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• 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 evidenceSuggests :- 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:• 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• Strong evidence :- beneficial effects of child obesity prevention

programmes on BMI– esp children aged six to 12 years

• Suggestions:• School

– Curriculum - healthy eating & physical activity– improvements in nutritional quality of the food supply

• 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• 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.

OutcomePrimary• 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

– 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

Are the benefits worth the harms and costs?

• Not looked at harm effects( like difficulties with diet etc)• Not discussed cost implications• The BMI for the control group was reasonable as well.

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