Transcript Department Presentation Title - Sheffield Children's Hospital

JOURNAL CLUB
U.NIRANJAN
ST6 Paediatrics
Article
• Effectiveness of home
based early intervention on
children’s BMI at age 2:
randomised controlled trial
Wen.L.M et al. BMJ 2012;344:e3732
doi: 10.1136/bmj.e3732 (Published 26 June 2012)
Overview
• Summary of the article
• Critical Appraisal
• Discussion
Interest
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Recent case where a 2yr old boy had a BMI of 23
Admitted with Viral wheeze
Dependant on oxygen at night despite recovery
Overnight oximetry - concerns re- sleep apnoea
• Healthy BMI for 2yrs
• 14.12-18.41 for boys
• 13.90-18.02 for girls
Ref: Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition
of child overweight and obesity worldwide: international survey. BMJ
2000;320:1240-3.
Available evidence
Suggests :- behaviours that contribute to obesity can be
positively impacted in a range of settings in children
– Declining diet quality
– Increasing sedentary behaviour
– Decreasing physical activity levels across childhood
Ref:
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Hesketh KD, Campbell KJ. Interventions to prevent obesity in 0-5 year olds: an updated
systematic review of the literature. Obesity 2010;18:S27-35
TYPES OF INTERVENTIONS
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Strong evidence :- beneficial effects of child obesity prevention
programmes on BMI
– esp children aged six to 12 years
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Suggestions:
School
– Curriculum - healthy eating & physical activity
– improvements in nutritional quality of the food supply
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environment and cultural practices  support children eating healthier
foods + being active
support for staff implement health promotion strategies and activities
parent support and home activities
Ref:
Waters, Elizabeth, et al. "Interventions for preventing obesity in
children." Cochrane Database Syst Rev 12 (2011): 00.
Summary of study
• Objective: To assess the
effectiveness of a home based early
intervention on children’s body mass
index (BMI) at age 2.
• Study design:
– RCT- Blinded
– during June 2007- Dec 10
PICO
• Population: First time mothers – disadvantaged area of
Sydney
• Intervention – The health start trial
• Comparison – Routine postnatal care
• Outcome
– Primary - BMI at 2yrs of age
– Secondary
• Infant feeding practices
• TV viewing time
Intervention
• Eight home visits from 4 x specially trained community
nurses
• Home based intervention X 8 sessions
• 1 x antenatal period( 30- 36wks)
• Rest @ 1, 3, 5, 9, 12, 18 and 24 months after birth.
Key messages
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Breast is best
No solids for me until 6 months
I eat a variety of fruit and vegetables every day
Only water in my cup
I am part of an active family.
Outcome
Primary
• BMI @ 2yrs
• Intervention grp: mean 16.49 (16.27 to 16.71)
• Control : 16.87 (16.66 to 17.08)
• Significance : −0.38 (−0.68 to −0.08)=p 0.01
• Significance after intention to treat analysis
– −0.29 (−0.55 to −0.02) = p 0.04
Secondary Outcome
• Intervention group- Significantly
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More likely to eat ≥1 fruit /day (83%, P=0.03)
less likely food for reward (62% v 72%, P=0.03)
Less TV while eating ( 66% v 76%, P=0.02)
Less Tele time (14% v 22%, P=0.02)
Mothers
• More vegetable in diet (52% v 36%,P<0.001)
• Increased physical activity (48% v 38%, P=0.04)
• All the other areas no significant difference
Critical Appraisal- ‘CASP’
Validity
• Did the trial address a clearly focused issue?
– YES
• Was the assignment of patients to treatments
randomized
– YES
• Were all of the patients who entered the trial properly
accounted for at its conclusion
– YES
Detailed assessment
• Were patients, health workers and study personnel
‘blind’ to treatment
– Data collectors and data entry staff - blinded to the
intervention
– Mothers not blinded
• Were the groups similar at the start of the trial?
– Don’t know about the mother’s BMI between groups
– But unsure of family support/social background
Cont….
• Aside from the experimental intervention, were the
groups treated equally?
– Difficult to be sure as intervention group had more frequent
visits support for the families
– But that is part of the intervention
Results
• How large was the treatment effect
– Improvement in BMI by
– −0.29 (−0.55 to −0.02) = p 0.04
• How precise was the estimate of the treatment
effect?
– Fairly – adequately powered to see a 0.25 BMI difference
– Intention to treat analysis used
– But… CI is wide
Will the results help locally
• Can the results be applied to the local population
– Genetic difference in tendency for wt gain/metabolism
– Looked at specific deprived population
• Were all clinically important outcomes
considered
– Most of them
– But all secondary outcomes were subjective- relied
on recall/ food & activity diaries- ?reliability
– The effect of being on a trial - mothers not blinded
• Not looked at harm effects( like difficulties with diet etc)
• Not discussed cost implications
• The BMI for the control group was reasonable as well.
Are the benefits worth the harms and
costs?
Summary
• Early home-based intervention is effective in reducing
BMI in children at 2yrs
• Benefits demonstrated but not sure
– about replicability in our population
– Cost effectiveness
– Persistence of benefits
conclusion
• Early Home intervention is effective in reducing BMI in
children at 2yrs
• But further long term persistence of beneficial outcomes
need to be explored
• Cost effectiveness needs to be considered
• There is need for further research
THANK YOU