Obesity prevention in children and adolescents

Childhood and adolescent obesity has been increasing in most middle- and high-income countries, and, as with adult obesity, this has been driven by increasingly obesogenic environments, especially the food environment. This constitutes a “market failure,” signaling the need for government interventions with policies, programs, and social marketing. Population prevention strategies are critical, and children and adolescents should be the priority populations. Food marketing to children is a central policy issue for governments to address, and comprehensive regulations are needed to provide substantive protection for children. Community-based intervention programs show some real promise in reducing childhood obesity, but the 2 big challenges ahead are to ensure that there is substantial ongoing funding so that the community capacity to promote healthy weights can be scaled up to a national level and to ensure that policies are in place to support these efforts. The social and cultural shifts that support healthy eating and physical activity occur differentially, and special efforts are needed to reduce the socioeconomic gradients associated with childhood obesity. A positive public health approach encompassing environmental, regulatory, sociocultural, and educational strategies offer the best chance of reducing obesity without increasing disordered eating patterns.

Family food environments as determinants of children's eating : implications for obesity prevention

The prevalence of childhood obesity is escalating rapidly and it considered to be a major public health problem. Diet is a recognised precursor of fatness, and current evidence supports the premise that in Westernised countries, the dietary intakes of children are likely to be important in obesity genesis. However, we have a relatively poor understanding of the environments in which a child’s eating is learnt and maintained. Much of the existing work in this area is based on small-scale or experimental studies, or has been derived from homogeneous populations within the USA. Despite these limitations, there is evidence that aspects of the child’s family environment are likely to be important in determining obesity risk in children. This thesis examines the impact of the family food environment on a child’s eating through two related studies. The first study, titled the Children and Family Eating (CAFÉ) study comprised three phases. Phase one involved qualitative interviews with 17 parents of 5-6 year-old children to explore parental perceptions regarding those factors in a child’s environment believed to influence the development of their child’s eating habits. These interviews were used to inform the development of quantitative measures of the family food environment. The second phase involved the development of a Food Frequency Questionnaire (FFQ) to assess dietary intake in 5-6 year-olds. The FFQ was informed by analysis of 1995 Australian National Nutrition Survey data. In the final phase the relationships between dietary intakes of 5-6 year-old children, and potential predictors of dietary intake were examined in a cross-sectional study of 560 families. Predictors included measures of: parental perceptions of the adequacy of their child’s diet; food availability and accessibility; child-feeding; the opportunities for parental modelling of food intake; a child’s television exposure; maternal Body Mass Index; and maternal education. Analysis of the CAFÉ data provides unique information regarding the relationships between a child’s family food environment and their food consumption. Models developed for a range of dietary outcomes considered to be predictive of increased risk for obesity, including total energy and fat intakes, vegetable variety, vegetable consumption, and high-energy (non-dairy) fluid consumption, explained between 11 and 20 percent of the variance in dietary intake. Two aspects of the family food environment, parental perception of a child’s dietary adequacy, and the total minutes of television viewed per day, were frequently found to be predictive of dietary outcomes likely to promote fatness in these children. The second study, titled the Parent Education and Support (PEAS) Feeding Intervention Study, was a prospective pre/post non-randomised intervention trial that assessed the impact of a feeding intervention to 240 first-time mothers of one-year-old children. This intervention focused on one aspect of the family food environment, child-feeding, which has been proposed as influential in the development of obesogenic eating behaviours. In this study, Maternal and Child Health Nurses (MCHNs), using a ‘Division of Responsibility’ model of feeding, taught parents to provide nutritious food at regular intervals and to let children decide if to eat and how much to eat. Thus parents were encourages to food their child without exerting pressure, or employing coercion or rewards (controlling behaviours). The aim was to influence parental attitudes and beliefs regarding child-feeding. Through the use of these feeding techniques, this intervention also aimed to increase the variety of fruits and vegetables a child consumed by teaching parents to persist with offering these foods, over the year of the intervention, in non-emotive environments. Fruits and vegetables were chosen in this intervention because they are likely to be protective in the development of obesity. Analysis of the PEAS data suggests that this low-level feeding intervention, delivered through existing Maternal and Child Health services, was modestly effective in changing parental attitudes and beliefs regarding the feeding of young children. Further, the validity of fruits offered to intervention group children increased. This thesis expands the existing knowledge base by providing a comprehensive analysis of the relative impact of aspects of the family environment on dietary intakes of 5-6 year-olds. Further, the analysis of a feeding intervention in first-time parents provides important insights regarding the potential to influence child-feeding and the impact this may have on the promotion of eating behaviours protective against obesity.

Cardiovascular health behaviours and health needs among people with psychiatric disabilities

Recent research in Australia has found that people with a mental illness experience higher mortality rates from preventable illnesses, such as cardiovascular disease, respiratory disease and diabetes compared to the general population. Lifestyle and other behavioural factors contribute significantly to these illnesses. Lifestyle behaviours that affect these illnesses include lack of physical activity, consumption of a poor diet and cigarette smoking. Research on the influence of these factors has been mainly directed towards the mainstream population in Australia. Consequently, there remains limited understanding of health behaviours among individuals with psychiatric disabilities, their health needs, or factors influencing their participation in protective health behaviours. This thesis presents findings from two studies. Study 1 evaluated the utility of the main components of Roger’s (1983) Protection Motivation Theory (PMT) to explain health behaviours among people with a mental illness. A clinical population of individuals with schizophrenia (N=83), Major Depressive Disorder (MDD) (N=70) and individuals without a mental illness (N=147) participated in the study. Respondents provided information on intentions and self-reported behaviour of engaging in physical activity, following a low-fat diet, and stopping smoking. Study 2 investigated the health care service needs of people with psychiatric disabilities (N=20). Results indicated that the prevalence of overweight, cigarette smoking and a sedentary lifestyle were significantly greater among people with a mental illness compared to that reported for individuals without a mental illness. Major predictors of the lack of intentions to adopt health behaviours among individuals with schizophrenia and MDD were high levels of fear of cardiovascular disease, lack of knowledge of correct dietary principles, lower self-efficacy, a limited social support network and a high level of psychiatric symptoms. In addition, findings demonstrated that psychiatric patients are disproportionately higher users of medical services, but they are under-users of preventive medical care services. These differences are primarily due to a lack of focus on preventive health, feelings of disempowerment and lower satisfaction of patient-doctor relationships. Implications of these results are discussed in terms of designing education and preventive programs for individuals with schizophrenia and MDD.

Prevention of body concerns and risk behaviours in adolescent boys

Overall, this thesis was designed to explore the nature of adolescent boys' body image, the effects of body image on body change strategies and psychological adjustment, and the factors that influence body image. The first study examined body image in 362 adolescent boys. Body image was considered in terms of attitudes to different body parts and attributes, including, lower, middle and upper body, as well as weight, shape and muscles. The relationships between Body Mass Index (BMI), body image, sociocultural messages, psychological adjustment and body change strategies, including strategies to decrease weight and increase muscles using food and exercise, drive for thinness, bulimic attitudes and behaviour, excessive exercise, food supplements to lose weight, increase muscles and steroids, were also investigated. Multiple regression analyses were used to examine the role of body image, sociocultural messages and psychological adjustment to predict satisfaction with different body attributes and body change strategies. The findings from study one led to the development of a program aimed at preventing the development of unhealthy attitudes and behaviours among adolescent boys. Study two involved the implementation and evaluation of this prevention program. One hundred and twenty one boys participated in the program. The program was based on social-cognitive theory, and included a focus on accepting differences and the development of self-esteem. The boys who participated in the program indicated some change in existing attitudes and showed less development of risk behaviours relative to the control group. The implications of the findings from this thesis in relation to future research, as well as the prevention of adolescent boys' body image problems are discussed.

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

Background

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.
Methods

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.
Results

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.
Conclusion

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.

Economic evaluation of skin cancer prevention in Australia

Objectives
Australia has the highest incidence of skin cancer in the world, despite prevention campaigns being implemented since the early 1980s. This study assesses the cost-effectiveness of a skin cancer prevention program (named SunSmart) since it was introduced, together with its potential cost-effectiveness as an upgraded and ongoing national program.

Methods
The reduction in melanoma incidence attributable to SunSmart was modelled as the primary end-point. Historical expenditures on SunSmart were obtained from representative Australian states in three latitude zones. Melanoma incidence rates from these states were used to model key health outcomes. Non-melanoma skin cancer was modelled separately based on national survey results.

Results
We estimate that SunSmart has averted 28,000 disability-adjusted life-years (DALYs), equivalent to 22,000 life-years saved, in the state of Victoria since its introduction in 1988, as well as saving money from cost offset in skin cancer management (dominant). An upgraded national program for the next 20 years is estimated to avert 120,000 DALYs, with associated reductions in the use of health care resources. It remains a dominant intervention in which every dollar invested in SunSmart will return an estimated AU$2.30.

Conclusions
This study demonstrates that a sustained modest investment in skin cancer control is likely to be an excellent value for money.

The Sustainable Farm Families Project : changing attittudes to health

Introduction: Farm health and safety has historically focussed on strategies such as injury prevention, safety audits and fulfilling legislative responsibilities. However, farmer injuries mask deeper health issues including higher rates of cancer, suicides, cardiovascular disease and stress. The relationship between occupational health and safety and farm family health has not been fully investigated. The Sustainable Farm Families (SFF) project attempts to make this connection in order to address premature death, morbidity and injury on Australian farms. The SFF project illustrates how increasing health literacy through education and physical assessment can lead to improved health and knowledge outcomes for farm families.

Methods: The SFF project focuses on the human resource in the triple bottom line and is working with farmers, families, industry and universities to collaboratively assess and promote improvement in the health and wellbeing of farm families. Based on a model of extension that engages farm families as active learners where they commit to healthy living and safe working practices, the SFF project is proving to be an effective model for engaging communities in learning and change. Health education and information is delivered to farm men and women aged 18 to 75 years using a workshop format. Pre- and post-knowledge surveys, annual physical assessments and focus group discussions form the methodological context for the research over a three-year intervention.

Results: This article discusses the progress of the research outlining the design of the SFF project, the delivery and extension processes used to engage 321 farm families from within a broadacre and dairy-farming family sample. The article presents key learnings on intersectoral collaboration, engaging farmers and families in health, and the future for this project extending into agricultural industries across the nation. Key results reveal that health issues do exist in farming families and are often underreported by family members. Health indicators were at a level where referral and intervention was required in over 60% of men and 70% of women in both broad acre and dairy industries. Farm men and women verbalised health concerns relating to access, support and control mechanisms of the health system. Participants also revealed how they put into practice their new knowledge and how this has influenced their health.

Conclusions: The key learning is that farm men and women who are at high risk of premature morbidity and mortality will participate in health education and assessment programs based on industry collaboration with high levels of individual participation. This program provides evidence that farmers will engage with health professionals if programs are presented to them in personally engaging and relevant ways. The SFF program is a definite tool for interventional health promotion that supports attitudinal change to health and farming practices.

Economic evaluation of a skin cancer prevention program in Australia : past achievements and future prospects

Objectives
Australia has the highest incidence of skin cancer in the world. Skin cancer prevention campaigns have been implemented in Australia for over two decades. The most notable is under the brand name, SunSmart. The aim of the current study is to assess the cost-effectiveness of SunSmart in the past and the potential cost-effectiveness of an ongoing national SunSmart program with optimal investment in the future.

Methods
An economic evaluation from a health sector perspective was conducted using the reduction in skin cancer incidence attributable to the SunSmart program modelled as the primary end-point. Historical SunSmart program expenditures were obtained from three representative states in three latitude zones, covering different levels of UVR exposure. Melanoma incidence rates from the three representative state cancer registers were used to model the health outcomes. Program effectiveness was assessed by the comparison between the well-resourced SunSmart state (Victoria) and the under-invested states (New South Wales and Queensland). Non-Melanoma Skin Cancer (NMSC) was modelled based on national survey results. 2003 was chosen as the reference year and future costs/outcomes over a 20 year time horizon were discounted at 3%.
The future level of investment in a national SunSmart was chosen to strengthen current practice by increasing current investment to a realistic and achievable level. This conservative increase in investment (expressed as ‘$ per capita’) reflected the investment level that has been achieved in Victoria over sustained periods. To model the potential cost-effectiveness of an upgraded national SunSmart program, a conservative approach was taken, whereby the same magnitude of effectiveness from 1988 to 2003 was applied to future skin cancer incidence.

Results
SunSmart in Victoria has saved 22,300 life-years, averted 27,900 disability-adjusted life-years(DALYs)(discounted) since its introduction in 1988 and achieved an incremental cost-effectiveness ratio (ICER) of $AUD 680 per life-year saved (LYS) and $AUD 540 per DALY averted. When the cost-offset from the estimated reduction in skin cancer treatment costs were taken into account, SunSmart achieved ‘dominance’. The net cost of SunSmart in the past was an estimated saving of $AUD 93 million. An upgraded national SunSmart for the next 20 years would save 91,000 life-years and avert 122,000 DALYs (discounted), involving an increased investment level from the current $AUD 0.07 per capita to the historical average of $AUD 0.28 per capita. The ICER for the upgraded SunSmart program was estimated at $AUD 940 per LYS and $AUD 700 per DALY averted. When the cost-offset is included, the program achieves dominance with a cost saving of $AUD 115 million – an estimated $AUD 2.32 return for every dollar invested between 2003 and 2022.

Conclusions
This study demonstrates that a sustained modest investment in skin cancer control is likely to be excellent value-for-money. While the available data base is certainly not prefect, key parameters would have to change dramatically for this conclusion to be challenged.

The Pacific OPIC project (Obesity Prevention in Communities) - objectives and designs

Background: Evidence on how to reduce the increasing prevalence of youth obesity is urgently needed in many countries.The Pacific OPIC Project (Obesity Prevention In Communities) is a series of linked studies in four countries (Fiji, Tonga, New Zealand, Australia) which is designed to address this important problem.
Objectives: The studies aim to: 1) determine the overall impact of comprehensive, community-based intervention programs on overweight/obesity prevalence in youth; 2) assess the feasibility of the specific intervention components and their impacts on eating and physical activity patterns; 3) understand the socio-cultural factors that promote obesity and how they can be infl uenced; 4) identify the effects of food-related policies in Fiji and Tonga and how they might be changed; 5) estimate the overall burden of childhood obesity (including loss of quality of life); 6) estimate the costs (and cost-effectiveness) of the intervention programs, and; 7) increase the capacity for obesity prevention research and action in Pacific populations.
Design: The community studies use quasi-experimental designs with impact and outcome assessments being measured in over 14,000 youth across the intervention and control communities in the four sites. The multi-strategy, multi-setting interventions will run for 3 years before fi nal follow up data are collected in 2008. The interventions are being informed by socio-cultural studies that will determine the family and societal infl uences on food intake, physical activity and body size perception.
Progress and conclusions: Baseline studies have been completed and interventions are underway. Despite the many challenges in implementing and evaluating community-based interventions, especially in the Pacifi c, the OPIC Project will provide rich evidence about what works and what does not work for obesity prevention in youth from European and Pacific backgrounds.

Rural smokers : a prevention opportunity

Background: Smoking is the largest single cause of preventable death and disease in Australia. This study describes smoking prevalence and the characteristics of rural smokers to guide general practitioners in targeting particular groups.

Methods: Cross sectional surveys in the Greater Green Triangle region of southeast Australia using a random population sample (n=1563, participation rate 48.7%) aged 25–74 years. Smoking information was assessed by a self administered questionnaire.

Results: Complete smoking data were available for 1494 participants. Overall age adjusted current smoking prevalence was 14.9% (95% CI: 13.1–16.7). In both genders, current smoking prevalence decreased with age. Those aged 25–44 years were more likely to want to stop smoking and to have attempted cessation, but less likely to have received cessation advice than older smokers.

Discussion: This study provides baseline smoking data for rural health monitoring and identifies intervention opportunities. General practice is suited to implement interventions for smoking prevention and cessation at every patient encounter, particularly in younger individuals.

Safer injections, fewer infections : management of needles and sharps and occupational blood exposure in rural north Indian health settings

This study investigated injection practices and occupational exposure to blood in rural north Indian health settings. The findings highlighted a range of practices potentially contributing to the transmission of hepatitis and HIV to both patients and staff in these settings. Interventions need to focus on the development of organisational structures to support and facilitate safer practices.

Effectiveness of an HIV / AIDS prevention approach across three countries

The study examined the effectiveness of one community based HIV / AIDS prevention approach, Community Counselling, in PNG, India and Zambia. Results indicated the three countries differed along cultural dimensions. Differences on behaviour, attitude, knowledge and risk perceptions associated with HIV / AIDS were noted within each country that reflected exposure to the approach. The professional portfolio examines the curent situations in which cultural guidelines have been developed to assist clinicians in considering indigenous cultural differences in increasingly multicultural societies. Four case studies are presented in which aspects of these issues are identified and discussed.