The economic case for prevention of population vitamin D deficiency: a modelling study using data from England and Wales.

BACKGROUND: Vitamin D deficiency (VDD) affects the health and wellbeing of millions worldwide. In high latitude countries such as the United Kingdom (UK), severe complications disproportionally affect ethnic minority groups. OBJECTIVE: To develop a decision-analytic model to estimate the cost effectiveness of population strategies to prevent VDD. METHODS: An individual-level simulation model was used to compare: (I) wheat flour fortification; (II) supplementation of at-risk groups; and (III) combined flour fortification and supplementation; with (IV) a 'no additional intervention' scenario, reflecting the current Vitamin D policy in the UK. We simulated the whole population over 90 years. Data from national nutrition surveys were used to estimate the risk of deficiency under the alternative scenarios. Costs incurred by the health care sector, the government, local authorities, and the general public were considered. Results were expressed as total cost and effect of each strategy, and as the cost per 'prevented case of VDD' and the 'cost per Quality Adjusted Life Year (QALY)'. RESULTS: Wheat flour fortification was cost saving as its costs were more than offset by the cost savings from preventing VDD. The combination of supplementation and fortification was cost effective (£9.5 per QALY gained). The model estimated that wheat flour fortification alone would result in 25% fewer cases of VDD, while the combined strategy would reduce the number of cases by a further 8%. CONCLUSION: There is a strong economic case for fortifying wheat flour with Vitamin D, alone or in combination with targeted vitamin D3 supplementation.

Weight status, cardiorespiratory fitness and high blood pressure relationship among 5-12-year-old Chinese primary school children.

Cardiorespiratory fitness (CRF) and adiposity contribute to high blood pressure (HBP) in adults and children. However, their relative importance as risk factors is unknown. We examined the relationships between weight status, CRF and HBP among Chinese primary school children. A cross-sectional study was conducted with 4926 school children aged 5-12 years. CRF was estimated from a modified Cooper test, body mass index z-scores and weight categories were calculated from objective height and weight measurements and BP was measured using an electronic sphygmomanometer. HBP was defined as >95th percentile based on reference cutoffs for Chinese boys and girls. Generalised Linear Mixed models, adjusting for age, pubertal status and height, were developed for boys and girls to explore the independent and combined associations between fitness, weight status and HBP. Seven hundred and fifty-two (15.3%) children had HBP, with a higher prevalence in obese (40.5% and 45.9% in boys and girls, respectively) and overweight (27.6% and 30.2% in boys and girls, respectively) compared with non-overweight (9.0% and 13.8% in boys and girls, respectively) children. HBP prevalence was lower in boys with higher CRF (odds ratio (OR) for the highest vs lowest CRF quartile in boys 0.64; 95% confidence interval (CI) 0.46-0.89). This association was not seen in girls. With weight status and CRF in the same model, weight status, but not CRF, remained significantly associated with HBP (obesity in boys: OR 4.19; 95% CI 2.63-6.67; in girls: OR 2.49; 95% CI 1.19-5.19). The interaction effect for CRF and weight status was non-significant. Overweight/obesity was significantly associated with HBP among children. There was no evidence of modification of this relationship by CRF.

Process evaluation results of a cluster randomised controlled childhood obesity prevention trial: the WAVES study.

BACKGROUND: Increasing prevalence of childhood obesity and its related consequences emphasises the importance of developing and evaluating interventions aimed at prevention. The importance of process evaluation in health intervention research is increasingly recognised, assessing implementation and participant response, and how these may relate to intervention success or failure. A comprehensive process evaluation was designed and undertaken for the West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study that tested the effectiveness of an obesity prevention programme for children aged 6-7 years, delivered in 24 UK schools. The four intervention components were: additional daily school-time physical activity (PA); cooking workshops for children and parents; Villa Vitality (VV), a 6-week healthy lifestyle promotion programme run by a local football club; and signposting to local PA opportunities. METHODS: Data relating to six dimensions (Fidelity, Reach, Recruitment, Quality, Participant Responsiveness, Context) were collected via questionnaires, logbooks, direct observations, focus groups and interviews. Multiple data collection methods allowed for data triangulation and validation of methods, comparing research observations with teacher records. The 6-stage WAVES study model ((i) Data collection, (ii) Collation, (iii) Tabulation, (iv) Score allocation and discussion, (v) Consultation, (vi) Final score allocation) was developed to guide the collection, assimilation and analysis of process evaluation data. Two researchers independently allocated school scores on a 5-point Likert scale for each process evaluation dimension. Researchers then discussed school score allocations and reached a consensus. Schools were ranked by total score, and grouped to reflect low, medium or high intervention implementation. RESULTS: The intervention was predominantly well-implemented and well-received by teachers, parents and children. The PA component was identified as the most challenging, VV the least. Median implementation score across schools was 56/75 (IQR, 51.0 - 60.8). Agreement between teacher logbooks and researcher observations was generally high, the main discrepancies occurred in session duration reporting where in some cases teachers' estimations tended to be higher than researchers'. CONCLUSIONS: The WAVES study model provides a rigorous and replicable approach to undertaking and analysing a multi-component process evaluation. Challenges to implementing school-based obesity prevention interventions have been identified which can be used to inform future trials. TRIAL REGISTRATION: ISRCTN97000586 . 19 May 2010.

Obesity prevention in English primary schools: headteacher perspectives.

Schools are seen as important contributors to obesity prevention, yet face barriers in fulfilling this function. This qualitative study investigates headteacher views on the primary school role in preventing obesity. Semi-structured interviews were held with 22 headteachers from ethnically and socio-economically diverse schools in the West Midlands, UK. Data analysis was conducted using the framework approach. Two over-arching categories were identified: 'School roles and responsibilities' and 'Influencing factors'. Participants agreed that although schools contribute towards obesity prevention in many ways, a moral responsibility to support children's holistic development was the principal motivator, rather than preventing obesity per se. The perceived impact on learning was a key driver for promoting health. Parents were believed to have the main responsibility for preventing obesity, but barriers were identified. Whilst headteachers recognized the advantageous position of schools in offering support to parents, opinion varied on the degree to which schools could and should take on this role. Headteachers serving more deprived areas reported adopting certain responsibilities that elsewhere were fulfilled by parents, and were more likely to view working with families on healthy lifestyles as an important school function. Several factors were perceived as barriers to schools doing more to prevent obesity, including academic pressure, access to expert support and space. In conclusion, school leaders need more support, through resources and government policy, to enable them to maximize their role in obesity prevention. Additionally, school-based obesity prevention should be an integral part of the education agenda rather than bolt-on initiatives.

Contributors to childhood obesity in Iran: the views of parents and school staff.

OBJECTIVE: To explore the contextual influences on childhood obesity in Tehran, Iran to inform future development of an obesity prevention intervention for Iranian primary school children. STUDY DESIGN: Qualitative study. METHODS: Focus groups and interviews with parents and school staff were convened to explore their perceptions of the causes of childhood obesity. Eleven focus groups and three interviews were held with parents and school staff (88 participants in total) from three different socio-economic areas in Iran's capital city, Tehran. All the discussions were transcribed verbatim in Persian. An iterative thematic approach was used for data analysis. RESULTS: Overall, the causes of childhood obesity were perceived to relate to macro-level policy influences, the school environment, sociocultural factors, and family and individual behavioural factors, acting in combination. A key emergent theme was the pervasive influence of Government policies on children's food intake and physical activity. Another key theme was the political and sociocultural context that does not support girls and women in Iran in having active lifestyles. CONCLUSION: The findings suggest that parents and school staff have sophisticated views on the possible causes of childhood overweight and obesity which encompassed behavioural, structural and social causes. A prominent emerging theme was the need for state level intervention and support for a healthy environment. Any local initiatives in Iran are unlikely to be successful without such support. WHAT IS KNOWN ON THIS SUBJECT: Childhood obesity is growing in Iran and it is seen as one of the features of the nutrition transition in developing countries. Findings from cross-sectional studies suggest a range of lifestyle factors contribute to obesity in the Iranian population. WHAT THIS STUDY ADDS: This qualitative study explores the socioenvironmental changes contributing to childhood obesity in primary school-aged children in Iran. Findings have provided important contextual data on the perceived contributors to childhood obesity in Iran, such as macro-level policy influences on accessibility to healthy food and physical activity, competing priorities at school level, sociocultural influences on diet and physical activity and limited knowledge and skills of parents. This has laid the foundation for the development of appropriate childhood obesity prevention interventions.

The views of stakeholders on the role of the primary school in preventing childhood obesity: a qualitative systematic review.

Schools are increasingly recognized as an ideal setting for interventions to tackle childhood obesity. A better understanding of the views of key stakeholders would help to engage schools and inform the feasibility of such interventions in practice. This meta-synthesis of 18 qualitative studies explores the views of parents, school staff, school governors, school nurses and students on the role of the primary school in preventing childhood obesity. Six categories emerged: 'School as a key setting'; 'What schools should be doing to promote healthy eating (HE)'; 'What schools should be doing to promote physical activity (PA)'; 'General barriers'; 'Barriers to promoting HE at school'; and 'Barriers to promoting PA at school'. Thirty-seven finer-level themes emerged within these categories. Stakeholders agreed on the key role of the primary school as a setting for obesity prevention, the importance of schools providing and promoting opportunities for HE and PA, and the need for schools to work with parents. Some perceived barriers could be overcome at school level, e.g. using unhealthy foods as rewards/fundraisers or withholding PA for bad behaviour. Leadership and guidance from government were considered to be needed to counteract other observed barriers, particularly regarding school canteens, support for parents and time for PA.

Syphilis outbreak in Walsall, UK: lessons for control and prevention.

An assessment of risk-taking behaviour among men who have sex with men (MSM) attending a sauna venue was undertaken, using a standardized questionnaire, after which outreach screening was introduced targeting MSM. The epidemiology of the continuing outbreak of syphilis was reviewed to determine the factors driving the outbreak and assess the benefit of continuing outreach screening. Findings among the 163 respondents at the sauna included a high rate of casual sex and a tendency not to disclose HIV status. Over 12 months, 51 cases of early syphilis were recorded. Our review showed a decline in incidence in MSM after outreach screening, but an increase in heterosexual spread. Given the frequent anonymous nature of syphilis transmission, traditional contact tracing is ineffective. Outreach screening is required at gay venues and other community settings to target at-risk populations.