Evaluation of implementation and effect of primary school based intervention to reduce risk factors for obesity

OBJECTIVES

To implement a school based health promotion programme aimed at reducing risk factors for obesity and to evaluate the implementation process and its effect on the school.

DESIGN

Data from 10 schools participating in a group randomised controlled crossover trial were pooled and analysed.

SETTING

10 primary schools in Leeds.

PARTICIPANTS

634 children (350 boys and 284 girls) aged 7-11 years.

MAIN OUTCOME MEASURES

Response rates to questionnaires, teachers' evaluation of training and input, success of school action plans, content of school meals, and children's knowledge of healthy living and self reported behaviour.

RESULTS

All 10 schools participated throughout the study. 76 (89%) of the action points determined by schools in their school action plans were achieved, along with positive changes in school meals. A high level of support for nutrition education and promotion of physical activity was expressed by both teachers and parents. 410 (64%) parents responded to the questionnaire concerning changes they would like to see implemented in school. 19 out of 20 teachers attended the training, and all reported satisfaction with the training, resources, and support. Intervention children showed a higher score for knowledge, attitudes, and self reported behaviour for healthy eating and physical activity.

CONCLUSION

This programme was successfully implemented and produced changes at school level that tackled risk factors for obesity.

Randomised controlled trial of primary school based intervention to reduce risk factors for obesity

OBJECTIVE

To assess if a school based intervention was effective in reducing risk factors for obesity.

DESIGN

Group randomised controlled trial.

SETTING

10 primary schools in Leeds.

PARTICIPANTS

634 children aged 7-11 years.

INTERVENTION

Teacher training, modification of school meals, and the development of school action plans targeting the curriculum, physical education, tuck shops, and playground activities.

MAIN OUTCOME MEASURES

Body mass index, diet, physical activity, and psychological state.

RESULTS

Vegetable consumption by 24 hour recall was higher in children in the intervention group than the control group (weighted mean difference 0.3 portions/day, 95% confidence interval 0.2 to 0.4), representing a difference equivalent to 50% of baseline consumption. Fruit consumption was lower in obese children in the intervention group (-1.0, -1.8 to -0.2) than those in the control group. The three day diary showed higher consumption of high sugar foods (0.8, 0.1 to 1.6)) among overweight children in the intervention group than the control group. Sedentary behaviour was higher in overweight children in the intervention group (0.3, 0.0 to 0.7). Global self worth was higher in obese children in the intervention group (0.3, 0.3 to 0.6). There was no difference in body mass index, other psychological measures, or dieting behaviour between the groups. Focus groups indicated higher levels of self reported behaviour change, understanding, and knowledge among children who had received the intervention.

CONCLUSION

Although it was successful in producing changes at school level, the programme had little effect on children's behaviour other than a modest increase in consumption of vegetables.

Growth of primary school children: a validation of the 1990 references and their use in growth monitoring

AIMS

To determine whether the British 1990 growth charts are valid for cross sectional and longitudinal use in primary school children.

METHODS

A total of 694 children aged 7-10 years from 10 Leeds primary schools were weighed and measured annually over three years by an expert auxologist. SD scores were calculated using both the Tanner-Whitehouse (TW) and the revised British 1990 growth references.

RESULTS

The growth of this sample of children approximated the 1990 growth reference, with mean (SD) scores for height 0.12 (1.01), weight 0.20 (1.07), and body mass index (BMI) 0. 19 (1.12). By comparison, the TW standards exaggerated the height and weight centiles. There was minimal channel crossing for height in either direction with 1.0% crossing up at least one channel width (0.67 SD scores), and 0.2% down for height. However, there was clear evidence of weight and particularly BMI increasing with age between and within subjects, at rates of up to 0.1 SD scores per year.

CONCLUSIONS

This study supports the adoption of the new growth references, and their use longitudinally for height monitoring. It also highlights the increasing weight of the school age population as a public health issue.

Anthropometric indices of failure to thrive

AIMS

To compare five anthropometric methods of classifying failure to thrive in order to ascertain their relative merits in predicting developmental, dietary, and eating problems.

METHODS

The five anthropometric methods were compared in 83 children with failure to thrive.

RESULTS

The methods were inconsistent in classification of severity, and no one method was superior in predicting problems.

CONCLUSIONS

Weight alone, being the simplest, is still the most reasonable marker for failure to thrive and associated problems.

Exploring the scope for advocacy by paediatricians

AIMS

To ascertain the type and extent of problems requiring advocacy in paediatrics. To develop an approach for analysing problems according to their root causes and the level of society at which advocacy is needed.

METHODS

Nine paediatricians kept detailed clinical diaries for two weeks to identify problems. Classifications were developed to categorise problems by cause and the level of society at which they needed to be addressed. The press was surveyed for one week for childhood issues attracting media attention.

RESULTS

60 problems requiring advocacy were identified. Root causes included failures within agencies, between agencies, and inadequate provision. In addition to advocacy required individually, "political" action was needed at the community level (16 issues), city level (16 issues), and nationally (15 issues). 103 articles were found in the press, these did not relate closely to issues identified by clinicians.

CONCLUSIONS

Many opportunities for advocacy arise in the course of daily work. A systematic way of analysing them has been developed for use in planning action. To optimise the health and health care of children, there is a need to train and support paediatricians in advocacy work for local as well as national issues. Ten issues were identified that might be prioritised by paediatricians working on an agenda for action.

A randomised controlled trial of specialist health visitor intervention for failure to thrive

AIMS

To determine whether home intervention by a specialist health visitor affects the outcome of children with failure to thrive.

METHODS

Children referred for failure to thrive were randomised to receive conventional care, or conventional care and additional specialist home visiting for 12 months. Outcomes measured were growth, diet, use of health care resources, and Bayley, HAD (hospital anxiety and depression), and behavioural scales.

RESULTS

Eighty three children, aged 4-30 months, were enrolled, 42 received specialist health visitor intervention. Children in both groups showed good weight gain (mean (SD) increase in weight SD score for the specialist health visitor intervention group 0.59 (0.63) v 0.42 (0.62) for the control group). Children < 12 months in the intervention group showed a higher mean (SD) increase in weight SD score than the control group (0.82 (0.86) v 0.42 (0.79)). Both groups improved in developmental score and energy intake. No significant differences were found for the primary outcome measures, but controls had significantly more dietary referrals, social service involvement, and hospital admissions, and were less compliant with appointments.

CONCLUSIONS

The study failed to show that specialist health visitor intervention conferred additional benefits for the child. However, the specialist health visitor did provide a more coordinated approach, with significant savings in terms of health service use. Problems inherent to health service research are discussed.

A search for the evidence supporting community paediatric practice

AIM

Controversy exists regarding the evidence base of medicine. Estimates range from 20% to 80% in various specialties, but there have been no studies in paediatrics. The aim of this study was to ascertain the evidence base for community paediatrics.

METHODS

Twelve community paediatricians working in clinics and schools in Yorkshire, Manchester, Teesside, and Cheshire carried out a prospective review of consecutive clinical contacts. Evidence for diagnostic processes, prescribing, referrals, counselling/advice, and child health promotion was found by searching electronic databases. This information was critically appraised and a consensus was obtained regarding quality and whether it supported actions taken.

RESULTS

Two hundred and forty-seven consultations and 1149 clinical actions were performed. Good evidence was found from a randomised controlled trial or other appropriate study for 39.9% of the 629 actions studied; convincing non-experimental evidence for 7%; inconclusive evidence for 25.4%; evidence of ineffectiveness for 0.2%; and no evidence for 27.5%. Prescribing and child health promotion activities had the highest levels of quality evidence, and counselling/advice had the lowest.

CONCLUSIONS

An encouraging amount of evidence was found to support much of community paediatric practice. This study improved on previous research in other specialties because actions other than medications and surgery were included.

What do we know about children who fail to thrive?

It is the aim of this article to provide an overview of difficulties in children with poor growth enrolled in an intensive community intervention trial for failure to thrive (FTT). Children were assessed for developmental delay (Bayley test), inadequate diet, iron deficiency, eating and other behavioural problems, and maternal anxiety and depression (HAD Scales). Sixty-three children aged 6 months to 2 1/2 years were studied. The majority of children were from families living in poverty with many from divorced, separated or single families. On developmental testing (Bayley Developmental Scales) 55% were delayed, 27% severely. Seventy-seven per cent had caloric intakes below the expected average requirement (EAR) with 19% reported at less than 50% of requirements. Iron intakes were similarly low and one-third had iron deficiency anaemia on testing. Sixty per cent of children were reported to have eating difficulties, principally in terms of responding negatively to food. Eating difficulties had commonly presented within the first weeks of life. Other behavioural and sleeping difficulties were also common. Children identified as failing to thrive in the community are likely to have associated developmental, dietary and behavioural problems which may not be immediately evident and to an extent which may require intensive multidisciplinary involvement.

Gender differences in infirmary use at a residential summer camp

Studies of health behavior in adults show that women report more morbidity and greater health service utilization than do men, despite lower mortality rates. Explanations involve social and biological gender differences in adult life. Infirmary utilization at a residential summer camp where parental influence is minimized was studied to determine whether these gender differences occur in the pediatric age group. Three hundred ninety-eight campers, 8 to 18 years old were studied. Girls were observed to make greater use of the infirmary than boys (p less than .01) and were especially likely to present with minor trauma, both musculoskeletal (p less than .05) and skin (p less than .01). No correlation was found between age and frequency of visits. Obvious morbidity was similar for boys and girls, in that no gender difference was observed in those visiting for definite medical indications alone or in those admitted. However, a difference was evident in those visiting for minor and trivial problems, particularly in those making three or more visits for minor and trivial problems (p less than .01). Although obvious morbidity was no different in campers, girls used the infirmary more than boys in a manner similar to that reported for adult health behavior. This suggests that gender differences occur earlier than suspected and are not simply related to adult social roles.

Neurosecretory dysfunction of growth hormone secretion in thalassemia major

The growth retardation of children with thalassemia major is multifactorial. Along the endocrine axis of growth hormone (GH), serum somatomedin has been shown to be deficient and GH response to GH-releasing hormone impaired, while GH response to provocative stimuli is normal. We studied the spontaneous secretion of GH in seven patients with thalassemia major and growth retardation. Three of the patients were hypothyroid, and the other four were euthyroid. Spontaneous secretion of GH in all seven patients was subnormal: the number of pulses, the mean pulse amplitude, and the integrated concentration of GH were all lower than in 14 age- and sex-matched (10 pubertal and 4 prepubertal) control subjects. GH response to provocative stimuli was normal in the euthyroid patients. This pattern of response corresponds with the definition of neurosecretory dysfunction of GH secretion. It is concluded that the growth retardation of patients with thalassemia major is partly due to neurosecretory dysfunction of GH secretion.

A randomized clinical trial of the insulin pump vs intensive conventional therapy in diabetic pregnancies

Improved perinatal outcome is associated with the prevention of hyperglycemia during pregnancy in diabetic women. To determine whether the method of insulin administration influences the degree of diabetic control obtained, we randomized 22 pregnant diabetic women to intensive conventional insulin therapy (N = 11) and insulin pump therapy (N = 11). Frequent outpatient visits; home glucose monitoring, at least six times daily; and frequent telephone contact were offered to all subjects. Patients were hospitalized in the inpatient clinical research center each trimester for a 24-hour metabolic profile. There were no differences between the two treatment groups with respect to outpatient mean glucose levels, symptomatic hypoglycemia, or glycosylated hemoglobin levels, or with respect to inpatient mean glucose level, glycemic excursions, chemical hypoglycemia, or hyperglycemia. Excellent metabolic control was achieved with both treatment methods.

Effect of intensive insulin treatment on linear growth in the young diabetic patient

Although impaired growth is a well-recognized complication of uncontrolled diabetes, it has not been established whether less severe metabolic derangements commonly seen with conventional treatment adversely affected growth potential. To examine this question, growth velocity was measured in nine type 1 diabetic patients (age 14 +/- 3 years) before and after six months of intensive insulin treatment either with the insulin pump or with multiple injections, which lowered mean plasma glucose concentration from 270 +/- 96 to 105 +/- 55 mg/dl and total glycosylated hemoglobin from 12.4 +/- 3.0 to 8.4 +/- 1.5% (mean +/- SD). During conventional treatment, growth velocity (5.3 +/- 2.2 cm/year) was within the range of normal despite elevations in plasma glucose concentrations. However, growth velocity increased sharply during intensive treatment (to 9.4 +/- 3.9 cm/year, P less than 0.005), reaching values in excess of normal in seven patients. The increase in growth velocity observed during intensive treatment was associated with a twofold rise in plasma somatomedin-C values. Skeletal maturation, previously normal or slightly delayed, did not advance excessively. These data indicate that the metabolic changes accompanying intensive treatment may enhance growth in diabetic children, even in those with apparently normal growth velocity during conventional therapy.

Long-term improvement of metabolic control with the insulin pump does not reverse diabetic microangiopathy

Restoration of near-normal glucose metabolism with the insulin pump reduces retinal fluorescein leakage and microalbuminuria in diabetes. However, it is not known whether these functional changes reflect a true reversal of diabetic retinopathy or nephropathy. To evaluate this question, we studied the effect of 1-2 yr of insulin pump treatment on clinical endpoints in 17 type I diabetic patients. In each patient, plasma glucose and total glycosylated hemoglobin levels fell to normal or near-normal levels. The total daily dose of insulin given during the first month of pump treatment (52 +/- 5 U/day) was comparable to that given during conventional treatment (44 +/- 3 U/day) and varied little over the 1-2 yr period of observation. Ten eyes without retinopathy at the start of the study remained without retinopathy after 15-23 mo of pump treatment. One of eleven eyes with background retinopathy developed proliferative retinopathy and 3 of 13 eyes with proliferative retinopathy progressed during pump treatment. Similarly, no improvement in renal function was observed in the six patients with diabetic nephropathy on entry to the study. In the first month of pump treatment, proteinuria consistently fell to values 30% below prepump levels (P less than 0.005). However, the diminution in proteinuria was not sustained and all remain proteinuric after 13-18 mo of pump therapy. Serum creatinine rose slightly and creatinine clearance did not significantly change. These data suggest that insulin pump treatment does not reverse established diabetic microvascular complications, despite a sustained improvement in metabolic control for up to 2 yr.(ABSTRACT TRUNCATED AT 250 WORDS)

Optimal insulin delivery in adolescents with diabetes: impact of intensive treatment on psychosocial adjustment

The psychosocial effects of recent advances in the management of diabetes mellitus are unknown and could conceivably be adverse, particularly during the critical period of adolescence. Seven teenagers were evaluated by standard psychosocial scales and a detailed questionnaire before and on completion of a 6-mo intensive management program utilizing home glucose monitoring and multiple injections or the insulin infusion pump. All achieved improved metabolic control with inpatient glucose values (during 24-h monitoring) falling from 244 +/- 58 to 108 +/- 10 mg/dl, glycosylated hemoglobin levels falling from 11.8 +/- 2.9% to 8.4 +/- 1.7%, and home glucose levels averaging 121 +/- 16 mg/dl. Standardized scales evaluating depression, diabetic adjustment, self-esteem, and social adjustment indicated no deterioration in psychosocial functioning. There was a statistically significant increase in locus of control scores, suggesting an improved sense of internal control of life events. The program questionnaire revealed a positive response to both the program and the control devices used. This study suggests that the positive metabolic benefits of intensive diabetic management during adolescence are not offset by adverse psychosocial effects and indeed positive psychosocial benefits may result.

Efficacy of the insulin pump in the home treatment of pregnant diabetics

The efficacy and feasibility of the insulin infusion pump in pregnancy were examined in seven class D to FR diabetics, maintained on the pump at home from 10 to 29 wk gestation until delivery. An improvement in glucose control was achieved within the first month and sustained to term. Home monitoring demonstrated a fall in mean blood glucose levels from 135 mg/dl range 98-175, prepump) to 104 mg/dl (range 84-120) and a 25-30% reduction in standard deviations during pump treatment. Furthermore, glycosylated hemoglobin levels were normalized in each patient. During periodic inpatient evaluations, mean 24-h plasma glucose levels were slightly, but not significantly, lower after pump treatment (97 vs 86 mg/dl). However, glycemic excursions were strikingly diminished; MAGE values and standard deviations fell by 45% and 34%, respectively. The total daily insulin dose required at the start of pump treatment was 31% less than the conventional dose used before the pump (P less than 0.002). Thereafter the insulin dose increased by approximately 2.5 U/wk, with the basal infusion remaining at 40% of the total dose throughout the pregnancy. All infants were born at term, had no macrosomia or neonatal problems, and had normal intravenous glucose tolerance tests at 2 h of age. We conclude that the insulin infusion pump, managed at home, is a highly efficient way to achieve normal or near-normal glucose levels in the pregnant diabetic.

Juvenile rheumatoid arthritis in children with diabetes mellitus

Seven children with insulin-dependent diabetes mellitus were found to have juvenile rheumatoid arthritis; six of these children had the polyarticular form of the disease. All six had positive serology (rheumatoid factor and/or antinuclear antibody) and clinical or serologic evidence of autoimmune diseases usually ascribed to the thyrogastric cluster. Five expressed HLA antigens associated with increased risk for both diabetes and rheumatoid arthritis in adults. Evidence of B cell hyperactivity and impaired T cell response was found in some, but immunoregulatory function was normal in all. The association of these two diseases may be the result of factors other than chance alone, and may be more common than previously suspected.