Obesity prevention: a proposed framework for translating evidence into action

Obesity as a major public health and economic problem has risen to the top of policy and programme agendas in many countries, with prevention of childhood obesity providing a particularly compelling mandate for action. There is widespread agreement that action is needed urgently, that it should be comprehensive and sustained, and that it should be evidence-based. While policy and programme funding decisions are inevitably subject to a variety of historical, social, and political influences, a framework for defining their evidence base is needed. This paper describes the development of an evidence-based, decision-making framework that is particularly relevant to obesity prevention. Building upon existing work within the fields of public health and health promotion, the Prevention Group of the International Obesity Task Force (IOTF) developed a set of key issues and evidence requirements for obesity prevention. These were presented and discussed at an IOTF workshop in April 2004 and were then further developed into a practical framework. The framework is defined by five key policy and
programme issues that form the basis of the framework. These are: (i) building a case for action on obesity; (ii) identifying contributing factors and points of intervention; (iii) defining the opportunities for action; (iv)evaluating potential interventions; and (v) selecting a portfolio of specific policies, programmes, and actions. Each issue has a different set of evidence requirements and analytical outputs to support policy and programme decision-making. Issue 4 was identified as currently the most problematic because of the relative lack of efficacy and effectiveness studies. Compared with clinical decision-making where the evidence base is dominated by randomized controlled trials with high internal validity, the evidence base for obesity prevention needs many different types of evidence and often needs the informed opinions of stakeholders to ensure external validity and contextual relevance.

Competition policy and prevention of abuses in the TRIPS agreement

The monopoly granted through intellectual property rights can lead to abuses ofsuch monopoly. The TRIPS Agreement recognizes such abuses along with the fact that competition policy can play a significant role in dealing with such abuses. The use of competition policy to deal with the abuse of IP monopolies reguires a discussion ofabuse of the dominant position, definition ot market and substitutability of products and whether the
patenting monopoly automatically puts the right holder in the dominant position. The issue of parallel trade and exhaustion of rights also has anti-competitive implications. The introduction of discriminatory pricing along with any ban on parallel trade would lead to absolute market control, market segregation and market exclusion by the monopolistic industries. [JEL Classiffication: K21, K33]

Evaluation of a prevention program to address body focus and negative affect among children

The current study evaluated a program to improve the body image and positive and negative affect of children. Participants were 368 children aged 8–12 years. The results demonstrated that boys placed more importance on and were less satisfied with their muscles; girls were less satisfied with their weight and the importance of weight increased with increasing age. Children with a large BMI were less satisfied with their weight. Boys in the intervention group showed reduced levels of negative affect over time. Further research is required to develop prevention and intervention programs to lower the effects of body dissatisfaction and negative affect among children.

Evaluation of a brief pilot nutrition and exercise intervention for the prevention of weight gain in general practice patients

Objective To pilot-test a brief written prescription recommending lifestyle changes delivered by general practitioners (GPs) to their patients.

Design The Active Nutrition Script (ANS) included five nutrition messages and personalised exercise advice for a healthy lifestyle and/or the prevention of weight gain. GPs were asked to administer 10 scripts over 4 weeks to 10 adult patients with a body mass index (BMI) of between 23 and 30 kg m− 2. Information recorded on the script consisted of patients' weight, height, waist circumference, gender and date of birth, type and frequency of physical activity prescribed, and the selected nutrition messages. GPs also recorded reasons for administering the script. Interviews recorded GPs views on using the script.

Setting General practices located across greater Melbourne.

Subjects and results Nineteen GPs (63% female) provided a median of nine scripts over 4 weeks. Scripts were administered to 145 patients (mean age: 54 ± 13.2 years, mean BMI: 31.7 ± 6.3 kg m− 2; 57% female), 52% of whom were classified as obese (BMI >30 kg m− 2). GPs cited ‘weight reduction’ as a reason for writing the script for 78% of patients. All interviewed GPs (90%, n = 17) indicated that the messages were clear and simple to deliver.

Conclusions GPs found the ANS provided clear nutrition messages that were simple to deliver. However, GPs administered the script to obese patients for weight loss rather than to prevent weight gain among the target group. This has important implications for future health promotion interventions designed for general practice.

Teaching landing skills in elite junior Australian football: evaluation of an injury prevention strategy

Objective: To evaluate the effectiveness of a preseason physical training programme that taught landing and falling skills in improving landing skills technique and preventing injury in junior elite Australian football players.

Methods: 723 male players who participated in an under 18 elite competition were studied prospectively in a non-randomised controlled trial over two consecutive football seasons. There were 114 players in the intervention group and 609 control players. The eight session intervention programme taught players six landing, falling, and recovery skills, which were considered fundamental for safe landing in Australian football. Landing skills taught in these sessions were rated for competence by independent and blinded assessors at baseline and mid-season.

Results: Evaluation of landing skills found no significant differences between the groups at baseline. Evaluation after the intervention revealed overall improvement in landing skills, but significantly greater improvement in the intervention group (z = –7.92, p = 0.001). Players in the intervention group were significantly less likely (relative rate 0.72, 95% confidence interval 0.52 to 0.98) to sustain an injury during the season than the control group. In particular, the time to sustaining a landing injury was significantly less for the intervention group (relative rate 0.40, 95% confidence interval 0.17 to 0.92) compared with the control group.

Conclusions: Landing and falling ability can be taught to junior elite Australian football players. Players in the intervention group were protected against injury, particularly injuries related to landing and falls.

Policy, preparation and prevention : proactive minimisation of student plagiarism

Countless cases of plagiarism are detected across the Australian higher education sector each year. Generally speaking, policy and other responses to the issue focus on punitive, rather than on educative, measures. Recently, a subtle shift is discernable. As well as ensuring appropriate consequences for plagiarists, several universities are beginning to formalise the inclusion of learning and teaching strategies in anti-plagiarism related policy and practice, as well as paying closer attention to the communication of unambiguous definitions of plagiarism. This article outlines one example of the emerging educative approach and details the ways in which this approach has been implemented across an entire university. The necessity of evidence-based evaluation of approaches to reducing plagiarism in higher education is discussed.

Policy, preparation, prevention and punishment: one faculty's holistic approach to minimising plagiarism

Most Australian universities have made attempts of various kinds to address plagiarism. Some have responded in recent times with a primary focus on catching and punishing plagiarists, often assisted by computer software packages. Others have taken a more holistic approach incorporating foci on policy, assessment regime and student preparation and education as well as on ensuring appropriate consequences for plagiarists. This paper outlines one example of the latter approach in one Australian university faculty and details the outcomes in terms of policy recommendations and resources to support the approach. The necessity of evidence-based evaluation of attempts to reduce plagiarism in higher education is argued.

Community-based study on knowledge, attitude and practice on the mode of transmission, prevention and treatment of the Buruli ulcer in Ga West District, Ghana

Buruli ulcer disease (BUD), a devastating tropical disease caused by Mycobacterium ulcerans, occurs in more than 80% of the administrative districts of Ghana. To elucidate community perceptions and
understanding of the aetiology of BUD, attitudes towards Buruli patients and treatment-seeking behaviours, we conducted a survey with 504 heads of households and seven focus group discussions in Ga West District, Ghana. Although 67% of participants regarded BUD as a health problem, 53% did not know its cause. Sixteen per cent attributed the cause to drinking non-potable water, 8.1% mentioned poor personal hygiene or dirty surroundings, and 5.5% identified swimming or wading in ponds as a risk factor. About 5.2% thought that witchcraft and curses cause BUD, and 71.8% indicated that BU sufferers first seek treatment from herbalists and only refer to the hospital as a last resort. The main
reasons were prospects of prolonged hospital stay, cost of transport, loss of earnings and opportunity associated with parents attending their children’s hospitalization over extended period, delays in being
attended by medical staff, and not knowing the cause of the disease or required treatment. The level of acceptance of BUD sufferers was high in adults but less so in children. The challenge facing health workers is to break the vicious cycle of poor medical outcomes leading to poor attitudes to hospital treatment in the community. Because herbalists are often the first people consulted by those who contract the disease, they need to be trained in early recognition of the pre-ulcerative stage of Buruli lesions.

Prevention of type 2 diabetes in a primary health care setting interim results from the Greater Green Triangle (GGT) Diabetes Prevention Project

Although clinical trials have shown that lifestyle modifications reduce the risk of type 2 diabetes, translating lessons from trials to primary care remains a challenge. The aim of the study was to evaluate efficacy and feasibility of primary care-based diabetes prevention model with modest resource requirements in rural Australia. Three hundred and eleven subjects with at least a moderate risk of type 2 diabetes participated in a combined dietary and physical activity intervention. Clinical measurements and fasting blood samples were taken at the baseline and after intervention. After 3 months intervention, total (change −3.5%, p < 0.001) and LDL cholesterol (−4.8%, p < 0.001) plasma levels as well as body mass index (−2.5%, p < 0.001), weight (−2.5%, p < 0.001), and waist (−1.6%, p < 0.001) and hip (−2.7%, p < 0.001) circumferences reduced significantly. A borderline reduction was found in triglyceride levels (−4.8%, p = 0.058) while no changes were observed in HDL cholesterol (+0.6%, p = 0.525), glucose (+0.06%, p = 0.386), or systolic (−0.98%, p = 0.095) or diastolic (−1.06%, p = 0.134) blood pressure levels. In conclusion, a lifestyle intervention improved health outcomes – especially obesity and blood lipids – in a population at high risk of developing type 2 diabetes. Our results suggest that the present model is effective and feasible to carry out in primary care settings.

Associations among individual, social, and environmental barriers and children's walking or cycling to school

Purpose. To examine associations among individual, social, and environmental barriers and children's walking or cycling to school.

Design. Exploratory cross-sectional study.

Setting. All eight capital cities in Australia.

Subjects. Parents (N = 720) of school-aged children (4-13 years; 27% response rate 49% parents of boys,).

Measures. Multivariate-adjusted odds ratios (OR) and 95% confidence intervals (CI) for parental reporting of barriers to their children's walking or cycling to school, based on a computer-assisted telephone interview.

Results. Forty-one percent of children walked or cycled to school at least once per week. Multivariable analyses found inverse associations with individual ("child prefers to be driven" [OR = 0.4, 95% CI = 0.3-0.6], "no time in the mornings" [OR 0.5, 95% CI = 0.3-0.8]); social ("worry child will take risk" [OR = 0.6, 95% CI = 0.3-0.9], "no other children to walk with" [OR = 0.7, 95% CI = 0.4-0.99], "no adults to walk with" [OR = 0.6, 95% CI = 0.4-0.9]); and environmental barriers ("too far to walk" [OR = 0.1, 95% CI = 0.0- 0.1], "no direct route" [OR = 0.4, 95% CI = 0.2-0. 7]) and positive associations with "concern child may he injured in a road accident" (OR = 1.9, 95% CI = 1.1-3.1) and active commuting.

Conclusion. Working with parents, schools, and local authorities to improve pedestrian, skills and environments may help to overcome barriers.

Obesity prevention programs demand high-quality evaluations

Obesity prevention programs are at last underway or being planned in Australia and New Zealand. However, it is imperative that they are well-evaluated so that they can contribute to continuous program improvement and add much-needed evidence to the international literature on what works and does not work to prevent obesity. Three critical components of program evaluation are especially at risk when the funding comes from service delivery rather than research sources. These are: the need for comparison groups; the need for measured height and weight; and the need for sufficient process and context information. There is an important opportunity to build collaborative mechanisms across community-based obesity prevention sites to enhance the program and evaluation quality and to accelerate knowledge translation into practice and policy.

Depression, anxiety and stress in women following acute coronary syndrome: implications for secondary prevention

Objective
To document incidence of depression, anxiety, and stress in women more than 6 months following an acute coronary syndrome.

Design
Participants were identified from a coronary care unit database. The Depression Anxiety Stress Scales 21 (DASS 21) was sent to potential participants via postal survey.

Setting
A metropolitan teaching hospital in Melbourne, Australia.

Participants
The cohort of women was aged between 55 and 70 years. They had been admitted to hospital with a diagnosis of acute coronary syndrome (ACS) between 6 and 14 months prior to participating in this study.

Main outcome measures
Scores on Depression, Anxiety, and Stress Scale (DASS 21).

Results
Of the 117 posted questionnaires, 39 women with a mean age of 63 (S.D. 4.97) responded to the survey, representing a response rate of 33.3%. Most participants scored within normal levels of depression (66.7%), anxiety (60.5%), and stress (70.3%), however, mild to extremely severe levels of each construct (33.4%, 39.6%, and 29.7%, respectively) were found.

Conclusions
The reporting of elevated levels of depression, anxiety and stress in a subset of women more than 6 months following an ACS event underscores the importance of ongoing screening for risk factors impacting on psychological well-being and the inclusion of this information in education and counseling strategies in both the inpatient and outpatient settings. Based on these pilot data, consideration of a screening system in the immediate post discharge period for women at risk and an education or support service are recommended.

Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting : Greater Green Triangle (GGT) Diabetes Prevention Project

Background
Randomised controlled trials demonstrate a 60% reduction in type 2 diabetes incidence through lifestyle modification programmes. The aim of this study is to determine whether such programmes are feasible in primary health care.

Methods
An intervention study including 237 individuals 40–75 years of age with moderate or high risk of developing type 2 diabetes. A structured group programme with six 90 minute sessions delivered during an eight month period by trained nurses in Australian primary health care in 2004–2006. Main outcome measures taken at baseline, three, and 12 months included weight, height, waist circumference, fasting plasma glucose and lipids, plasma glucose two hours after oral glucose challenge, blood pressure, measures of psychological distress and general health outcomes. To test differences between baseline and follow-up, paired t-tests and Wilcoxon rank sum tests were performed.

Results
At twelve months participants' mean weight reduced by 2.52 kg (95% confidence interval 1.85 to 3.19) and waist circumference by 4.17 cm (3.48 to 4.87). Mean fasting glucose reduced by 0.14 mmol/l (0.07 to 0.20), plasma glucose two hours after oral glucose challenge by 0.58 mmol/l (0.36 to 0.79), total cholesterol by 0.29 mmol/l (0.18 to 0.40), low density lipoprotein cholesterol by 0.25 mmol/l (0.16 to 0.34), triglycerides by 0.15 mmol/l (0.05 to 0.24) and diastolic blood pressure by 2.14 mmHg (0.94 to 3.33). Significant improvements were also found in most psychological measures.

Conclusion
This study provides evidence that a type 2 diabetes prevention programme using lifestyle intervention is feasible in primary health care settings, with reductions in risk factors approaching those observed in clinical trials.

Trial Number
Current Controlled Trials ISRCTN38031372

Mental health promotion and socio-economic disadvantage: lessons from substance abuse, violence and crime prevention and child health

Issue addressed: Mental health promotion aimed at populations with low socio-economic status (SES) may benefit by investigating prevention strategies that effectively address related child and adolescent problems.
Methods: Evidence from a number of literature reviews and program evaluations was synthesised. First, the impact of SES on development from childhood to adulthood is considered in light of research on substance
abuse, violence, crime, and child development problems. Second, evaluations of interventions are reviewed to identify those that have shown outcomes in research studies (efficacy) or in real-world settings (effectiveness) in reducing developmental problems associated with low SES. Low SES is measured in different ways including low levels of education and/or income or definitions that combine several variables into a new indicator of low SES.
Results: Factors associated with low SES are also associated to varying extent with the development of violence and crime, substance abuse and child health problems. Interventions that address underlying determinants of low SES show strong efficacy in decreasing adolescent crime and violence and effectiveness in improving child health outcomes. Although there is limited efficacy evidence that substance abuse prevention can be effectively addressed by targeting low SES, programs designed to improve educational pathways show some efficacy in reducing aspects of adolescent substance use.
Conclusion: Mental health promotion strategies can draw on the approaches outlined here that are associated with the prevention of child and adolescent problems within low SES communities. Alternatively, such interventions could be supported in mental health promotion policy as they may assist in preventing related problems that undermine mental health.