confidence interval (CI) 7, 155. Time spent in sedentary behaviour averaged 80.9% (s.d. 6.6) in the obese group and 79.3% (s.d. 6.2) in the non-obese group, with no significant between-group difference (95% CI -3.9, 0.6). Light intensity activity was similar in the obese and non-obese groups (15.9 vs 17.3%; 95% CI -0.3, 3.0). Participation in MVPA was significantly higher in the non-obese vs obese group (3.9 vs 2.4%; 95% CI 0.6, 2.0).

CONCLUSION

This study supports the hypothesis that a clinical sample of obese children is less physically active than non-obese children, although the difference in total activity and MVPA between the groups was small.

Effect of socioeconomic status on objectively measured physical activity

BACKGROUND

A socioeconomic gradient in childhood obesity is known to be present by the age of school entry in the UK. The origin of this gradient is unclear at present, but must lie in socioeconomic differences in habitual physical activity, sedentary behaviour, or dietary intake.

AIMS

To test the hypothesis that habitual physical activity and/or sedentary behaviour are associated with socioeconomic status (SES) in young Scottish children.

METHODS

Observational study of 339 children (mean age 4.2 years, SD 0.3) in which habitual physical activity and sedentary behaviour were measured by accelerometry over six days (study 1). In a second study, 39 pairs of children of distinctly different SES (mean age 5.6 years, SD 0.3) were tested for differences in habitual physical activity and sedentary behaviour by accelerometry over seven days.

RESULTS

In study 1, SES was not a significant factor in explaining the amount of time spent in physical activity or sedentary behaviour once gender and month of measurement were taken into account. In study 2, there were no significant differences in time spent in physical activity or sedentary behaviour between affluent and deprived groups.

CONCLUSION

Results do not support the hypothesis that low SES in young Scottish children is associated with lower habitual physical activity or higher engagement in sedentary behaviour.

Low physical activity levels and high levels of sedentary behaviour are characteristic of rural Irish primary school children

There is increasing public health concern that levels of physical activity in children are extremely low. This study aimed to describe objectively levels of physical activity and sedentary behaviour during the waking hours in a sample of 4-5 year old (median 5.4 years range 4.3, 6.0) rural Irish children (n=41) and to test for gender differences in patterns of physical activity and sedentary behaviour. There were significant gender differences in physical activity (Boys (median) 834 accelerometer counts per minute (cpm), girls (median) 628cpm; p = 0.0015), sedentary behaviour (Boys 74% of waking time, girls 81% of waking time, p=0.0011) and moderate-vigorous physical activity (Boys 4% of waking time, girls 2% of waking time; p=0.0175). This study that suggests young rural Irish children lead sedentary lifestyles.