Can Australain general practitioners tackle chidhood overweight/obesity? Methods and processes from the LEAP (live, eat, and play) randomized controlled trial

Background: General practitioners (GPs) could make an important contribution to management of childhood overweight. However, there are no efficacy data to support this, and the feasibility of this approach is unknown.

Objectives: To determine if GPs and families can be recruited to a randomized controlled trial (RCT), and if GPs can successfully deliver an intervention to families with overweight/obese 5- to 9-year-old children.

Methods: A convenience sample of 34 GPs from 29 family medical practices attended training sessions on management of childhood overweight. Practice staff trained in child anthropometry conducted a cross-sectional body mass index (BMI) survey of 5- to 9-year-old children attending these practices. The intervention focused on achievable goals in nutrition, physical activity and sedentary behaviour, and was delivered in four solution-focused behaviour change consultations over 12 weeks.

Results: General practitioners were recruited from across the sociodemographic spectrum. All attended at least two of the three education sessions and were retained throughout the trial. Practice staff weighed and measured 2112 children in the BMI survey, of whom 28% were overweight/obese (17.5% overweight, 10.5% obese), with children drawn from all sociodemographic quintiles. Of the eligible overweight/obese children, 163 (40%) were recruited and retained in the LEAP RCT; 96% of intervention families attended at least their first consultation.

Conclusions: Many families are willing to tackle childhood overweight with their GP. In addition, GPs and families can participate successfully in the careful trials that are needed to determine whether an individualized, family-based primary care approach is beneficial, harmful or ineffective.

Parent-reported health status of overweight and obese Australian primary school children: a cross-sectional population survey

Introduction: Childhood overweight/obesity is associated with poor physical and psychosocial health in clinical samples. However, there is little information on the health status of overweight and obese children in the community, who now represent a large proportion of the child population. We examined parent-reported child health and well-being and parent concern about child weight by body mass index (BMI) category in a population sample of primary school children.

Design: A stratified two-stage random cluster sample of 24 primary schools representative of the state of Victoria, Australia.

Measures: BMI (weight/height2) transformed to normalised Z-scores using the 1990 UK Growth Reference; the Child Health Questionnaire (CHQ), a 13-scale 50-item parent-completed measure of health and well-being; parent self-reported height and weight; parent concern about child's weight.

Results: Data were available for 2863 children aged 5-13 y (50.5% male), of whom 17% were overweight and 5.7% obese. Using logistic regression analyses with 'normal weight' as the referent category, obese boys were at greater risk of poor health (ie <15th centile) on seven of the 12 CHQ scales: Physical Functioning (odds ratio (OR) 2.8), Bodily Pain (OR 1.8), General Health (OR 3.5), Mental Health (OR 2.8), Self Esteem (OR 1.8), Parent Impact¾Emotional (OR 1.7) and Parent Impact¾Time (OR 1.9). Obese girls were at greater risk of poor health on only two scales: General Health (OR 2.1) and Self Esteem (OR 1.8). Forty-two percent of parents with obese children and 81% with overweight children did not report concern about their child's weight. Parents were more likely to report concern if the child was obese (OR 21.3), overweight (OR 3.5) or underweight (OR 5.4) than normal weight (P<0.05). Concern was not related to child gender, parental BMI or parental education after controlling for child BMI. Perceived health and well-being of overweight/obese children varied little by weight category of the reporting parent (overweight vs non-overweight).

Conclusions: Parents were more likely to report poorer health and well-being for overweight and obese children (particularly obese boys). Parental concern about their child's weight was strongly associated with their child's actual BMI. Despite this, most parents of overweight and obese children did not report poor health or well-being, and a high proportion did not report concern. This has implications for the early identification of such children and the success of prevention and intervention efforts.

Depression : an important comorbidity with metabolic syndrome in a general population

OBJECTIVE—There is a recognized association among depression, diabetes, and cardiovascular disease. The aim of this study was to examine in a sample representative of the general population whether depression, anxiety, and psychological distress are associated with metabolic syndrome and its components.

RESEARCH DESIGN AND METHODS—Three cross-sectional surveys including clinical health measures were completed in rural regions of Australia during 2004–2006. A stratified random sample (n = 1,690, response rate 48%) of men and women aged 25–84 years was selected from the electoral roll. Metabolic syndrome was defined by the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, Adult Treatment Panel III (NCEP ATP III), and International Diabetes Federation (IDF) criteria. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale and psychological distress by the Kessler 10 measure.

RESULTS—Metabolic syndrome was associated with depression but not psychological distress or anxiety. Participants with the metabolic syndrome had higher scores for depression (n = 409, mean score 3.41, 95% CI 3.12–3.70) than individuals without the metabolic syndrome (n = 936, mean 2.95, 95% CI 2.76–3.13). This association was also present in 338 participants with the metabolic syndrome and without diabetes (mean score 3.37, 95% CI 3.06–3.68). Large waist circumference and low HDL cholesterol showed significant and independent associations with depression.

CONCLUSIONS—Our results show an association between metabolic syndrome and depression in a heterogeneous sample. The presence of depression in individuals with the metabolic syndrome has implications for clinical management.

Haptically enabled interactive virtual reality prototype for general assembly

Desktop computers based virtual training systems are attracting paramount attention from manufacturing industries due to their potential advantages over the conventional training practices. Significant cost savings can be realized due to the shorter training-scenarios development times and reuse of existing engineering models. In addition, by using computer based virtual reality (VR) training systems, the time span from the product design to commercial production can be shortened due to non-reliance on hardware parts. Within the aforementioned conceptual framework, a haptically enabled interactive and immersive virtual reality (HIIVR) system is presented. Unlike existing VR systems, the presented idea tries to imitate real physical training scenarios by providing comprehensive user interaction, constrained within the physical limitations of the real world imposed by the haptics devices within the virtual environment. As a result, in contrast to the existing VR systems, capable of providing knowledge generally about assembly sequences only, the proposed system helps in procedural learning and procedural skill development as well, due to its high physically interactive nature.

Market makers v's the general public : a first look at S & P500 futures trade data

This paper considers 15 minute records of trading volume and traded prices coinciding with the reporting intervals required by the Commodity Futures Trading Commission. Records are extracted from trade records for market trade and also two way trade between market makers (CT1) and the general public (CT4) from January 1994 to June 2004. Futures price records are matched with S&P500 cash index price records. Simultaneous volatility models are specified and estimated to test trading volume to futures volatility lead/lag effects and also futures volatility to cash index volatility lead/lag effects. As we disaggregate from the market records to CT1 and CT4 records and further into year to year samples volume to futures volatility leading effects and also futures volatility to cash volatility leading effects dominate. The results raise important issues for risk management and dynamic hedging models employing intra-day trader data. A number of important issues for further analysis are also raised in this paper.

Changing violent behaviour : forensic mental health and criminological models compared

Evidence-based interventions designed to reduce the risk of re-offending, particularly violent re-offending, are commonly offered in correctional systems around the world. The interventions are often based upon the application of several principles of service delivery that have become widely known as the 'what works' approach to offender rehabilitation. The applicability of these principles to forensic psychiatric services has yet to be determined. The aims are to examine the possible application of the 'what works' approach and its implications for forensic mental health practice. The method used was a review of relevant research from both the general offender and forensic psychiatry literature. The principles underlying the 'what works' approach are likely to have utility in service delivery in forensic psychiatry, particularly when a treatment target is a reduction in risk of harm to others. The individualized models of patient care practiced in forensic psychiatry are also likely to have utility in improving treatment outcomes in correctional settings. The conclusion is that an increased interchange of ideas and interventions between the two areas of practice is likely to be of mutual benefit. This is an area that requires significant development.

Dispersion of information or market behaviour : general public trading in S & P 500 index futures

This paper considers 15 minute records of trading volume and traded prices coinciding with the reporting intervals required by the Commodity Futures Trading Commission. Records are extracted from trade records for two way trade between market makers (CTI1) and the general public (CTI4) from January 1994 to June 2004. Futures price records are matched with S&P500 cash index price records. Simultaneous volatility models are specified and estimated to test trading volume to futures volatility lead/lag effects and also futures volatility to cash index volatility lead/lag effects. There is evidence that existing theoretical models of the general public trading behaviour do not explain such behaviour in these very actively traded markets. These effects can depend more on market conditions than what is suggested in theoretical models.

Relevance of health literacy models for people with severe mental illness

People with severe mental illness experience elevated levels of impairment, morbidity and health-risk behaviours compared with the general population. Despite this, it is consistently reported that they do not visit health professionals, including preventative health professionals, as regularly as the general population. Their poor health suggests that current health promotion efforts have been largely ineffective in addressing their specific needs. Barriers that might explain this include lack of motivation, expense and lack of access. Health literacy is also a potentially important factor. As a part of a programme of work to develop appropriate and effective health promotion for this group, we have explored existing health-literacy models and their relevance to marginalized populations, in particular, people experiencing severe mental illness. A comprehensive search of the literature was undertaken. Models of health literacy identified were analyzed to determine the source population, underpinning theory/frameworks, supporting research evidence and to consider their potential generalisability. This paper presents an analysis of existing health-literacy models in the context of severe mental illness. We propose that because existing models of health literacy were developed through consultation with people experiencing challenges to specific health and social issues, for example, cancer, low income and limited education, this raises questions as to the applicability of these models to people experiencing severe and ongoing mental illness. Whilst such individuals were not actively excluded in the development of the existing models, we propose the development of an alternative model which considers this population's needs and limitations in accessing effective health-promotion campaigns/programs.

Symbolic computation and perfect fluids in general relativity

Focuses on two areas within the field of general relativity. Firstly, the history and implications of the long-standing conjecture that general relativistic, shear-free perfect fluids which obey a barotropic equation of state p = p(w) such that w + p = 0, are either non-expanding or non-rotating. Secondly the application of the computer algebra system Maple to the area of tetrad formalisms in general relativity.

Practice nurses' role and knowledge about diabetes management within rural and remote Australian general practices

Background: The increasing prevalence of diabetes and obesity represents a significant disease burden in Australia. Practice nurses (PNs) play an important role in diabetes education and management.

Aim: To explore PNs' roles, knowledge and beliefs about diabetes education and management in rural and remote general practice in Australia.

Method: Exploratory study undertaken in three phases: 1) Pilot study to test the performance of the questionnaire; 2) One-shot cross-sectional survey using self-complete questionnaires; 3) Individual interviews.

Results: Ten PNs completed the pilot test; the draft questionnaire was deemed appropriate to the study purpose. Then, 65 questionnaires were distributed to PNs and 21 responded. Fourteen respondents had worked in the role <5 years, and most PNs attended diabetes education programmes in their workplace. A minority (40%) used diabetes management guidelines regularly. Most knew obesity to be the most common risk factor for diabetes but only 50% knew that glycosylated haemoglobin indicates blood glucose levels over the preceding three months. Self-reported competency to assess patients' self-care practices and medication management practices varied.

Conclusion: PNs' diabetes management was self-reported; their knowledge varied and their perceived benefits of diabetes education differed from those of patients.

Is dietary management a responsibility of general practitioners? The views of Victorian general practitioners

Rationale : Australia is experiencing an evolving healthcare system, resulting in an aim of systematic managed care for patients with chronic disease. One outcome has been debate on doctors' dietary management responsibilities.
Aim : To identify general practitioners' perceptions of their dietary management responsibilities for adult cardiac patients.
Methods : A Two phase study was conducted. First, semi-structured interviews with 30 Melbourne general practitioners were conducted to gather preliminary information about dietary management. The results informed a questionnaire for the second phase. This was completed by 248 general practitioners (30%) in Victoria.
Principal findings : Themes arising in interviews, and also supported by cross-sectional survey showed that doctors perceive themselves as filling one or more of three roles. The majority (87.4%) endorsed an 'Influencing' role, 27.4% endorsed 'Dietary Educator' and 44.0% a 'Coordinator' role. The Influencer role was characterised by encouragement of dietary behaviour change, such as discussing benefits and consequences of inaction to dietary change. The Educator role was characterised by the provision of a range of behaviour change strategies- 'how to' achieve change. 'Coordinators' reported the provision of dietary counselling belonged to dietitians alone.
Implications : The results indicate doctors' awareness of need for patients' dietary education should be increased. This could be accomplished by one-on-one education. Patients' access to dietary education should also be facilitated by doctors' referring on. Embedding dietary management protocols in doctors' managed care templates could improve patients' access to dietary education and enhance doctor's collaborative roles.
Presentation type : Paper
Session theme : Getting Evidence into Practice 2

The relevance of the Heart Foundation of Australia's dietary recommendations for adult Australians : a comparison of views of general practitioners, cardiologists and dietitians

PURPOSE: To compare the views of general practitioners, cardiologists and dietitians about the relevance of the Heart Foundation of Australia's dietary recommendations for adult cardiac patients.

BASIC PROCEDURES: Quantitative-cross sectional study. Postal questionnaires were self-completed by 248 Victorian general practitioners (30% response), 189 Australia-wide cardiologists (47% response) and 180 Victorian dietitians (45% response). Responses were represented as percentages and analyses of variance were conducted to explore the impact of the independent variables: age, work status and gender on the dependent variable: dietary recommendation.

MAIN FINDINGS: Approximately half of the recommendations were viewed as strongly important to implement; these related to lean meats, limiting takeaways and cakes/biscuits, and adjusting energy intake. Others of importance were eating fruits, vegetables and fish. However, most of these goals were seen as difficult to achieve. Dietitians appeared to share responses of doctors, except for greater importance of eating fruit and vegetables and a greater difficulty in limiting cakes and biscuits. There was a high level of agreement among the three groups (mean 87%) about patients having difficulty implementing adjusting energy intake.

CONCLUSIONS: There is agreement amongst these professionals that many of the recommendations lack importance, specifically those pertaining to unsaturated oils, low fat dairy products, cholesterol rich foods, intake of legumes and grains and the restriction of salt. This may reflect a need for further nutrition education.

Contribution of Australian cardiologists, general practitioners and dietitians to adult cardiac patients’ dietary behavioural change

Aim:  To investigate the use of behavioural change techniques by cardiologists, general practitioners and dietitians in adult cardiac patients within 12 months of their cardiac event.
Method:  Quantitative cross-sectional surveys. Frequency analyses were conducted on the respondents' answers to questionnaire items. Chi-squared test of independence compared responses of the three professional groups on the questionnaire items. Analyses of variance were conducted to explore the impact of the independent variables: age, sex and time worked on the behavioural change techniques used by the respondents.
Results:  The respondents included 248 general practitioners (30% response), 189 cardiologists (47% response) and 180 dietitians (60% response). General practitioners and cardiologists acted mainly as advocates for dietary change in the dietary management process. Dietitians provided nutrition knowledge and a range of techniques to assist dietary behavioural change. Cardiologists and dietitians shared little nutrition information with general practitioners (cardiologists with general practitioners = 8%, dietitians with general practitioners = 49%).
Conclusion:  The present study shows that cardiac patients may have insufficient access to knowledge of nutrition and techniques to assist them with dietary behavioural change.

Enhancing the dietary management of general practice patients through collaborative care: perspectives of general practitioners and dietitians

Aim:  To describe how general practitioners and dietitians view their role in the dietary management of cardiac patients and to provide insights on how to facilitate collaborative care.
Methods:  Two studies were conducted in Victoria (Australia) 2005–2006. Study One: semi-structured interviews with general practitioners. Study Two: cross-sectional quantitative surveys of general practitioners and dietitians. Study One: texts were analysed using the grounded theory approach. Study Two: frequency analysis was conducted and chi-squared test for independence was used to explore the impact of age, sex and consultation time on the role and reporting scales.
Results:  Study One: Themes arising from the interviews with 30 general practitioners showed their involvement in dietary management fell into three broad roles: ‘Influencing’, ‘Coordinator’ of referrals and dietary ‘Educator’. They described dietetic education as a process that included dietary assessment, education, application of behavioural change techniques and reporting back to general practitioners. Study Two: Respondents were 248 general practitioners (30% response) and 180 dietitians (60% response). General practitioners' counselling consisted mostly of advocating for dietary change, coordinating dietetic referrals and reinforcing dietitians' recommendations. General practitioners considered dietary education as the role of dietitians. Dietitians reported a much broader role in the management of patients with some overlap with general practitioners' roles.
Conclusions:   The findings indicate the need: (i) for more structured reporting to ensure general practitioners receive appropriate information to enable them to reinforce dietetic counselling and recommendations; and (ii) to streamline the communication process in order to expedite dietitians' reports to general practitioners.