Interventions for childhood obesity in Southern New Zealand

Abstract

Background Childhood obesity continues to be a one of the biggest health issues facing children worldwide, with major health effects well recognised. Multiple steps are involved in intervening in childhood obesity. This thesis looked into several ways to address childhood obesity in both the secondary care, as well as the community setting.

This study was made up of four separate studies, aiming to look at different aspects of childhood obesity management. The first looked at Growth recording. Growth charts are required to identify abnormal growth patterns. This has traditionally been performed on paper charts, but the introduction of electronic growth charts provides the opportunity for improved availability and consistency of information to support clinical decision making. The Southern District Health Board introduced electronic growth charts in 2010 and this provided an opportunity to evaluate their use and uptake.

Once growth is recorded consideration must be given to the growth, it must be addressed if abnormal and appropriate clinical management engaged. The second study in this thesis involves a clinical audit of children identified through the electronic database as being obese to assess their clinical management.

The thesis then moves into the community to look at management of childhood obesity further afield. Once obesity is identified, early intervention is assumed to give the best outcomes for future health. The Before School Check (B4SC) Referrals initiative set up by the New Zealand Government aims to do this by referring children identified as obese at their B4SC to community interventions. This study (The Kids BMI Study) aimed to assess this by following these children up a year later to review their growth and quality of life. Unfortunately this study suffered poor recruitment with feedback suggesting negative experiences around discussions of growth at the B4SC, which may have been affecting engagement both in the study as well as with the obesity interventions offered. Therefore, a caregiver survey study was set up as the fourth study in the thesis, to investigate parental experiences and preferences regarding the growth discussion held at the B4SC.

Aims 1. Examine how well an electronic-growth module introduced to the Southern District Health Board (SDHB) has been used 2. Describe obesity prevalence in children presenting to secondary care in the SDHB 3. Describe the management of obese children in secondary care at SDHB in terms of diagnosis, investigation and management plans 4. To evaluate the B4SC Referrals initiative for childhood obesity regarding service delivery and impact 5. To investigate how the discussions around childhood obesity are being carried out at the B4SC and explore caregiver preferences around how this conversation should transpire

Methods

Studies 1 and 2 - Electronic Database Studies All records between 2010–2015 in the Southern District Health Board (SDHB) anthropometry database were downloaded and examined in a retrospective cohort analysis. Records were extracted after matching to demographic and clinical-setting data from the hospital patient-management system. All clinical records were further examined using a standard data extraction form for 333 obese children regarding their clinical management.

Studies 3 and 4 - Kids BMI Studies The families of children in the South Island identified as having a BMI in the obese range at their B4SC (aged 4yrs) between November 2016 and October 2017 were invited to participate in a one year follow-up home visit evaluating growth, quality of life and exploring the interventions they had received. Those who did not respond were invited to participate in a caregiver survey regarding their experiences of the discussion around growth at the B4SC.

Results

Electronic Database Studies Analysis included 30,670 data entry points, representing 8,551 children. Data entry increased over time. By the fifth year of use up to 67% of available clinical encounters had anthropometry recorded in the outpatient department. Errors identified were low (0.2% of all data). Weight was the most commonly recorded measurement (98.2% of anthropometry entries, 35.1% of available clinical presentations). A BMI z-score was available for 81.5% of entries, 29.1% of presentations.

The prevalence of overweight and obesity was higher than the average national rates, but stable over the five year period. Children of Maori and Pacific Island ethnicity, those most deprived and males were over-represented in terms of obesity.

Of the 333 obese children whose clinical management was examined, 45.0% received a diagnosis of obesity. Of those diagnosed 24.7% had further investigations, and 72.7% were given management plans. Older females were more likely to receive clinical intervention, while Maori and Pacific Island children less likely.

Kids BMI Study Home visits were performed on 104 of 839 eligible children. For these participants the child’s weight had been discussed at the B4SC for 76.0%, referral to either a health assessment or community intervention were made in 49.0%, and attended by 26.0% of participants. Maternal obesity appeared to be a barrier to both the discussion of high BMI and attendance at interventions. There was no difference in change in BMI or QOL between those that had received intervention for their high BMI and those who had not. Caregiver surveys were completed by 43 families and reported discussion of child’s growth to be occurring in 88.4% of B4SC visits (although descriptions of weight ranged from obese to healthy). Caregivers were happy with the words used to describe their child’s weight in 78.4% of surveys. Themes identified in comments included; inconsistency of messaging, not feeling listened to, underlying perceptions of weight or health, and emotion/stigma around childhood obesity.

Conclusion

The introduction of an electronic anthropometry database has been successful with increasing rates of use over time, especially in outpatient clinics. Further focus to improve inpatient recording of height and weight is needed.

In the SDHB secondary care setting, 40% of children were overweight or obese, and yet the rate of clinical intervention left room for improvement suggesting a need for further staff education and clear guidelines. Children of Maori and Pacific Island ethnicity had higher obesity burden, yet were less likely to receive clinical intervention.

Referral rates for health assessment and community intervention programmes in the B4SC Referrals were lower than the recommended 95% health target. This is likely to be affecting opportunities for early intervention for childhood obesity. In order to have maximum service uptake the initial conversation informing a parent that their child is obese needs to be optimised to ensure ongoing positive rapport. The effectiveness of the B4SC initiative must at this point be questioned, and whether valuable resources could be funnelled toward more effective population based resources.