The Effectiveness of a School Intervention Program. A Panacea against Obesity?
A large randomised controlled trial was conducted in the West Midlands, looking into the effectiveness of a school and family based healthy lifestyle programme, in comparison to usual practice. 1,467 year 1 pupils aged 5 to 6 years (control, 778 pupils), were randomised into the study, with follow-ups at 15 months and 30 months. The intervention consisted of encouraging healthy eating and physical activity, which included a daily additional 30-minute school time physical activity opportunity and a 6-week interactive skills programme in conjunction with Aston Villa football club. There was also signposting of family physical opportunities and termly workshops looking at healthy eating cooking skills.
The main outcome measured in the study was BMIz score at 15 and 30 months respectively. They also looked at other anthropometric, dietary, physical activity and psychological measurements. Unfortunately, at 15 and 30 months follow up, there was no statistically significant improvement in any of the outcomes measured. Despite this rigorous in-school intervention, the primary analysis suggests that it was in fact, ineffective. Although this study was inconclusive, the authors go on to point out that it highlights the difficulty of the task of reducing weight in children, and that schools alone may not be the answer. A holistic approach that incorporates school, home, environment and policy is one that is most likely to succeed, and the idea that school-based interventions will solve the problem is likely oversimplifying the issue.
Rethinking public mental health: learning from obesity
This commentary piece written in the Lancet Psychiatary, reviews Stanley J Ulijaszek’s new book, Models of Obesity. It argues that the field of mental health could learn a lot from the challenges of obesity and the approaches used to tackle it. It first argues that the obesity debate has been reframed in a way that presents it as a chronic relapsing-remitting condition. This has shifted the approach to the treatment of obesity and would be a useful if implemented in mental health.
Next, it highlights the standard unit of measurement that exists in obesity; BMI. Despite its faults, this practice has meant that it’s far easier to make sense of population obesity through epidemiological studies. Mental health researchers often use confused terminology, meaning that it is difficult to perform population studies and so to grasp the scale and nature of the issue.
Third, the field of obesity considers the complex systems that create public health problems better than that of mental health. This means that considerations for environmental factors and psychopathogenic factors are much better integrated into obesity care than in mental health.
Fourth, there is a polyrational approach in obesity that frames obesity public health in a field of competing interests and behaviours, such as between corporations and governments. This means that there is a better understanding of the rationalities and their relationship to each other.
Finally, “viable clumsy solutions” are used to address obesity; these are “a combination of single rational policies towards a particular problem”. This follows from the polyrational approach of understanding obesogenic environments. It involves bringing individual stakeholders together to find solutions, which combine to advise policy.
Read MoreThe obesity paradox in cancer: clinical insights and perspectives
The obesity paradox refers to the paradoxical relationship between obesity and instances of better long-term survival in cancer, given the huge body of evidence for obesity’s carcinogenic effects. This article, published in Eating and weight disorders- studies on anorexia, bulimia and Obesity, seeks to explore the available studies concerning cancer incidence, survival and obesity in order to offer possible explanations for the paradox and a methodological framework.
The potential mechanisms highlighted for the ‘obesity paradox’ are that obesity provides a nutritional reserve, helping the patient survive surgical interventions and anti-cancer treatments. Also, that obesity is associated with a lower-stage of disease, smaller tumour size and less aggressive subtypes. Finally, that obese patients are likely to be frequent users of healthcare, therefore cancer may be diagnosed sooner.
There are however, methodological issues with these explanations. The issue of BMI, which is a proportional score based on weight and height, gives no information regarding body composition which is important in cancer care. Furthermore, the overall literature that supports this relationship, uses mainly retrospective studies and often fails to include confounding variables such as age and smoking. Rigorous prospective studies need to be conducted to define the impact of obesity in the oncology setting.
Read MoreSocioeconomic status in childhood and obesity in adults: a population-based study
This paper, published in Revista de Saúde Pública, aimed to determine the relationship between socioeconomic status (SS) in childhood and obesity in adult life. It conducted a cross-sectional analysis of a population of 1,222 adults in Florianópolis, Southern Brazil. Socioeconomic status was determined using the participant’s parents level of education as a proxy. Adult obesity was determined as a combination of BMI and waist circumference (WC).
The results showed a difference between genders. It was found that women with lower SS in childhood had a higher mean BMI and WC in adulthood. While in men, higher SS in childhood was found to be associated with increased BMI and WC in adulthood. It is suggested that this pattern is related to the income of the country, meaning countries of a similar income share this pattern. Although inconclusive, it raises the interesting point that patterns of obesity and socioeconomic status vary in different countries, so researchers must be careful when making assumptions about these two factors.
Read MoreFuture Pharmacotherapy for Obesity: New Anti-Obesity Drugs on the Horizon
This review published in Current obesity reports looks at how our increased understanding of energy regulation and neurohormonal pathways in energy homeostasis (the body’s mechanism for controlling caloric intake and energy expenditure) are being utilised to find pharmacological solutions to obesity. The review looks at centrally acting agents, gut hormones & incretin targets and other novel targets which include anti-obesity vaccines.
Centrally acting agents are drugs which work by altering brain neuronal circuits, by simulating or blocking the effects of other brain neurotransmitters, leading to changes in metabolism and behavior. This paper discusses four of these drugs, which can increase resting energy expenditure- leading to weight-loss- and can also change feelings of hunger/satiety, which then leads to decreased food intake.
Gut hormones and incretin targets are drugs that utilise the complex neurohormonal system of the gut and pancreas to alter feelings of hunger and fullness, with some also improving glucose control. The seven drugs discussed are at varying stages of clinical trials, some only being tested in animals while others are in phase-II. The promise in the phase-II trials is high though, meaning that this new class of anti-obesity drug could soon enter clinical practice.
Five other novel targets were also discussed. Firstly, a drug that reduces production of new fatty acids by the liver and converts stored fats into useful energy; leading to increased energy expenditure. Second, an enzyme inhibitor which leads to reduced absorption of fats in the gut; meaning fewer calories are extracted from food. Third, a triple monoamine reuptake inhibitor of neurotransmitters in the brain, which has proven effective and entered phase-II trials, despite some safety concerns. Fourth is a growth hormone that turns white fat into brown fat; this leads to increased energy expenditure. Alongside this it also provides added benefits such as anti-inflammatory properties. The final drugs discussed are anti-obesity vaccines; these involve targeting molecules that lead to obesity (e.g. ghrelin) or a vaccine to an adenovirus that has been shown to cause significant obesity in mice and may also do so in humans.
Read MorePractical Strategies for Engaging Individuals with Obesity in Primary Care
In this review article published by the Mayo Clinic, Dr Scott Kahan discusses the best strategies for engaging patients in obesity management, as well as looking at the barriers to good clinical practice. His findings are based on PubMed searches as well as his own clinical experience.
The two strategies identified as being practiced sub-optimally are screening and referral for counselling. Screening for obesity has been shown to be effective as it can lead to better perception of weight status, increased likelihood of trying to lose weight and of starting an obesity management programme. Patients with obesity who receive counselling have been shown to have a four-fold increased chance of losing weight.
The reason for suboptimal implementation of these strategies has been attributed to lack of training in obesity at medical school, with only 25% offering a dedicated nutrition course. Other reasons given by healthcare professionals are insufficient time, training, confidence in the method and resources. From the patient perspectives, stigma, inappropriate facilities (e.g. small waiting room furniture), previous negative care experience and a belief in moral failure in seeking help were found as barriers to care.
The practical guidance for improvement, aims at small changes to many aspects of care. It highlights the importance of people-first language and motivating terminology that encourages the patient rather than demeans them. In addition, improvements to the clinical environment so the patient doesn’t feel embarrassed, for example putting the weighing scales in a private place. Integration of digital technology was highlighted, such as reminders to measure BMI, as this would help with sub-optimal screening. In addition, using available online teaching resources and the multi-disciplinary team to minimize the burden of obesity management, as well improve the effectiveness of counselling technique. Finally, taking a long-term view of the support required, with extended duration weight-loss counselling and monitoring of progress.
Read MoreEffectiveness of a Kindergarten-Based Intervention for Preventing Childhood Obesity.
Pediatrics conducted a pilot study over 12 months in Guangzhou, China, aimed at demonstrating the feasibility of a multifaceted intervention for preschool children and to provide an assessment of the efficacy. The study involved 648 children, who underwent a 3-component intervention (training of staff, initiating a healthy curriculum and close collaboration with families) while the other cohort consisted of 336 children, who received routine health care and acted as the control.
By 12 months, children within the intervention group had a smaller BMIz score increase (0.24) compared to the control (0.41), the prevalence of overweight or obesity was also lower among the intervention group at the end of the study. These results add further weight to the argument that multi-component health behaviour intervention might be the most effective in reducing the burden of obesity.
Read MoreClinic and Home-Based Behavioral Intervention for Obesity in Preschoolers: A Randomized Trial
In this phase III randomised controlled trial of 151 children, published in the Journal of Pediatrics, the authors sought to investigate whether a skills-based behavioural family clinic and home-based intervention (LAUNCH) would be more effective at reducing BMI than motivational interviewing or to standard care in preschool-aged children with obesity.
LAUNCH is an 18-session clinic and home, family-based behavioral weight management intervention. Motivational interviewing was a parent only intervention consisting of 18 sessions over 6 months and focused on making changes to the child’s caregiver by encouraging diet and activity changes. Standard care informed caregivers of their child’s weight status during the recruitment process, but neither the children nor caregivers received any treatment.
LAUNCH demonstrated a mean (±SD) decrease in BMIz of −0.32 (±0.33) while motivational interviewing yielded a decrease of −0.05 (±0.27), standard care yielded a decrease of −0.13 (±0.31). Children in motivational interviewing and standard care gained almost triple the amount of weight during the 6-month period as children in LAUNCH. This slowing of weight gain resulted in a 4.45% decrease in percent overweight for LAUNCH, while both motivational interviewing and standard care increased in their percent overweight by 2.43% and 1.45%, respectively. Thus, the decrease in BMIz for LAUNCH was not only statistically significant, but clinically meaningful as well.
Read MorePilates and aerobic training improve levels of depression, anxiety and quality of life in overweight and obese individuals
It is common knowledge that exercise can play an important role in treating the physical parts of obesity, however the emotional benefits are less often talked about. In this study, published by the Brazilian journal Arquivos de Neuro-Psiquiatria 63 overweight or obese patients were randomly split into 3 groups, a control group (n=20), a Pilates group (n=22) and a walking group (n=21). The two exercise groups had to complete three, 60-minute sessions per week of their exercise. There were three psychological assessments conducted on each patient looking at quality of life, depression, state-anxiety and trait-anxiety. These were conducted before and after the 8 weeks.
The Walking group showed improvements in the quality of life domains of social functioning (20.3%) and mental health (21.8%). In addition, there were significant decreases in the levels of depression (35.2%), trait-anxiety (15.1%), and state-anxiety (18.5%).
For the Pilates group, improvements were observed in the quality of life domains of vitality (28%), social functioning (29.2%) and mental health (19%). In addition, there were significant decreases in the levels of depression (27.5%) and trait-anxiety (14.1%).
In some patients with obesity, emotional malfunction seems to inhibit the positive perception of the physical benefits of exercise. An alternative approach could point towards the mental and emotional benefits of exercise; this may be the trigger/motivator for people’s perception of physical activity programs to change and thus be taken up more enthusiastically.
Read MoreEffect of 7 days of exercise on exogenous carbohydrate oxidation and insulin resistance in children with obesity
It has been shown in adults that the capacity to match carbohydrate (CHO) oxidation with carbohydrate availability, known as metabolic flexibility (MetFlex), may be important for type 2 diabetes prevention. Improved MetFlex is associated with improvements to insulin resistance (IR) and can be achieved with as little as 7 days exercise.
In this small study published in the Journal of Applied Physiology and Metabolism, 12 children (8 boys and 4 girls) underwent 7 days of exercise in order to determine whether MetFlex and IR would improve. Participants underwent a combination of continuous and high intensity exercise sessions over the course of seven days. Each session consisting of 3 20-minute blocks. In spite of good adherence, no improvement to MetFlex or IR was found. The authors go on to comment that future research should investigate exercise volume, sex and pubertal effects on the responsiveness of MetFlex to exercise in children.
Read MoreSleep Health and Psychopathology Mediate Executive Deficits in Paediatric Obesity
A new study from Childhood Obesity has found that paediatric obesity is associated with impairment of some components of reward-related decision-making and executive functioning, as well as poorer sleep health and greater risk of internalising psychopathology. Obese children showed reduced ability to adapt behaviour to changing reward contingencies and also the presence of executive dysfunction under everyday behaviour regulation. There were 112 participants in the study, in which researchers conducted a range of tasks to test different psycho-metrics, using only non-food stimuli. Alongside this, parents were asked to fill out standardised questionnaires to assess sleep health, psychiatric symptoms and executive function.
The parental reports indicated that children with obesity had poorer sleep, despite equal sleep duration, and a four times greater risk of experiencing internalising psychopathology. Importantly these mediated the negative effects on everyday behavioural regulation and meta-cognitive abilities. One of the constraints of the study, that the authors highlight, is that it’s unclear whether obesity is the cause or consequence.
Further studies have been proposed which would closely monitor physiological and metabolic variables in Pre and Post weight loss subjects to disambiguate the relationship. The study authors go on to reiterate the importance of understanding this relationship as it could be a key new therapy target.
Read MoreHarmful effects of overweight are underestimated
A study from the University of Bristol has found that the harmful effects of overweight and obesity are being underestimated. The study, which contained data from around 60,000 parents and their children, analysed how obesity and BMI influences the risk of death. Previous studies have suggested the optimal BMI, at which the risk of death is minimised, is slightly above the recommended ‘normal’ range, meaning that it is good for you to be slightly overweight. However some disease courses can lead to you having a lower BMI but a higher risk of death, this makes it highly difficult to estimate how BMI actually influences risk of death.
The researchers used parent and child combinations as BMI is related due to genetic factors, however the BMI of ‘adult’ children is not influenced by illness amongst the parents, therefore using the offspring BMI avoids the problems inherent with simply relating the parent BMI to their risk of death. They found that when offspring BMI was used instead of the parent’s own BMI, the apparent harmful effects of low BMI were reduced, and the harmful effects of high BMI were greater than those found in the conventional analyses. These results therefore suggest that current studies may tend to underestimate the harmful effects of a higher BMI. The authors are therefore calling for more robust approaches for identifying causal relationships influencing health, especially the relationship of BMI to overall health.
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