Preventing childhood obesity, phase II feasibility study focusing on South Asians

12 Pages·2014·1.32 MB·English

Open Access Research
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Preventing childhood obesity, phase II J O
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feasibility study focusing on : firs
South Asians: BEACHeS t pu
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Peymané Adab,1 Miranda J Pallan,1 Janet Cade,2 Ulf Ekelund,3,4 Timothy Barrett,5 1
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Amanda Daley,1 Jonathan Deeks,1 Joan Duda,6 Paramjit Gill,1 Jayne Parry,1 .1
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Raj Bhopal,7 K K Cheng1 36
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Tocite:AdabP,PallanMJ, ABSTRACT 0
Strengths and limitations of this study 1
CcfSehaoaidusldetibhhJiolA,iotseyditasoantulbs.de:PsyBriteEfyovA,ecCpnuHhtsieainnSsgge.BoIInMJ Oaprbmejveueclnttitfiianvcege:toeTbdoe,sacistuyslteuisnrsaSlfloeyauastphibpiArliostypiarnaiantcdehiailncdtcreeernpv,etanabtniiolditnytofoofr ▪ Wcheildrhepooordt tohbeefsinitdyinpgrsevoefnatiofneasiinbtielirtvyensttuiodny othfaat 3-004579
Open2014;4:e004579. obtain data to inform sample size for a definitive focuses on primary school-aged children from o
doi:10.1136/bmjopen-2013- trial. South Asian communities in the UK. Despite n 1
004579 Design: Phase II feasibility study of a complex their susceptibility to the cardiometabolic conse- 0 A
intervention. quences of obesity, little obesity prevention p
▸ Prepublicationhistoryand Setting: 8 primary schools in inner city research has been undertaken in these commu- ril 2
additionalmaterialforthis Birmingham, UK, within populations that are nitiespreviously. 01
paperisavailable.Toview predominantly South Asian. ▪ The early phases of the UK Medical Research 4. D
pleasevisitthejournal Participants: 1090 children aged 6–8years took Frameworkforcomplexhealthinterventionshave o
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(http://dx.doi.org/10.1136/ part in the intervention. 571 (85.9% from South guided the intervention development and evalu- n
bmjopen-2013-004579). Asian background) underwent baseline measures. ationprocessundertakeninthisfeasibilitystudy. loa
85.5% (n=488) were followed up 2years later. ▪ The feasibility and acceptability of the childhood de
Received29November2013 d
RAcecveispetded1213MMaracrhch20210414 sInctheorovle-bnatsioednsa:ndThfeam1-ilyye-abrasinetderavcetnivtiiotinesc,otanrsgisetteindgof ovabreiasbitlyeparenvdenctioonnteixntterdveepnetniodnencto;mhpoowneevnetrs,wthaes from
dietary and physical activity behaviours. The exploratory nature of the study enabled us to h
intervention was modified and refined throughout the modify and refine delivery of the intervention ttp
period of delivery. throughout. ://b
Main outcome measures: Acceptability and ▪ Developmentandevaluationofthefeasibilityand mjo
feasibility of the intervention and of measurements acceptability of the intervention was undertaken pe
required to assess outcomes in a definitive trial. The in materially disadvantaged, predominantly n.b
difference in body mass index (BMI) z-score between South Asian communities, thus its transferability m
arms was used to inform sample size calculations would be dependent on tailoring to the specific j.c
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for a definitive trial. localcontext. m
Results: Some intervention components (increasing ▪ The final intervention programme, following o/
n
school physical activity opportunities, family cooking modification and refinement in this feasibility F
skills workshops, signposting of local leisure study, is being definitively evaluated in an eb
ongoingcluster-randomisedcontrolledtrial. ru
facilities and attending dayevent at a football club) a
were feasible and acceptable. Other components were ry 1
acceptable, but not feasible. Promoting walking 9
groups was neither acceptable nor feasible. At INTRODUCTION , 2
0
follow-up, children in the intervention compared with Childhood obesity is a growing problem 23
the control group were less likely to be obese (OR worldwide.1 Apart from psychological and b
y
0.41; 0.19 to 0.89), and had lower adjusted BMI social problems, longitudinal studies show g
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z-score (−0.15 kg/m2; 95% CI −0.27 to −0.03). adverse future health consequences in chil- e
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Conclusions: The feasibility study informed dren as young as 7years old who are obese.2 t. P
components for an intervention programme. The In the UK, although childhood overweight ro
favourable direction of outcome for weight status in prevalence has stabilised, socioeconomic dis- tec
Fornumberedaffiliationssee the intervention group supports the need for a te
parities have widened, with increasing trend d
endofarticle. definitive trial. A cluster randomised controlled trial in more deprived subpopulations.3 Data by
is now underway to assess the clinical and cost- c
from the national childhood surveillance o
Correspondenceto effectiveness of the intervention. p
programmes in England show that at school y
[email protected];.uk Trial registration number: ISRCTN51016370. entry (age 4–5years), 9.5% of children are righ
t.
AdabP,PallanMJ,CadeJ,etal.BMJOpen2014;4:e004579.doi:10.1136/bmjopen-2013-004579 1
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obese (ie, above 95th centile for national reference stan- pupilsfromSAbackground(mean75%).These,compared J
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dards), but this prevalence doubles (19.2%) by the end withtheremainder,hadahigherproportionofchildreneli- p
of primaryschool (age 11).4 The rate of increase among giblefor freeschool meals (FSM),indicating higher depriv- en
children from South Asian (SA) ethnic groups, espe- ation. Schools were ranked in order of FSM eligibility, and : firs
cially girls, is greater than that for the population as a those from either extreme were successively invited until t p
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whole (increasing trend of 1.13% and 0.66% per year eightagreedtotakepart. b
for Bangladeshi and Pakistani girls, respectively, com- lis
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pared with 0.35% yearly increase in White British).5 Participants ed
Thusthe primaryschool period presents a key phase for Pupils from years 1 and 2 (aged 5–7years) were invited as
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prevention, and SA arean importanttarget group. to participate. Parents of the children were approached 0
However,despitenumeroussystematicreviews,67reports89 by letter distributed through the schools, and active .11
and guidelines,10 evidence for effective approaches to pre- opt-in consent was sought for their child to participate 36
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vention is limited, particularly among minority ethnic in measurements. Consent for participation in the inter- m
groups.Relevanttrialssuggestthatmultifacetedschool-based vention was sought at the school level. jo
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interventions have potential, particularly those that also n
includeahomeorcommunityelement,butthemosteffect- Baseline and follow-up measures -20
ivecombinationofcomponentsisnotclear.79Theneedfor Age, sex and ethnicity data (from parent report at 13
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involving stakeholders, such as families, schools and local school entry) were obtained from school records on all 0
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communities, in the decision-making regarding potential eligible children in participating schools. Children with 5
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intervention strategies has been highlighted.6 Furthermore, consent also underwent a range of anthropometric mea- 9 o
foracomplexinterventionsuchasobesityprevention,which surements, including standing height (measured to n 1
has several interconnecting components, a rigorous and nearest 0.1cm with a Leicester Height Measure), weight 0
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iterative-phased approach is required to improve study (measured to nearest 0.1kg with a Tanita bioimpedance p
design, execution and applicability of results. The UK monitor), two measures of waist circumference (mea- ril 2
MedicalResearchCouncil(MRC)proposedaframeworkfor sured to nearest 0.5cm) and skinfold thickness at five 01
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such interventions.11 Given the growing problem of obesity sites (biceps, triceps, subscapular, suprailiac and thigh; . D
and lack of clarity on effective approaches to prevention, it measured using a Holtain calliper). Children also com- o
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would be unwise to embark on another trial without thor- pleted interviewer-administered questionnaires (not dis- nlo
ough attention to the early phases described in the MRC cussed in this paper, but including: quality of life ad
framework. (PedsQL),13 self-concept (Marsh self-description ques- ed
The Birmingham healthy Eating and Active lifestyle tionnaire),14 perceived physical competence (Harter fro
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for CHildren Study (BEACHeS, http://www. Pictorial Scale for Young Children)15 and body image h
birmingham.ac.uk/research/activity/mds/projects/HaPS/ perception (adapted Collin’s Pictorial Image Scale)16). ttp
PHEB/WAVES/BEACHeS/index.aspx), used the theor- All measures were undertaken by trained researchers ://b
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etical and modelling phases of the MRC framework to using standard protocols.
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develop a multifaceted childhood obesity prevention Dietary intake was assessed using the Child And p
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programme, targeting SA children (phase I).12 Here we Dietary Evaluation Tool (CADET)17; a 24h food tick list n.b
report on the feasibilitystudy (phase II). The aim wasto that has been validated against a semiweighed diary in m
assess feasibility and acceptability of the intervention. In children aged 3–7years. A researcher completed the j.co
addition we wanted to obtain data to inform a definitive CADET for children during school hours, and parents om/
(phase III)cluster randomised controlled trial (RCT). were given instructions for completing it for the remain- n
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der of the 24h period. Physical activity levels were e
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assessed using the Actiheart monitor (CamnTech, ru
MATERIALS AND METHODS Papworth, UK) worn for five consecutive days, including ary
The feasibilitystudy was conducted in eight Birmingham a weekend. This is validated for use in children18 and 1
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primary schools from 2006 to 2009. Children underwent was set up to measure acceleration and heart rate at 30s , 2
baseline measures between December 2006 and June epochs. In addition, parents were asked to complete 02
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2007. Four schools were selected to receive the interven- questionnaires which included questions on family com- b
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tion (2007/2008 academic year), and the remainder position, and family dietaryand physical activity habits. g
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hadnoactiveintervention.Follow-updatawerecollected e
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2years after baseline. Intervention t. P
The process for intervention development has been ro
Setting reported elsewhere,12 but in brief, the multicomponent tec
BirminghamisUK’ssecondcitywithahighminorityethnic intervention was developed by combining evidence from ted
population (34%), one-fifth being from the three main SA the literature with views from key stakeholders drawn by
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communities (Pakistani, Bangladeshi and Indian). We from SA communities (including parents, teachers, o
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socbhtoaionlesdinaBliirsmt ionfghalalmL.oOcafl3A0u4thscohriotyo-lms,a5in2tahinaedd≥p5r0i%maoryf secrhnooorsl naunrdsesr,edtaieilticainadns,leciosumrmeurneiptyrelseeandteartisv,esschcolooslegotvo- yrigh
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2 AdabP,PallanMJ,CadeJ,etal.BMJOpen2014;4:e004579.doi:10.1136/bmjopen-2013-004579
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schools) and a multidisciplinary group of relevant pro- Exploratory comparison between intervention and control J
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fessionals. Important contextual data were gained from childrenwasalsoundertakentodetermineeffectsize. p
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stakeholders, which was critical for informing interven- Height and weight data were used to calculate BMI n
tion development and highlighted potential barriers (kg/m2) and converted into SD scores (BMI z-score) : firs
(eg, cultural unacceptability of certain types of physical using the UK 1990 growth reference charts.21 Children t p
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activity for girls), as well as opportunities for interven- were categorised as underweight, healthy weight, over- b
tion (eg, schools being considered a natural environ- weight or obese using the 2nd, 85th and 95th centile lis
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ment for providing skills to families), in relation to SA cut-offs. For waist circumference and skinfolds, the d
communities.18 19 A review of local facilities, resources mean was used for analyses. Skinfold measures were as
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and opportunities related to healthy eating and the pro- combined toobtain sum, upper (biceps, tricepsand sub- 0
motion of physical activity targeting children was used to scapular) and lower (suprailiac and thigh) skinfolds. .11
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inform the design and encourage longer term sustain- Data from the CADET were coded and analysed by a 6
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ability of the intervention. We also took account of food diary analysis programme (DANTE, University of m
national childhood obesity prevention policy during the Leeds) to estimate total energy intake (kJ) and amount jo
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development processto tryand ensure that the interven- of fruit and vegetables, and sugar consumed. Data on n
tion had an impact that was additional to existing foods consumed in school and at home were analysed -20
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national initiatives. The intervention targeted both diet separately, then combined to obtain estimates for the 3
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and physical activity behaviours and consisted of two complete 24hmeasurement period. 0
main strands: (1) increasing children’s physical activity Accelerometry data were used to assess physical 45
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levels and promoting healthy eating through schools activity levels. Total daily volume of physical activity was 9 o
and (2) increasing skills among family members estimated and expressed as average counts per minute n 1
through family educational activities. A number of inter- (cpm). The mean duration of daily moderate-to-vigorous 0
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vention techniques (as defined in the CALO-RE physical activity (MVPA, min/day) was calculated p
Taxonomy of behaviour-change techniques for physical (400cpm cut-off for lower threshold).22 The proportion ril 2
activity and healthy eating20) were utilised to deliver of children participating in ≥60min MVPA (as recom- 01
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each intervention component. A more detailed descrip- mendedbyinternationalguidelines)wasalsocalculated. . D
tion ofthe intervention is provided intable 1. Statistical analyses were undertaken using STATA o
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(V.11). The intraclass correlation coefficient (ICC) for nlo
Allocation of intervention the main outcome (BMI z-score) was calculated, but ad
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Thiswasanon-randomisedfeasibilitytrial.Afterbaseline because of the small number of schools, clustering was d
measurements were completed, schools were allocated not taken into account in the analysis. We analysed final fro
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to intervention or control arms. We matched schools by BMI, diet and physical activity levels of children in the h
size, and proportion of children eligible for FSM. We intervention, compared with those in the control group. ttp
then took the geographical location of the schools into To adjust for baseline differences, we initially developed ://b
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account and allocated the matched pairs to either the multiple linear regression models, which included the
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intervention or control arm so that we minimised the relevant baseline values of BMI, dietary factors or phys- p
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chance ofcontamination between the two arms. ical activity measures as covariates. Further models were .b
then developed which also included potential confoun- m
Process measures ders as covariates (age, sex and ethnicity). Logistic j.co
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The main aim of the study was to assess intervention regression was used to assess risk of obesity (compared o/
feasibility and acceptability. Each component was evalu- with all non-obese children), and likelihood of meeting n
ated separately, using a variety of methods. These ≥60min MVPA at follow-up in the intervention, com- Fe
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included collection of uptake data, direct observation, pared with control children. ru
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questionnaires to children and parents and interviews ry
with key school staff. The questionnaires were also used 1
9
to evaluate overall perceptions of the intervention and RESULTS , 2
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engagement with different intervention components. Feasibilityandacceptabilityof intervention components 2
3
Topics covered in the semistructured interviews included Some intervention components (particularly those deliv- b
y
exploration of how the different intervention compo- ered through school) were more successfully delivered g
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nents were implemented, which elements were per- than others. The intervention components were modi- es
ceived to work well and ideas for further development. fied during the course of delivery to optimise participa- t. P
The interviews were tape-recorded, transcribed and ana- tion and in response to feedback. The findings are ro
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lysed thematically. summarised in table 1, and details are reported in the c
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onlinesupplementaryappendix. d
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Othermeasuresand analysis Two intervention components were found to be y
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Weassessedthefeasibilityofobtainingoutcomedata,primar- unsuitable to include within an intervention programme o
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ilybodymassindex(BMI),andalsodietandphysicalactivity in the format delivered. First wasthe scheme to incentiv- yrig
and other anthropometric measures as described above. ise out of school leisure activities. Poor co-operation h
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AdabP,PallanMJ,CadeJ,etal.BMJOpen2014;4:e004579.doi:10.1136/bmjopen-2013-004579 3
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Table1 Interventioncomponentsandtechniques20includedintheBEACHeSinterventionprogrammeandfindingsfromtheprocessevaluation
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Intervention Intervention Agentresponsiblefor n
component Aim techniques Description delivery Evaluationmethod Evaluationfindings A
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School-basedactivities c
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Physical Toincreasethe Environmental Threeelements Trainedschoolstaff ▸ Interviewswith Overall,schoolstaffwitha s
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activitieswithin amountoftimethat restructuring introducedintoschools (includingteachers, schoolstaff responsibilityforhealth
schoolday childrenare Promptpractice 1.‘WakeUpShakeUp’: teachingassistantsor ▸ Observationof wereenthusiasticand
physicallyactive ashort (10min) lunchtimeassistants). sessionsinschools committedtointroducing
withintheschool organiseddailydance Thedecisionofwhich ▸ Self-completion theseschemes,andall
day orexerciseroutineto staffmemberstotrainfor questionnaires schemeswereacceptable
music thiscomponenttookinto administeredto tochildren.Individual
2.Organised accountindividualschool childrenandparents schoolandstafffactors
playgroundactivities circumstancesandwas stronglyinfluencedthe
atlunchandbreak madeinconsultationwith successofeachelementin
timesthroughthe eachschool thedifferentschools.
trainingofschoolstaff Parents,ingeneralfeltthat
toactas‘play theamountofphysical
Ad leaders’ activitytheirchildrenwere
a
b 3.‘Take10’:teaching undertakinginschoolhad
P
,P resourcewhichlinks increasedoverthelastyear
a
lla 10minphysical
n
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, classroomto
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ad curricularsubjects
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J, Incentivescheme Toincreasethe Prompt Childrenreceiveda Stickercollectioncard ▸ Interviewswith Althoughthistypeof
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t toencourage amountoftime self-monitoringof stickercollectioncard deliveredthroughschool schoolstaff incentiveschemeappears
a
.lB physicalactivity outsideofschool behaviour fromschooland classteacher.Stickers ▸ Telephonesurveyof acceptabletochildren,
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J outofschool hoursthatchildren Promptpractice informationonlocal handedoutbystaffat leisurevenuestaff parentsandschoolstaff
Op spenddoingleisure Providerewards participatingsportsand leisurevenues ▸ Assessmentof alike,itwasnotfeasiblein
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n physicalactivities contingenton leisurevenues.Each returnedcollection termsofmaintaining
2
01 successful timeachildattendeda cards cooperationofparticipating
44; behaviour venue,theycollecteda ▸ Questionnairesto venues.Anelementthat
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0 sticker.Thechildwith children waswellreceivedandcould
0
4
5 themoststickersin beretained,isthe
7
9. eachschoolreceiveda signpostinginformation
d
oi:1 prize giventochildrenand
0 families
.1
13 Attendanceata Toencourage Provide Schoolclassesattenda AstonVillaFootballClub ▸ Interviewswith Thiswashighlyacceptable
6/b courserunbya physicalactivity informationon ‘VillaVitality’day.Half Communityprogramme schoolstaff tochildrenandschoolstaff
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jo Premierleague andhealthyeating consequencesof thedayisspentwith staffdeliverondayof ▸ Self-completion andisfeasibletodeliverto
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e footballclub throughaniconic behaviour FootballClubcoaches, visittoclub questionnairesto thetargetagegroup.There
n
-20 sportinginstitution Model/ exercisingandlearning Schoolclassteachers parents issomeevidencethatit
1
3 demonstrate footballskills,andthe
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04 Continued
5
7
9
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d Table1 Continued
a
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P Intervention Intervention Agentresponsiblefor
,
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a component Aim techniques Description delivery Evaluationmethod Evaluationfindings
lla
nM behaviour otherhalfofthedayis deliver6weeklylessons ▸ Preinterventionand mayfavourablyalter
J, Prompt aninteractivelearning afterclubvisit 6-week children’shealth-behaviours
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ad identificationof sessiononhealthy postintervention
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J rolemodel/ eatingandhealthy questionnaires
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et advocate lifestyles.Teachers (knowledge,attitudes
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.l Goalsetting providedwithmaterial andbehaviour)
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n andencourageweekly
2
0 challengesorgoals
1
4
4; Increasingskillsoffamiliesthroughactivity-basedlearning
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04 Cookingcourses Toincreasehealthy Provide Five-weekcourseson BirminghamCommunity ▸ Interviewswith Thiscomponentwas
5
79 forfamily cookingskills,and informationon healthycookingwere NHSTrustdieteticsstaff schoolstaff popularwiththosewho
.d members confidencedand consequencesof deliveredthrough ▸ Uptakeratesfor participatedandtherewas
o
i:1 influencedietary behaviourin schoolstoparentsor courses someevidencethatit
0
.1 behaviour general otherfamilymembers, ▸ Participant influencedconfidenceand
1
3
6 Model/ somecoursesinclude precourseand cookingpractices.Running
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m demonstrate children.Coursesran postcourse sessionsforparentsand
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p behaviour successivelytoallowall questionnaires childrenwasthemost
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n-2 Provideinstruction parentstoattendifthey popularmodel,andhaving
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1 onhowtoperform wanted.Healthyrecipes thesessionsbasedin
3
-0 thebehaviour weredistributedto schooltimeforchildrenand
0
45 Prompt supportthecourse invitingparentstoattend
7
9 generalisationof content improvedattendance
behaviour
Informationon Toequipfamilies Provide Parentsweregiven BEACHeSresearchstaff ▸ Interviewswith Thiscomponentwas
localleisure withtheknowledge informationon informationonlocal compiledlistsofvenues schoolstaff resourceintensiveto
opportunitiesand andskillsto whenandwhere sportingandleisure andpreparedsignposting ▸ Uptakeofthetaster deliver,anduptakewas
‘taster’sessions undertakephysical toperform venuesandevents. sheets.BEACHeS sessions verylow.However,the
forfamilies activitieswiththeir behaviour Theywereinvitedto researchstaff ▸ Self-completion signpostinginformationwas
childrenintheir Model/ attendweekendtaster accompaniedfamiliesto questionnairesto usedbyfamilies,andwas
leisuretime demonstrate sessionswiththeir leisurevenues,where parentsandchildren appreciated
behaviour children,through leisurevenuestaff
school.Activities deliveredsessions
ranged,fromcricketand
football,toarchery, O
climbinganddry-slope p
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skiing.Therewasno n
costfortheactivities A
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andtransportwas c
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provided
s
5 Continued s
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from leisure venues and lack of resources to continually J
Evaluationfindings Thiscomponentprovedunfeasibleastherewasalackofvolunteers.Eventhosewhoexpressedaninitialinterestfailedtoattendthetraining.Despiterepeatedeffortstorecruitcommunityvolunteers,nooneattendedthetraininginanyofthefourBEACHeSinterventioncommunities rolitugopeneerffnaaeflmoOrddlreutuesniehennpierseritnsdsuwsws..treceiaecaaonDrnonlemtfedmdapspcpatpmniorsrilooactienotenihtnineteeoitnivessnfnoatoftlgftiar.noewntsrhatdScdttascshheifovdcfeitpa.lmoodralnHrioinronerdtcooeiungaawtcs.llwrcleyfuaaouvoTrsiennrtsehrumtda,tertchehisawcberrteootuaotasesfntutskenrflpgpeadyudhuoilan.tbpapnoislunSneccictilgeyhrgahistornoeyaoow,pnatfflavomaoolsiskwwltlotruuiiaaghnnnrfnlafogggke,-- Open: first published as 10.11
3
s nised taster sessions was poor, which was outweighed by 6
valuationmethod AssessmentofnumbersattendingtrainingtobewalkleadersMonitoringnumberjoiningwalkinggroups tdfdlihogeerTehlgeihrvteeenheedroisgttohhhfoteeohfaswestcsiraobufmdflceicenpealttioosnvesnerd,irnevyenacnmnltu.tcdoidooTneunhtelhidetneacrtaoyabpmslertareoprercgiosmeeonssreupsestrrnsrcoeitioeavsvesnla.dlsuh.raawetdqIeinourednivriaevthhrdidyieigurnthaeogl-- /bmjopen-2013-004
E ▸ ▸ school characteristics and differences between staff 5
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members strongly influenced the success of each 9 o
Agentresponsiblefordelivery Walk-leadertrainingprogrammedeliveredthroughHeartofBirminghamNHSTrust eAAinsvnuelcecetnpcecemetpedripoopvetfirnntaoeatbt.wrbitisliaIonilntiwcyttcyohioootnehfomtthafrdpecolilnoreflofnnocaecnastrroratme-oiitnnonel.tnttrOsefostcorcolnhrvheeocsonncoowohontlolittosorsu.ootnblalldesf,fwin.hasgaAtsvaleoflaffslufsieekenrxesdespddeerdreastlsthtsoteeehordrndionatuttthieghvarheet- n 10 April 2014. Downlo
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Description Communityvolunteerswererecruitedthroughschoolstobecometrainedwalkleaders.Trainingwasprovidedtoequipvolunteerstoorganiseandleadwalksintheirlocalcommunity HildrenStudy. bwsOFTipnceeauahhagriytesncoesirso,gnbocemailthl’ainwp.etolydaesorrocltcesfoooo1n(nu0frstate9rctnni0hobgtmeueelteaies5gntmdu4idb–detla1oeysa8ucnth0hhrt)aehei.dslrdOsocrbpfeheonotnhmoeienlfie’sstettrth,seitced6at0eum6tihsge(ehaa5msts5upa.6raie‘n%rhstie)ocawithlphetahaerdteyr- http://bmjopen.bmded from
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Interventiontechniques Model/demonstratebehaviourPromptpractice andActivelifestylefor fowoac(onofffetrm=erwCe5rAph7Actrli1heDcte,ithethEeu9edTrbt4awna.r2oeoswte%d-natwlhisneaitotrrehmdefobsmosaacre(vseoeenaanlii=silnsvnua1eaber7nresl,4itecase)2h,bdf6ol4ho)e9o8ar..8ld(5UA4o0cu7slh8ntes.h1aial(ob%dbm8ulrle9)eeeg%nahdwds)aue(a.t4rr8tae4Cea5.5m.ocT5(moe%w≥(nm7op3)t7lpedy.w9ldteaeie%aayotrsreyne))ss, on February 1j.com/
s g 9
Aim Toincreasewalkingbyfamilieandothercommunitymembersthroughorganisedleisurewalks nghamhealthyEatin sApaFuilrnctcohtdcipoihenouesgrsagstfrhiuoftrlnooldymnalt(fyatonh1l=wel6o4af3w5esa4e(ss,d3iimb69i%uil3iltap%y)r.sh)ttTaouddhhbyeauadssapeblraiolnepecoh.oroHmtmioopwenleedtvewaedtirath.aChAuisDgahEbelTer, , 2023 by guest. P
ContinuedTable1 Interventioncomponent Trainingwalkleaderstoinitiatecommunitywalkingprogrammes BEACHeS,TheBirmi ompstcArehflixeatbiwoltrudaeithstandreioeloddnmfonoe.firttn58oh575n7tt4.h9ai1cb%ceihotlceyfihwlodt2aehfrrreeta(ehnca5otnSew7sAtre4ehi.rsrwpteBoihacpairsnosoteocimtcllfoiuinpetodhetakeretiidcpcnnhagiomanrntrcaet-hwhccaieotesledrunetrrrsrieeesisatnsinimlc)tw(se.ifiledTaargrrheeeuleiirncgseauoidbg1mmile)se,,--- rotected by copyrigh
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6 AdabP,PallanMJ,CadeJ,etal.BMJOpen2014;4:e004579.doi:10.1136/bmjopen-2013-004579
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Over 90% in both arms were from the most deprived to be lost to follow-up (n=58; 11.9%) compared with J
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areas, in keeping with the location and ethnic compos- those from otherethnic groups (n=28; 34.6%). p
ition of the population. Around one in five (n=115) en
were overweight or obese. This proportion was slightly Estimation of effect size to inform definitive trial : firs
higher inthe control (21.7%) compared tothe interven- Anthropometric, physical activity and dietary measures in t p
u
tion (18.3%) schools. A similar pattern was seen for interventionand controlgroupsatfollow-upareshownin b
other measures of body fat (skinfold measures, bioimpe- table 3. The proportion of children who were overweight lis
h
e
dance), but not for waist circumference which was or obese had increased in all schools from baseline to d
a
similar in intervention and control groups. Under half follow-up (from 7.3% to 9.9%, and from 12.8% to 19.1% s
of the children (47.9%) undertook ≥60min of MVPA. foroverweightandobese,respectively).Theriskofobesity 10
Levels of physical activity (total cpm) and duration of was significantly lower in the intervention compared with .11
3
time spent in MVPAwere slightly higheramong children the control group (OR 0.41; 95% CI 0.19 to 0.89). The 6
from control, compared with intervention schools. Total increase in BMI z-score was also significantly lower in the /bm
dietaryenergy, fruit and vegetable and sugar intakewere intervention compared with control, after adjustment jo
p
slightly higher among children in intervention, com- (−0.15kg/m2; 95% CI −0.27 to −0.03; table 4). A similar en
pared with control schools. trend was seen for all other anthropometric measures, -20
Two years postbaseline, 254 (83.3%) children in the althoughnonewerestatisticallysignificant. 13
control and 234 (86.2%) in the intervention schools The ICC for the outcome ‘overweight/obese’ com- -00
were successfully followed up. There was no significant pared to non-overweight, was 0.00 (95% CI 0 to 0.02), 45
7
difference in baseline weight status, MVPA, diet or sex, while for BMI z-score, the ICC was 0.01 (95% CI 0 to 9 o
between those followed up and those lost to follow-up 0.04).Therefore,takingaccountofclustering intheana- n 1
(data not shown). However, SA children were less likely lysis would make marginal difference to the findings. 0
A
p
ril 2
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4
Figure1 Flowdiagramof . D
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participantsinthefeasibility lo
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AdabP,PallanMJ,CadeJ,etal.BMJOpen2014;4:e004579.doi:10.1136/bmjopen-2013-004579 7
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Table2 BaselinecharacteristicsofchildrenmeasuredfortheBEACHeSfeasibilitystudy O
p
Interventiongroup:N=269 Controlgroup:N=305 e
n
Characteristic/measure* n(%)ormean(SD) n(%)ormean(SD) : firs
Sex(n=574) t p
Male 144(53.5) 142(49.8) u
b
Female 125(46.5) 153(50.2) lis
h
Ageinyears(n=574) 6.53(0.59) 6.44(0.58) e
d
Ethnicity(n=574) a
s
Bangladeshi 36(13.4) 46(15.1) 1
0
Indian 22(8.2) 5(1.6) .1
Pakistani 181(67.3) 203(66.6) 1
3
Other 30(11.2) 51(16.7) 6/b
Townsendscoredecile(n=572) m
1(mostdeprived) 250(93.3) 285(93.8) jop
e
2 6(2.2) 9(3.0) n
3 8(3.0) 5(1.6) -2
0
4–7 4(1.5) 5(1.6) 13
BMI-SDSscore(n=571) -0.03(1.37) 0.08(1.39) -0
0
Weightstatus(n=571) 4
5
Underweight 6(2.3) 10(3.3) 79
Healthyweight 212(79.4) 228(75.0) o
n
Overweight 15(5.6) 27(8.9) 1
0
Obese 34(12.7) 39(12.8) A
p
WSkainisftocldircmuemafseurerensce(m(cmm))(n=569) 55.6(7.7) 55.3(6.9) ril 2
0
Biceps(n=563) 7.5(3.6) 8.0(4.0) 1
4
Triceps(n=563) 10.9(4.1) 11.6(4.5) . D
Subscapular(n=559) 7.5(4.4) 7.9(5.0) o
w
Suprailiac(n=561) 7.0(4.4) 7.4(4.7) n
lo
Sumof4skinfolds(n=556) 32.5(14.7) 34.8(16.8) a
d
Thigh(n=433) 14.4(5.5) 15.7(6.3) e
d
Sumofupperskinfolds(n=557) 25.7(10.9) 27.5(12.5) fro
Sumoflowerskinfolds(n=433) 21.0(8.8) 22.9(10.1) m
Bioimpedance(Ω)(n=521) 692.6(72.5) 695.1(80.8) h
Physicalactivity(n=535) ttp
Counts/min 79.9(23.4) 83.4(27.3) ://b
m
MVPAmin/24h 52.8(28.4) 62.9(25.0) jo
≥60minsMVPAperday(n=535) 100(40.2) 156(54.5) pe
n
1dayschooldietaryintake(n=441) .b
Meanenergy(kJ) 2378.2(1619.2) 1917.1(1821.7) m
Fruitandvegetables(g) 140.6(121.4) 105.8(118.7) j.c
o
Sugar(g) 41.0(60.9) 35.3(62.9) m
1dayhomedietaryintake(n=174) o/
n
Meanenergy(kJ) 7021.3(3181.1) 6058.34(3138.2) F
e
Fruitandvegetables(g) 329.85(232.2) 267.95(193.3) b
ru
Sugar(g) 105.36(50.2) 93.50(36.6) a
24hdietaryintake(n=173) ry
1
Totalenergy(kJ) 9326.6(3083.7) 8397.3(4035.5) 9
Fruitandvegetables(g) 475.6(261.4) 368.7(220.2) , 2
0
Sugar(g) 154.1(108.7) 129.7(85.8) 23
*ninthiscolumnindicateshowmanychildrenhaduseabledataforeachcharacteristic/measure. by
BEACHeS,TheBirminghamhealthyEatingandActivelifestyleforCHildrenStudy;BMI,bodymassindex;MVPA,moderate-to-vigorous g
u
physicalactivity. e
s
t. P
ro
The proportion of children who undertook ≥60min Total energy intake had increased slightly at follow-up tec
te
MVPA reduced (from 48.8% to 27.1%) at follow-up, (7473kJ at baseline to 8130kJ at follow-up). Therewere no d
with the reduction being greater among control significantdifferencesindietaryintakebetweencontroland by
c
(30.2%) compared with intervention (23.8%) children. interventionchildren,although24hdietaryintakedatawere o
p
The differences in physical activity levels at follow-up onlyavailablefor 163 (33%)children at follow-up,andonly y
were not significant between groups (table 4). 61childrenhaddietarydataatbothbaselineandfollow-up. righ
t.
8 AdabP,PallanMJ,CadeJ,etal.BMJOpen2014;4:e004579.doi:10.1136/bmjopen-2013-004579
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Table3 Anthropometric,dietandphysicalactivitymeasuresininterventionandcontrolgroupsatfollow-up O
p
Interventiongroup(N=234) Controlgroup(N=254) e
n
Measure* n(%)ormean(SD) n(%)ormean(SD) : firs
Anthropometricmeasures t p
BMIz-score(n=488) 0.13(1.5) 0.40(1.5) u
b
Weightstatus(n=488) lis
h
Underweight 11(4.7) 8(3.2) e
d
Healthyweight 160(68.4) 168(66.1) a
s
Overweight 27(11.5) 21(8.3) 1
0
Obese 36(15.4) 57(22.4) .1
Waistcircumference(cm)(n=472) 59.4(9.5) 60.4(9.1) 1
3
Skinfoldmeasures(mm) 6/b
Biceps(n=486) 6.9(3.5) 7.7(3.8) m
Triceps(n=485) 11.2(4.8) 11.9(4.6) jop
e
Subscapular(n=479) 8.5(5.3) 9.3(5.8) n
Suprailiac(n=475) 8.8(5.9) 9.4(5.9) -2
0
Sumof4skinfolds(n=471) 35.2(18.1) 37.6(18.4) 13
Thigh(n=404) 17.3(7.5) 18.9(8.1) -0
0
Sumofupperskinfolds(n=479) 26.5(12.7) 28.7(13.1) 4
5
Sumoflowerskinfolds(n=402) 25.3(11.8) 27.6(13.1) 79
Bioimpedance(Ω)(n=453) 692.0(83.1) 688.3(81.3) o
n
Physicalactivity(n=467) 1
0
Counts/min 68.7(33.4) 71.0(22.9) A
p
MAcVhPieAvimngin≥/2640hminMVPA 495.13((2231..68)) 517.31((3200..22)) ril 2
0
Dietaryintake 1
4
School(n=454) . D
Energy(kJ) 1908.7(831.8) 2045.1(777.9) o
w
Fruitandvegetables(g) 143.1(135.0) 93.9(94.0) n
lo
Sugar(g) 25.0(15.7) 29.8(16.7) a
d
Home(n=163) e
d
Energy(kJ) 7860.5(4366.4) 8145.4(4004.5) fro
Fruitandvegetables(g) 367.5(316.6) 342.0(224.9) m
Sugar(g) 113.8(63.7) 121.0(56.8) h
24hdietaryintake(n=163) ttp
Energy(kJ) 9527.8(4400.3) 9820.7(3773.1) ://b
m
Fruitandvegetables(g) 519.1(350.2) 446.0(238.5) jo
Sugar(g) 137.2(64.2) 150.5(59.9) pe
n
*ninthiscolumnindicateshowmanychildrenhaduseabledataforeachmeasure. .b
BMI,bodymassindex;MVPA,moderate-to-vigorousphysicalactivity. m
j.c
o
m
However, school dietary intake data were more complete opportunity to refine and modify the programme and o/
n
(93% with follow-up data and 73% with both baseline and yielded important information on acceptability and feasi- F
e
follow-updata),andchildrenininterventionschoolshadsig- bility of the intervention and measurements required for b
nificantlymorefruitsandvegetablesandlowersugarintake, assessingoutcomesinadefinitiveRCT. rua
ry
comparedwiththoseincontrolschools(table4). 1
9
Astheintervention wasdesigned tobeparticularlyrele- Strengths and limitations , 2
vant to SA children, we repeated the multivariate analyses 0
This is one of few studies focusing on SA populations, 2
3
including only children of SA ethnicity. The mean differ- which comprise the largest minority ethnic group in the b
y
ences and ORs for the outcomes were of a similar magni- UK, with higher risk of obesity and its consequences. g
u
tudetothemainanalyses(datanotshown). The iterative process of intervention refinement was es
informed by the MRC framework for complex interven- t. P
tions. While the framework has been used for the devel- ro
te
DISCUSSION opment of other interventions in National Health c
te
We demonstrated the feasibility of delivering a multicom- Service (NHS) settings, we have demonstrated its use in d
b
ponent obesity prevention intervention targeting dietary thewidercommunitysetting. y
andphysicalactivitybehaviourstoasocioeconomicallydis- Thecomponentsoftheinterventionwereinfluencedby co
p
advantaged, multiethnic population of primary school- stakeholder views and available resources, thus its applic- yrig
aged children. The feasibility study provided an ability for wider populations and settings is potentially h
t.
AdabP,PallanMJ,CadeJ,etal.BMJOpen2014;4:e004579.doi:10.1136/bmjopen-2013-004579 9
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Table4 Adjusteddifferencesinanthropometric,dietandphysicalactivitymeasuresbetweencontrolandinterventiongroups O
p
Interventionvscontrol Interventionvscontrol e
n
Outcomevariable* O(aRdju(9s5te%dCfoI)rbaseline) pValue (Afidnjaulslyteadd†jOuRste(9d5)†%CI) pValue : firs
t p
Obese(n=486) 0.36(0.17to0.77) 0.01 0.41(0.19to0.89) 0.02 u
b
Achieving≥60minMVPA 0.82(0.52to1.28) 0.38 0.74(0.45to1.20) 0.22 lis
h
(n=441) e
d
Meandifference(95%CI) Adjusted†meandifference(95%CI) a
s
BMIz-score(n=486) −0.15(−0.26to−0.03) 0.02 −0.15(−0.27to−0.03) 0.02 10
Waistcircumference(cm) −0.88(−1.87to0.10) 0.08 −0.86(−1.87to0.15) 0.09 .11
3
(n=482) 6
Skinfoldmeasures(mm) /bm
Biceps(n=479) −0.48(−0.98to0.01) 0.06 −0.44(−0.93to0.06) 0.08 jo
p
Triceps(n=478) −0.14(−0.68to0.40) 0.61 −0.10(−0.64to0.45) 0.71 e
n
Subscapular(n=469) −0.46(−0.98to0.06) 0.09 −0.38(−0.89to0.14) 0.15 -2
Suprailiac(n=468) −0.23(−0.84to0.37) 0.45 −0.23(−0.83to0.37) 0.46 01
3
Sumof4skinfolds(n=461) −1.09(−2.85to0.67) 0.23 −0.97(−2.70to0.77) 0.27 -0
Thigh(n=324) −0.31(−1.39to0.78) 0.58 −0.27(−1.38to0.84) 0.63 04
Sumofupperskinfolds −0.90(−2.21to0.42) 0.18 −0.76(−2.05to0.53) 0.25 57
9
(n=468) o
Sumoflowerskinfolds(n=323) −0.36(−1.91to1.19) 0.65 −0.40(−1.98to1.18) 0.62 n 1
Bioimpedance(Ω)(n=409) 3.33(−5.23to11.89) 0.45 3.50(−5.14to12.15) 0.43 0 A
Counts/min(incrementsof20) −0.15(−0.34to0.04) 0.12 −0.18(−0.36to0.01) 0.06 p
(n=441) ril 2
MVPAmin/24h(n=441) 1.52(−2.14to5.17) 0.42 0.51(−2.97to3.99) 0.77 01
4
ScEhnoeorlgy(kJ)(n=358) −78.78(−240.75to83.18) 0.34 −86.02(−250.29to78.20) 0.30 . Do
w
Fruitandvegetables(g) 59.88(34.56to85.19) <0.001 63.35(37.53to89.17) <0.001 n
(n=358) lo
a
Sugar(g)(n=358) −3.86(−7.27to−0.45) 0.03 −3.86(−7.37to−0.36) 0.03 de
d
HoEmneergy(kJ)(n=61) 1322.94(−292.75to2938.60) 0.12 1534.73(−117.74to3187.20) 0.07 fro
m
Fruitandvegetables(g) 21.61(−81.26to124.47) 0.68 18.98(−89.43to127.40) 0.73 h
(n=61) ttp
Sugar(g)(n=61) 6.88(−17.04to30.81) 0.57 9.17(−15.16to33.51) 0.45 ://b
24hdietaryintake m
Energy(kJ)(n=61) 883.16(−888.31to2654.66) 0.32 1092.36(−723.33to2908.09) 0.23 jop
e
Fruitandvegetables(g) 89.64(−32.51to211.79) 0.15 86.70(−42.92to216.32) 0.19 n
.b
(n=61) m
Continued j.c
o
m
o/
n
F
e
b
limited. However, the multifaceted intervention aimed to directly to the children and through school staff (phys- ru
a
modifyschool and familyenvironments and included ele- ical activity component and Villa Vitality) were more ry
mentsthathavebeenidentifiedaspromisinginsystematic likely to have high uptake than those delivered to fam- 1
9
reviews.7 23 Furthermore the intervention components ilies (leisure taster sessions or walk leader training). The , 2
0
havetheoreticalvalidityforbehaviourchangeinanypopu- complexity of delivering community-based interventions 2
3
lation, and the incorporated techniques are transferrable. targeting children probably explains why most previous b
y
ThetargetingofSAstakeholdersforinterventiondevelop- trialsareschool based. g
u
ment is likely to have allowed us to exclude intervention During the trial, all children in schools allocated to e
s
componentsthatwouldnotbeacceptabletothissubpopu- the intervention arm were exposed to the intervention t. P
lation.Nevertheless,thedevelopedinterventionislikelyto components. However, only about half had consent for ro
be acceptable not only in these ethnic groups, but also in measurements. We found no significant differences in tec
te
thewiderUKpopulation. sex and ethnicity between consented and non-consented d
b
Delivery of intervention, undertaken by staff outside children. Further, the distribution of weight status y
c
the research team, was non-standardised. This allowed a among children who were measured is similar to o
p
pragmatic approach to be tested, which could be more national data for this age group,24 suggesting that selec- y
rig
easily rolled out. Intervention components delivered tion bias was unlikely. h
t.
10 AdabP,PallanMJ,CadeJ,etal.BMJOpen2014;4:e004579.doi:10.1136/bmjopen-2013-004579