The Early Prevention of Obesity in CHildren (EPOCH) collaboration : an individual patient data prospective meta-analysis

<b>Background</b><br />Efforts to prevent the development of overweight and obesity have increasingly focused early in the life course as we recognise that both metabolic and behavioural patterns are often established within the first few years of life. Randomised controlled trials (RCTs) of interventions are even more powerful when, with forethought, they are synthesised into an individual patient data (IPD) prospective meta-analysis (PMA). An IPD PMA is a unique research design where several trials are identified for inclusion in an analysis before any of the individual trial results become known and the data are provided for each randomised patient. This methodology minimises the publication and selection bias often associated with a retrospective meta-analysis by allowing hypotheses, analysis methods and selection criteria to be specified a priori.<br /><br /><b>Methods/Design</b><br />The Early Prevention of Obesity in CHildren (EPOCH) Collaboration was formed in 2009. The main objective of the EPOCH Collaboration is to determine if early intervention for childhood obesity impacts on body mass index (BMI) z scores at age 18-24 months. Additional research questions will focus on whether early intervention has an impact on children's dietary quality, TV viewing time, duration of breastfeeding and parenting styles. This protocol includes the hypotheses, inclusion criteria and outcome measures to be used in the IPD PMA. The sample size of the combined dataset at final outcome assessment (approximately 1800 infants) will allow greater precision when exploring differences in the effect of early intervention with respect to pre-specified participant- and intervention-level characteristics.<br /><br /><b>Discussion</b><br />Finalisation of the data collection procedures and analysis plans will be complete by the end of 2010. Data collection and analysis will occur during 2011-2012 and results should be available by 2013.<br />

'Traffic-light' nutrition labelling and 'junk-food' tax : a modelled comparison of cost-effectiveness for obesity prevention

<b>Introduction:</b> Cost-effectiveness analyses are important tools in efforts to prioritise interventions for obesity prevention.<br />Modelling facilitates evaluation of multiple scenarios with varying assumptions. This study compares the cost-effectiveness of<br />conservative scenarios for two commonly proposed policy-based interventions: front-of-pack &lsquo;traffic-light&rsquo; nutrition labelling<br />(traffic-light labelling) and a tax on unhealthy foods (&lsquo;junk-food&rsquo; tax).<br /><b>Methods:</b> For traffic-light labelling, estimates of changes in energy intake were based on an assumed 10% shift in consumption<br />towards healthier options in four food categories (breakfast cereals, pastries, sausages and preprepared meals) in 10% of adults. For the &lsquo;junk-food&rsquo; tax, price elasticities were used to estimate a change in energy intake in response to a 10% price increase in seven food categories (including soft drinks, confectionery and snack foods). Changes in population weight and body mass index by sex were then estimated based on these changes in population energy intake, along with subsequent impacts on disability-adjusted life years (DALYs). Associated resource use was measured and costed using pathway analysis, based on a health sector perspective (with some industry costs included). Costs and health outcomes were discounted at 3%. The cost-effectiveness of each intervention was modelled for the 2003 Australian adult population.<br /><b>Results:</b> Both interventions resulted in reduced mean weight (traffic-light labelling: 1.3 kg (95% uncertainty interval (UI): 1.2;<br />1.4); &lsquo;junk-food&rsquo; tax: 1.6 kg (95% UI: 1.5; 1.7)); and DALYs averted (traffic-light labelling: 45 100 (95% UI: 37 700; 60 100);<br />&lsquo;junk-food&rsquo; tax: 559 000 (95% UI: 459 500; 676 000)). Cost outlays were AUD81 million (95% UI: 44.7; 108.0) for traffic-light<br />labelling and AUD18 million (95% UI: 14.4; 21.6) for &lsquo;junk-food&rsquo; tax. Cost-effectiveness analysis showed both interventions were<br />&lsquo;dominant&rsquo; (effective and cost-saving).<br /><b>Conclusion:</b> Policy-based population-wide interventions such as traffic-light nutrition labelling and taxes on unhealthy foods are<br />likely to offer excellent &lsquo;value for money&rsquo; as obesity prevention measures.<br />

The Cool Little Kids randomised controlled trial population-level early prevention for anxiety disorders

<b>Background:</b> The World Health Organization predicts that by 2030 internalising problems (e.g. depression and anxiety) will be second only to HIV/AIDS in international burden of disease. Internalising problems affect 1 in 7 school aged children, impacting on peer relations, school engagement, and later mental health, relationships and employment. The development of early childhood prevention for internalising problems is in its infancy. The current study follows two successful &lsquo;efficacy&rsquo; trials of a parenting group intervention to reduce internalising disorders in temperamentally inhibited preschool children. Cool Little Kids is a population-level randomised trial to determine the impacts of systematically screening preschoolers for inhibition then offering a parenting group intervention, on child internalising problems and economic costs at school entry.<br /><b>Methods/Design:</b> This randomised trial will be conducted within the preschool service system, attended by more than 95% of Australian children in the year before starting school. In early 2011, preschool services in four local government areas in Melbourne, Australia, will distribute the screening tool. The &asymp;16% (n&asymp;500) with temperamental inhibition will enter the trial. Intervention parents will be offered Cool Little Kids, a 6-session group program in the local community, focusing on ways to develop their child&rsquo;s bravery skills by reducing overprotective parenting interactions. Outcomes one and two years post-baseline will comprise child internalising diagnoses and symptoms, parenting interactions, and parent wellbeing. An economic evaluation (costconsequences framework) will compare incremental differences in costs of the intervention versus control children to incremental differences in outcomes, from a societal perspective. Analyses will use the intention-to-treat principle, using logistic and linear regression models (binary and continuous outcomes respectively) to compare outcomes between the trial arms.<br /><b>Discussion:</b> This trial addresses gaps for internalising problems identified in the 2004 World Health Organization Prevention of Mental Disorders report. If effective and cost-effective, the intervention could readily be applied at a population level. Governments consider mental health to be a priority, enhancing the likelihood that an effective early prevention program would be adopted in Australia and internationally.<br />

Obesity prevention in the family day care setting : impact of the romp & chomp intervention on opportunities for children's physical activity and healthy eating

<b>Background</b> The Romp &amp; Chomp intervention reduced the prevalence of overweight/obesity in pre-school children in Geelong, Victoria, Australia through an intervention promoting healthy eating and active play in early childhood settings. This study aims to determine if the intervention successfully created more health promoting family day care (FDC) environments.<br /><b>Methods</b> The evaluation had a cross-sectional, quasi-experimental design with the intervention FDC service in Geelong and a comparison sample from 17 FDC services across Victoria. A 45-item questionnaire capturing nutrition- and physical activity-related aspects of the policy, socio-cultural and physical environments of the FDC service was completed by FDC care providers (in 2008) in the intervention (n = 28) and comparison (n = 223) samples.<br /><b>Results</b> Select results showed intervention children spent less time in screen-based activities (P = 0.03), organized active play (P &lt; 0.001) and free inside play (P = 0.03) than comparison children. There were more rules related to healthy eating (P &lt; 0.001), more care provider practices that supported children&rsquo;s positive meal experiences (P &lt; 0.001), fewer unhealthy food items allowed (P = 0.05), higher odds of staff being trained in nutrition (P = 0.04) and physical activity (P &lt; 0.001), lower odds of having set minimum times for outside (P &lt; 0.001) and organized (P = 0.01) active play, and of rewarding children with food (P &lt; 0.001).<br /><b>Conclusions</b> Romp &amp; Chomp improved the FDC service to one that discourages sedentary behaviours and promotes opportunities for children to eat nutritious foods. Ongoing investment to increase children&rsquo;s physical activity within the setting and improving the capacity and health literacy of care providers is required to extend and sustain the improvements.<br />

The development of a network for community based obesity prevention : the CO-OPS collaboration

<b>Background:</b> Community-based interventions are a promising approach and an important component of a comprehensive response to obesity. In this paper we describe the Collaboration of COmmunity-based Obesity Prevention Sites (CO-OPS Collaboration) in Australia as an example of a collaborative network to enhance the quality and quantity of obesity prevention action at the community level. The core aims of the CO-OPS Collaboration are to: identify and analyse the lessons learned from a range of community-based initiatives aimed at tackling obesity, and; to identify the elements that make community-based obesity prevention initiatives successful and share the knowledge gained with other communities.<br /><b>Methods:</b> Key activities of the collaboration to date have included the development of a set of Best Practice Principles and knowledge translation and exchange activities to promote the application (or use) of evidence, evaluation and analysis in practice.<br /><b>Results:</b> The establishment of the CO-OPS Collaboration is a significant step toward strengthening action in this area, by bringing together research, practice and policy expertise to promote best practice, high quality evaluation and knowledge translation and exchange. Future development of the network should include facilitation of further<br />evidence generation and translation drawing from process, impact and outcome evaluation of existing communitybased interventions.<br /><b>Conclusions:</b> The lessons presented in this paper may help other networks like CO-OPS as they emerge around the globe. It is important that networks integrate with each other and share the experience of creating these networks.<br />

Significant challenges remain to achieve risk reduction targets for cardiovascular secondary prevention and diabetes

Objective: To examine population-level evidence treatment gaps for cardiovascular risk among rural patients with existing cardiovascular disease or diabetes.<br /><br />Methods: Three population surveys were undertaken in the Greater Green Triangle region of southeastern Australia 2004-2006. Adults aged 25-84 yrs were randomly selected using age/sex stratified electoral role samples. A representative 1690 participants were recruited (48% participation rate). Anthropometric, clinical and self-administered questionnaire chronic disease risk data were collected in accordance with the WHO MONICA protocol. Detailed investigation of cardiovascular and diabetes history, key cardiovascular risk factors, medication use and health behaviours were included.<br /><br />Results: After adjusting for age and sex, an estimated 12% (sample n=272) of the population had one or more of coronary heart disease, stroke, or diabetes. Blood pressure was at target (&lt;130/80 mmHg) for 26% of these individuals, and 61% were treated with antihypertensive medications. Lipid targets were achieved by 17% for total cholesterol (&lt;4 mmol/L), 18% for LDL cholesterol (&lt;2 mmol/L), 77% for HDL cholesterol (&gt;1.0 mmol/L) and 44% for triglycerides (&lt;1.5 mmol/L); overall 6% achieved all four lipid targets and 60% reported use of lipid-lowering therapy, including 51% overall using statins. Ten percent were current smokers, and four in every five patients (82%) had suboptimal BMI (outside the range 18.5 - 25.0).<br /><br />Conclusions: All participants with uncontrolled blood pressure and most with uncontrolled lipids should be taking medications. The magnitude of evidence treatment gaps suggests existing models of care need fundamental reform and renewed focus on prevention.<br />

Relapse prevention : a critique and proposed reconceptualisation

Relapse prevention (RP) plays a significant role in current treatments and post-treatment approaches to substance abuse problems. It is also widely used in a number of other problem areas, including other addictive behaviours and sexual offending. The widespread use of RP in various fields is due to both its clearly articulated theoretical basis, which has significant face validity, and its transferability into clinical practice. Also, there is a growing (though arguably still modest) body of empirical evidence that demonstrates its efficacy in a range of therapeutic contexts. However, arguably, in terms of both the theoretical underpinnings and the practical application of RP there is room for improvement. This article hypothesises that one of the key weaknesses of RP is that it takes a generally unconstructive approach to the therapeutic process through the use of negative concepts and avoidance goals. It is suggested that a 'good lives' framework of psychological wellbeing can provide a means of remedying these weaknesses of the traditional RP model. It is argued that a good lives framework can lead to a more optimistic approach to the prevention of relapse among individuals with substance use problems.