The cost-effectiveness of a successful community-based obesity prevention program: the be active eat well program.

OBJECTIVE: To examine the cost-effectiveness of Be Active Eat Well (BAEW), a large, multifaceted, community-based capacity-building demonstration program that promoted healthy eating and physical activity for Australian children aged 4-12 years between 2003 and 2006. DESIGN AND METHODS: A quasi-experimental, longitudinal design was used with anthropometric data collected at baseline (1001 children-intervention; 1183-comparator) and follow-up. A societal perspective was employed, with intervention resource use measured retrospectively based on process evaluation reports, school newsletters, reports, and key stakeholder interviews, and valued in 2006 Australian dollars (AUD). Outcomes were measured as Body Mass Index (BMI) units saved and Disability Adjusted Life Years (DALYs) averted over the predicted cohort lifetime, and reported as incremental cost-effectiveness ratios (with 95% uncertainty intervals). RESULTS: The intervention cost AUD0.34M ($0.31M; $0.38M) annually, and resulted in savings of 547 (-104; 1209) BMI units and 10.2 (-0.19; 21.6) DALYs. This translated to modest cost offsets of AUD27 311 (-$1803; $58 242) and a net cost per DALY saved of AUD29 798 (dominated; $0.26M). CONCLUSIONS: BAEW was affordable and cost-effective, and generated substantial spin-offs in terms of activity beyond funding levels. Elements fundamental to its success and any potential cost efficiencies associated with scaling-up now require identification.

Process and impact evaluation of the Romp & Chomp obesity prevention intervention in early childhood settings: lessons learned from implementation in preschools and long day care settings.

BACKGROUND: The Romp & Chomp controlled trial, which aimed to prevent obesity in preschool Australian children, was recently found to reduce the prevalence of childhood overweight and obesity and improve children's dietary patterns. The intervention focused on capacity building and policy implementation within various early childhood settings. This paper reports on the process and impact evaluation of this trial and the lessons learned from this complex community intervention. METHODS: Process data was collected throughout and audits capturing nutrition and physical activity-related environments and practices were completed postintervention by directors of Long Day Care (LDC) centers (n = 10) and preschools (n = 41) in intervention and comparison (n = 161 LDC and n = 347 preschool) groups. RESULTS: The environmental audits demonstrated positive impacts in both settings on policy, nutrition, physical activity opportunities, and staff capacity and practices, although results varied across settings and were more substantial in the preschool settings. Important lessons were learned in relation to implementation of such community-based interventions, including the significant barriers to implementing health-promotion interventions in early childhood settings, lack of engagement of for-profit LDC centers in the evaluation, and an inability to attribute direct intervention impacts when the intervention components were delivered as part of a health-promotion package integrated with other programs. CONCLUSIONS: These results provide confidence that obesity prevention interventions in children's settings can be effective; however, significant efforts must be directed toward developing context-specific strategies that invest in policies, capacity building, staff support, and parent engagement. Recognition by funders and reviewers of the difficulties involved in implementing and evaluating such complex interventions is also critical to strengthening the evidence base on the effectiveness of such public health approaches to obesity prevention.

Screen time and physical activity behaviours are associated with health-related quality of life in Australian adolescents.

PURPOSE: To explore the cross-sectional relationships between health-related quality of life (HRQoL) and physical activity (PA) behaviours and screen-based media (SBM) use among a sample of Australian adolescents. METHODS: Data came from baseline measures collected for the It's Your Move! community-based obesity prevention intervention. Questionnaire data on sociodemographics, PA, SBM and HRQoL were collected from 3,040 students (56% boys) aged 11-18 years in grade levels 7-11 in 12 secondary schools. Anthropometric data were measured. RESULTS: The highest level of PA at recess, lunchtime and after school was associated with higher HRQoL scores (boys, by 5.3, 8.1, 6.3 points; girls, by 4.2, 6.1, 8.2 points) compared with not being active during these periods. Exceeding 2 h of SBM use each day was associated with significantly lower HRQoL scores (boys, by 3.2 points; girls, by 4.0 points). Adolescents who were physically active and low SBM users on school days had higher HRQoL scores (boys, by 6.6 points; girls, by 7.8 points) compared with those who were not physically active every school day and high SBM users on school days. CONCLUSIONS: Several of the relationships between low PA and high SBM use and HRQoL were comparable to those previously observed between chronic disease conditions and HRQoL, indicating that these behaviours deserve substantial attention.

A prospective study of diet quality and mental health in adolescents.

OBJECTIVES: A number of cross-sectional and prospective studies have now been published demonstrating inverse relationships between diet quality and the common mental disorders in adults. However, there are no existing prospective studies of this association in adolescents, the onset period of most disorders, limiting inferences regarding possible causal relationships. METHODS: In this study, 3040 Australian adolescents, aged 11-18 years at baseline, were measured in 2005-6 and 2007-8. Information on diet and mental health was collected by self-report and anthropometric data by trained researchers. RESULTS: There were cross-sectional, dose response relationships identified between measures of both healthy (positive) and unhealthy (inverse) diets and scores on the emotional subscale of the Pediatric Quality of Life Inventory (PedsQL), where higher scores mean better mental health, before and after adjustments for age, gender, socio-economic status, dieting behaviours, body mass index and physical activity. Higher healthy diet scores at baseline also predicted higher PedsQL scores at follow-up, while higher unhealthy diet scores at baseline predicted lower PedsQL scores at follow-up. Improvements in diet quality were mirrored by improvements in mental health over the follow-up period, while deteriorating diet quality was associated with poorer psychological functioning. Finally, results did not support the reverse causality hypothesis. CONCLUSION: This study highlights the importance of diet in adolescence and its potential role in modifying mental health over the life course. Given that the majority of common mental health problems first manifest in adolescence, intervention studies are now required to test the effectiveness of preventing the common mental disorders through dietary modification.

Splash!: a prospective birth cohort study of the impact of environmental, social and family-level influences on child oral health and obesity related risk factors and outcomes.

BACKGROUND: Dental caries (decay) is the most prevalent disease of childhood. It is often left untreated and can impact negatively on general health, and physical, developmental, social and learning outcomes. Similar to other health issues, the greatest burden of dental caries is seen in those of low socio-economic position. In addition, a number of diet-related risk factors for dental caries are shared risk factors for the development of childhood obesity. These include high and frequent consumption of refined carbohydrates (predominately sugars), and soft drinks and other sweetened beverages, and low intake of (fluoridated) water. The prevalence of childhood obesity is also at a concerning level in most countries and there is an opportunity to determine interventions for addressing both of these largely preventable conditions through sustainable and equitable solutions. This study aims to prospectively examine the impact of drink choices on child obesity risk and oral health status. METHODS/DESIGN: This is a two-stage study using a mixed methods research approach. The first stage involves qualitative interviews of a sub-sample of recruited parents to develop an understanding of the processes involved in drink choice, and inform the development of the Discrete Choice Experiment analysis and the measurement instruments to be used in the second stage. The second stage involves the establishment of a prospective birth cohort of 500 children from disadvantaged communities in rural and regional Victoria, Australia (with and without water fluoridation). This longitudinal design allows measurement of changes in the child's diet over time, exposure to fluoride sources including water, dental caries progression, and the risk of childhood obesity. DISCUSSION: This research will provide a unique contribution to integrated health, education and social policy and program directions, by providing clearer policy relevant evidence on strategies to counter social and environmental factors which predispose infants and children to poor health, wellbeing and social outcomes; and evidence-based strategies to promote health and prevent disease through the adoption of healthier lifestyles and diet. Further, given the absence of evidence on the processes and effectiveness of contemporary policy implementation, such as community water fluoridation in rural and regional communities it's approach and findings will be extremely informative.

Increasing community capacity to prevent childhood obesity: challenges, lessons learned and results from the Romp & Chomp intervention.

BACKGROUND: Obesity is a major public health issue; however, only limited evidence is available about effective ways to prevent obesity, particularly in early childhood. Romp & Chomp was a community-wide obesity prevention intervention conducted in Geelong Australia with a target group of 12,000 children aged 0-5 years. The intervention had an environmental and capacity building focus and we have recently demonstrated that the prevalence of overweight/obesity was lower in intervention children, post-intervention. Capacity building is defined as the development of knowledge, skills, commitment, structures, systems and leadership to enable effective health promotion and the aim of this study was to determine if the capacity of the Geelong community, represented by key stakeholder organisations, to support healthy eating and physical activity for young children was increased after Romp & Chomp. METHODS: A mixed methods evaluation with three data sources was utilised. 1) Document analysis comprised assessment of the documented formative and intervention activities against a capacity building framework (five domains: Partnerships, Leadership, Resource Allocation, Workforce Development, and Organisational Development); 2) Thematic analysis of key informant interviews (n = 16); and 3) the quantitative Community Capacity Index Survey. RESULTS: Document analysis showed that the majority of the capacity building activities addressed the Partnerships, Resource Allocation and Organisational Development domains of capacity building, with a lack of activity in the Leadership and Workforce Development domains. The thematic analysis revealed the establishment of sustainable partnerships, use of specialist advice, and integration of activities into ongoing formal training for early childhood workers. Complex issues also emerged from the key informant interviews regarding the challenges of limited funding, high staff turnover, changing governance structures, lack of high level leadership and unclear communication strategies. The Community Capacity Index provided further evidence that the project implementation network achieved a moderate level of capacity. CONCLUSIONS: Romp & Chomp increased the capacity of organisations, settings and services in the Geelong community to support healthy eating and physical activity for young children. Despite this success there are important learnings from this mixed methods evaluation that should inform current and future community-based public health and health promotion initiatives. TRIAL REGISTRATION NUMBER: ANZCTRN12607000374460.

Reducing obesity in early childhood: results from Romp & Chomp, an Australian community-wide intervention program.

BACKGROUND: There is growing evidence that community-based interventions can reduce childhood obesity in older children. OBJECTIVE: We aimed to determine the effectiveness of the Romp & Chomp intervention in reducing obesity and promoting healthy eating and active play in children aged 0-5 y. DESIGN: Romp & Chomp was a community-wide, multisetting, multistrategy intervention conducted in Australia from 2004 to 2008. The intervention occurred in a large regional city (Geelong) with a target group of 12,000 children and focused on community capacity building and environmental (political, sociocultural, and physical) changes to increase healthy eating and active play in early-childhood care and educational settings. The evaluation was repeat cross-sectional with a quasiexperimental design and comparison sample. Main outcome measures were body mass index (BMI), standardized BMI (zBMI; according to the Centers for Disease Control and Prevention 2000 reference charts), and prevalence of overweight/obesity and obesity-related behaviors in children aged 2 and 3.5 y. RESULTS: After the intervention there was a significantly lower mean weight, BMI, and zBMI in the 3.5-y-old subsample and a significantly lower prevalence of overweight/obesity in both the 2- and 3.5-y-old subsamples (by 2.5 and 3.4 percentage points, respectively) than in the comparison sample (a difference of 0.7 percentage points; P < 0.05) compared with baseline values. Intervention child-behavioral data showed a significantly lower intake of packaged snacks (by 0.23 serving), fruit juice (0.52 serving), and cordial (0.43 serving) than that in the comparison sample (all P < 0.05). CONCLUSION: A community-wide multisetting, multistrategy intervention in early-childhood settings can reduce childhood obesity and improve young children's diets. This trial was registered with the Australian Clinical Trials Registry at anzctr.org.au as ACTRN12607000374460.

The VicGeneration study--a birth cohort to examine the environmental, behavioural and biological predictors of early childhood caries: background, aims and methods.

BACKGROUND: Dental caries (decay) during childhood is largely preventable however it remains a significant and costly public health concern, identified as the most prevalent chronic disease of childhood. Caries in children aged less than five years (early childhood caries) is a rapid and progressive disease that can be painful and debilitating, and significantly increases the likelihood of poor child growth, development and social outcomes. Early childhood caries may also result in a substantial social burden on families and significant costs to the public health system. A disproportionate burden of disease is also experienced by disadvantaged populations. METHODS/DESIGN: This study involves the establishment of a birth cohort in disadvantaged communities in Victoria, Australia. Children will be followed for at least 18 months and the data gathered will explore longitudinal relationships and generate new evidence on the natural history of early childhood caries, the prevalence of the disease and relative contributions of risk and protective biological, environmental and behavioural factors. Specifically, the study aims to:1. Describe the natural history of early childhood caries (at ages 1, 6, 12 and 18 months), tracking pathways from early bacterial colonisation, through non-cavitated enamel white spot lesions to cavitated lesions extending into dentine.2. Enumerate oral bacterial species in the saliva of infants and their primary care giver.3. Identify the strength of concurrent associations between early childhood caries and putative risk and protective factors, including biological (eg microbiota, saliva), environmental (fluoride exposure) and socio-behavioural factors (proximal factors such as: feeding practices and oral hygiene; and distal factors such as parental health behaviours, physical health, coping and broader socio-economic conditions).4. Quantify the longitudinal relationships between these factors and the development and progression of early childhood caries from age 1-18 months. DISCUSSION: There is currently a lack of research describing the natural history of early childhood caries in very young children, or exploring the interactions between risk and protective factors that extend to include contemporary measures of socio-behavioural factors. This study will generate knowledge about pathways, prevalence and preventive opportunities for early childhood caries, the most prevalent child health inequality.

Scaling up community-based obesity prevention in Australia: background and evaluation design of the Health Promoting Communities: Being Active Eating Well initiative.

BACKGROUND: There is only limited evidence available on how best to prevent childhood obesity and community-based interventions hold promise, as several successful interventions have now been published. The Victorian Government has recently funded six disadvantaged communities across Victoria, Australia for three years to promote healthy eating and physical activity for children, families, and adults in a community-based participatory manner. Five of these intervention communities are situated in Primary Care Partnerships and are the subject of this paper. The interventions will comprise a mixture of capacity-building, environmental, and whole-of-community approaches with targeted and population-level interventions. The specific intervention activities will be determined locally within each community through stakeholder and community consultation. Implementation of the interventions will occur through funded positions in primary care and local government. This paper describes the design of the evaluation of the five primary care partnership-based initiatives in the 'Go for your life' Health Promoting Communities: Being Active Eating Well (HPC:BAEW) initiative. METHODS/DESIGN: A mixed method and multi-level evaluation of the HPC:BAEW initiative will capture process, impact and outcome data and involve both local and state-wide evaluators. There will be a combined analysis across the five community intervention projects with outcomes compared to a comparison group using a cross-sectional, quasi-experimental design. The evaluation will capture process, weight status, socio-demographic, obesity-related behavioral and environmental data in intervention and comparison areas. This will be achieved using document analysis, paper-based questionnaires, interviews and direct measures of weight, height and waist circumference from participants (children, adolescents and adults). DISCUSSION: This study will add significant evidence on how to prevent obesity at a population level in disadvantaged and ethnically diverse communities. The outcomes will have direct influence on policy and practice and guide the development and implementation of future obesity prevention efforts in Australia and internationally. TRIAL REGISTRATION: ACTRN12609000892213.

Assessing the intake of obesity-related foods and beverages in young children: comparison of a simple population survey with 24 hr-recall.

BACKGROUND: With an increasing focus on obesity prevention there is a need for simple, valid tools to assess dietary indicators that may be the targets of intervention programs. The objective of this study was to determine the relative validity of previous day dietary intake using a newly developed parent-proxy questionnaire (EPAQ) for two to five year old children. METHODS: A convenience sample of participants (n = 90) recruited through preschools and the community in Geelong, Australia provided dietary data for their child via EPAQ and interviewer-administered 24-hour dietary recall (24 hr-recall). Comparison of mean food and beverage group servings between the EPAQ and 24 hr-recall was conducted and Spearman rank correlations were computed to examine the association between the two methods. RESULTS: Mean servings of food/beverage groups were comparable between methods for all groups except water, and significant correlations were found between the servings of food and beverages using the EPAQ and 24-hr recall methods (ranging from 0.57 to 0.88). CONCLUSION: The EPAQ is a simple and useful population-level tool for estimating the intake of obesity-related foods and beverages in children aged two to five years. When compared with 24-hour recall data, the EPAQ produced an acceptable level of relative validity and this short survey has application for population monitoring and the evaluation of population-based obesity prevention interventions for young children.