Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight/mild obesity

OBJECTIVES: To reduce gain in body mass index (BMI) in overweight/mildly obese children in the primary care setting.
DESIGN: Randomized controlled trial (RCT) nested within a baseline cross-sectional BMI survey.
SETTING: Twenty nine general practices, Melbourne, Australia.
PARTICIPANTS: (1) BMI survey: 2112 children visiting their general practitioner (GP) April-December 2002; (2) RCT: individually randomized overweight/mildly obese (BMI z-score <3.0) children aged 5 years 0 months-9 years 11 months (82 intervention, 81 control).
INTERVENTION: Four standard GP consultations over 12 weeks, targeting change in nutrition, physical activity and sedentary behaviour, supported by purpose-designed family materials.
MAIN OUTCOME MEASURES: Primary: BMI at 9 and 15 months post-randomization. Secondary: Parent-reported child nutrition, physical activity and health status; child-reported health status, body satisfaction and appearance/self-worth.
RESULTS: Attrition was 10%. The adjusted mean difference (intervention-control) in BMI was -0.2 kg/m(2) (95% CI: -0.6 to 0.1; P=0.25) at 9 months and -0.0 kg/m(2) (95% CI: -0.5 to 0.5; P=1.00) at 15 months. There was a relative improvement in nutrition scores in the intervention arm at both 9 and 15 months. There was weak evidence of an increase in daily physical activity in the intervention arm. Health status and body image were similar in the trial arms.
CONCLUSIONS: This intervention did not result in a sustained BMI reduction, despite the improvement in parent-reported nutrition. Brief individualized solution-focused approaches may not be an effective approach to childhood overweight. Alternatively, this intervention may not have been intensive enough or the GP training may have been insufficient; however, increasing either would have significant cost and resource implications at a population level.

The epidemiology of overweight and obesity among Australian children and adolescents, 1995-97

A study attempts to determine the population prevalence of overweight and obesity among Australian children and adolescents, based on measured body mass index (BMI) to determine if overweight and obesity are distributed differentially across the population of young Australians. Data from three independent surveys were analyzed and results indicate that the population prevalence and distribution of overweight, obesity and overweight/obesity combined were 79%-81%, 14%-16%, 5% and 19%-21% (boys) respectively, and 76%-79%, 16%-18%, 5%-6% and 21%-24% (girls). There were no consistent relationships between the prevalence of overweight/obesity and sex, age or SES. It is concluded that some 19%-23% of Australian children and adolescents are either overweight or obese. Only cultural background differential warrant a targeted health promotion response.

Early detection of emotional and behavioural problems in children with diabetes: the validity of the child health questionnaire as a screening instrument

Aims: To assess the validity of the Child Health Questionnaire (CHQ) as a screening tool for detecting 'at risk' emotional and behavioural  maladjustment in children with diabetes, using the Behaviour Assessment System for Children (BASC) as a gold standard measure. Methods: CHQ and BASC were administered to 103 parents of children with Type 1 diabetes, aged 7–12 years. Sub-scales of the two measures were compared using Pearson's bivariate correlations. CHQ sensitivity and specificity cut-points were optimized against the BASC borderline category using receiver operating characteristic curves. Results: The BASC Externalizing Problems scale correlated strongly with CHQ Behaviour, Global Behaviour, Mental Health, Family Activities and Family Cohesion scales (r-values −0.68, −0.54, −0.51, −0.59, and −0.42, respectively). BASC Internalizing Problems scale correlated strongly with CHQ Behaviour, Mental Health and Family Cohesion scales (r-values −0.40, −0.43 and −0.45, respectively). Using receiver operating characteristic curve analysis, the CHQ Mental Health scale most effectively identified children classified as borderline on the BASC Internalizing Problems scale (sensitivity 87%, specificity 78%), while the CHQ Global Behaviour scale most effectively identified children classified as borderline on the BASC Externalizing Problems scale (sensitivity 73%, specificity 82%). Conclusions: Significant correlations were seen between the CHQ Global Behaviour and Mental Health scales and the BASC Externalizing and Internalizing scales, respectively. Sequential use of the CHQ, as a screening tool, followed by an established mental health measure such as the BASC, may help identify children with diabetes 'at risk' for chronic maladjustment and poor health outcomes.

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.

Television, computer use and body mass index in Australian primary school children

Objective: To investigate relationships between children's body mass index (BMI) and parent reports of children's television and video game/computer habits, controlling for other potential risk factors for paediatric obesity.

Methods: Child BMI was calculated from measured height and weight collected in 1997 as part of a large, representative, cross-sectional study of children in Victoria, Australia. Parents reported the amount of time children watched television and used video games/computers, children's eating and activity habits, parental BMI and sociodemographic details.

Results: A total of 2862 children aged 5−13 years participated. Child mean BMI z-score was significantly related to television (F = 10.2₃, P < 0.001) but not video game/computer time (F = 2.2₃, P = 0.09), but accounted for only 1 and 0.2% of total BMI variance, respectively. When parental BMI, parental education, number of siblings, food intake, organized exercise and general activity level were included, television ceased to be independently significantly related to child BMI. Using adjusted logistic regression, the odds of being overweight and obese generally increased with increasing television viewing. No relationship was found for video game/computer use.
Conclusions: A small proportion of variance in child BMI was related to television, but not video game/computer time. This was far outweighed by the influence of other variables. Causal pathways are likely to be complex and interrelated.

A review of epidemiological studies on children`s health and wellbeing

New epidemiological studies on children's health and wellbeing are essential to guide policy development. To ensure that these studies are based on the current conceptualisation of health, they should have a theoretical rationale for the selection of their domains. The scales used to measure each domain must be psychometrically sound, and also reflect the current conceptualisation of the domain. When selecting scales for each domain, child questionnaires must be considered, in addition to adult proxy measures. Through following these recommendations, researchers can ensure that their studies have theoretical and practical relevance. (non-author abstract)

Autonomy and disintegration in Indonesia

Fragmentation in Indonesia is by far the most critical issue now facing the state. This book analyses social unrest, autonomy and separatism in the wake of the Indonesian economic crisis, placing them in the context of state evolution, and looking at the competing aims of economic and political globalisation with local agendas.

Political Islam and human security

In the wake of the September 11 and subsequent terrorist attacks, the academic and media commentaries on 'Islam the religion' and 'Islam the basis for political ideology' has received an unprecedented high level of attention. This book deals with such questions as the nature of Islamism, the impact of the 'war on terror' on militancy, and more.

Anti-Americanism: recent sources

Anti-American sentiment has, it would seem, increased in the wake of the election of George Bush, jr. and the US’s response to the events of
September 11. Commentators within the US, and globally, have analysed the recent variants of a long-standing condition. Below is a review of recent coverage of the phenomenon. The entries for the print sources are divided into:

(1) analyses of anti-Americanism written in the US,
(2) accounts of international expressions of anti-Americanism.

Economic Evaluation of a Primary Care Trial to Reduce Weight Gain in Overweight/Obese Children: The LEAP Trial

Background:- A common policy response to the childhood obesity epidemic is to recommend that primary care physicians screen for and offer counseling to the overweight/obese. As the literature suggests, this approach may be ineffective; it is important to document the opportunity costs incurred by brief primary care obesity interventions that ultimately may not alter body mass index (BMI) trajectory.

Methods:- Live, Eat and Play (LEAP) was a randomized controlled trial of a brief secondary prevention intervention delivered by family physicians in 2002-2003 that targeted overweight/ mildly obese children aged 5 to 9 years. Primary care utilization was prospectively audited via medical records, and parents reported family resource use by written questionnaire. Outcome measures were BMI (primary) and parent-reported physical activity and dietary habits (secondary) in intervention compared with control children.

Results:- The cost of LEAP per intervention family was AU $4094 greater than for control families, mainly due to increased family resources devoted to child physical activity. Total health sector costs were AU $873 per intervention family and AU $64 per control, a difference of AU $809 {P < .001). At 15 months, intervention children did not differ significantly in adjusted BMI or daily physical activity scores compared with the control group, but dietary habits had improved.

Conclusions:- This brief intervention resulted in higher costs to families and the health care sector, which could have been devoted to other uses that do create benefits to health and/or family well-being. This has implications for countries such as the United States, the United Kingdom, and Australia, whose current guidelines recommend routine surveillance and counseling for high child BMI in the primary care sector.

Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children

Objective
 To assess from a societal perspective the incremental cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. The intervention was modelled on the LEAP (live, eat and play) trial, a randomised controlled trial conducted by the Centre for Community Child Health, Melbourne, Australia in 2002–2003. This study was undertaken as part of the assessing cost-effectiveness (ACE) in obesity project which evaluated, using consistent methods, 13 interventions targeting unhealthy weight gain in children and adolescents.
Method
A logic pathway was used to model the effects of the intervention compared to no intervention on body mass index (BMI) and health outcomes (disability-adjusted life years—DALYs). Disease costs and health benefits were tracked until the cohort of eligible children reached the age of 100 years or death. Simulation-modelling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. The intervention was also assessed against a series of filters (‘equity’, ‘strength of evidence’, ‘acceptability’, ‘feasibility’, sustainability’ and ‘side-effects’) to incorporate additional factors that impact on resource allocation decisions.
Results
The intervention, as modelled, reached 9685 children aged 5–9 years with a BMI z-score of ≥3.0, and cost $AUD6.3M (or $AUD4.8M excluding time costs). It resulted in an incremental saving of 2300 BMI units which translated to 511 DALYs. The cost-offsets stemming from the intervention totalled $AUD3.6M, resulting in a net cost per DALY saved of $AUD4670 (dominated; $0.1M) (dominated means intervention costs more for less effect).
Conclusion
Compared to a ‘no intervention’ control group, the intervention was cost-effective under current assumptions, although the uncertainty intervals were wide. A key question related to the long-term sustainability of the small incremental weight loss reported, based on the 9-month follow-up results for LEAP.

Whose risk? 'Managing' risk in school leadership

This article discusses the rise in prominence of 'risk' in schools and the processes and procedures it has triggered in its wake. The discussion commences with formal definitions of 'risk' and how risk is mandated and 'managed' in schools. Alternative views are canvassed and hegemonic emphases in risk policy and practice are critiqued. Taking a socio-cultural approach, the article explores risk from the perspective of school leaders, raising topics elided in risk discourses. The article takes the view that current conceptions of 'risk' have created greater complexity and further risks for the school leaders who 'manage' it. The article investigates school leaders 'and risk' - how risks emerge in the course of everyday school leadership work; school leaders 'at risk' - interrogating the personal and professional risk borne by school leaders through risk policies; and leaders 'as risk' - broaching the rarely raised topic of 'bad' leadership in schools, with its deleterious effects on individuals and whole school communities. These aspects of risk are not found in current literature on risk in educational leadership. The article then goes further to raise the 'undiscussable' topic of risky central leadership practices which render school leaders at even more risk. The article concludes with discussion of risks that school leaders cannot afford not to take in dealing with risk, particularly with regard to collective action to address mandated policy procedures which are detrimental to the foundational issues of teaching, learning, professional agency and community perceptions.

Political Islam and human security

Summary: "In the wake of the September 11 and subsequent terrorist attacks, the academic and media commentaries on Islam the religion and Islam the basis for political ideology haves received an unprecedented high level of exposure and attention. The acts of political violence by extremist groups and the omnipresent war on terror have added fresh uncertainties to an already complex global order. Just as terrorism and counter-terrorism are locked in a mutually re-enforcing symbiosis, the sense of insecurity felt by Muslims and non-Muslims alike is mutually dependent and has the potential to escalate. This general assessment holds true for Muslims living in the Muslim world and beyond. The pervasive sense of being under attack physically and culturally by the United States and its allies has contributed to a growing unease among Muslims and re-enforced deep-seated mistrust of the ʻWestʼ. Public articulation of such misgivings has in turn, lent credence to Western observers who posit an inherent antipathy between the West and the Muslim world. The subsequent policies that have emerged in this context of fear and mutual distrust have contributed to the vicious cycle of insecurity. The present volume is anchored in the current debates on the uneasy and potentially mutually destructive relationship between the Muslim world and certain West countries. It brings together leading international scholars in this interdisciplinary field to deal with such inter-related questions as the nature of Islamism, the impact of the ʻwar on terrorʼ on the spread of militancy, the growing sense of being under siege by Muslim Diasporas and the many unintended ramifications of a security-minded world order. This volume deliberately focuses on these issues both at a broad theoretical level but more importantly in the form of a number of prominent case studies including Indonesia, Algeria and Turkey."--Publisher description.