Objective The aim of this study was to report outcomes of the UK service level delivery of MEND (Mind,Exercise,Nutrition...Do it!) 5-7, a multicomponent, community-based, healthy lifestyle intervention designed for overweight and obese children aged 5–7 years and their families.
Design Repeated measures.
Setting Community venues at 37 locations across the UK.
Participants 440 overweight or obese children (42% boys; mean age 6.1 years; body mass index (BMI) z-score 2.86) and their parents/carers participated in the intervention.
Intervention MEND 5-7 is a 10-week, family-based, child weight-management intervention consisting of weekly group sessions. It includes positive parenting, active play, nutrition education and behaviour change strategies. The intervention is designed to be scalable and delivered by a range of health and social care professionals.
Primary and secondary outcome measures The primary outcome was BMI z-score. Secondary outcome measures included BMI, waist circumference, waist circumference z-score, children's psychological symptoms, parenting self-efficacy, physical activity and sedentary behaviours and the proportion of parents and children eating five or more portions of fruit and vegetables.
Results 274 (62%) children were measured preintervention and post-intervention (baseline; 10-weeks). Post-intervention, mean BMI and waist circumference decreased by 0.5 kg/m2 and 0.9 cm, while z-scores decreased by 0.20 and 0.20, respectively (p<0.0001). Improvements were found in children's psychological symptoms (−1.6 units, p<0.0001), parent self-efficacy (p<0.0001), physical activity (+2.9 h/week, p<0.01), sedentary activities (−4.1 h/week, p<0.0001) and the proportion of parents and children eating five or more portions of fruit and vegetables per day (both p<0.0001). Attendance at the 10 sessions was 73% with a 70% retention rate.
Conclusions Participation in the MEND 5-7 programme was associated with beneficial changes in physical, behavioural and psychological outcomes for children with complete sets of measurement data, when implemented in UK community settings under service level conditions. Further investigation is warranted to establish if these findings are replicable under controlled conditions.
- Public Health
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Childhood obesity prevalence rates remain high in the UK and globally.
To our knowledge, there are no published, peer-reviewed weight management trials or service level evaluations for children aged 5–7 years in England.
The MEND 5-7 programme has high attendance and retention rates and produced positive changes in physical, behavioural and psychological outcomes.
This study demonstrates that a community-based intervention delivered by non-obesity specialists has a potentially valuable contribution to make as part of a comprehensive care pathway for families of overweight and obese children.
Strengths and limitations of this study
By using service-level data, this study contributes to the literature on appropriate targets for community level interventions.
Most of the outcome literature on community-based child weight management programmes has been delivered by highly skilled professionals under trial conditions. This limits the conclusions that can be drawn about whether such outcomes can be translated to community settings under different conditions of service delivery. The results of this paper suggest that outcomes similar to those achieved by controlled trials can be achieved under conditions of normal service delivery.
Only 62% of participants who started the programme completed postprogramme measurements. Although this level of completion is not atypical for reports of service-level implementation, it is still possible that biases due to selective attrition could lead to an overestimation of treatment effect.
Childhood obesity is associated with adverse effects on short-term and long-term health.1 ,2 Prevalence rates continue to be high globally and more specifically in the UK.3 In 2005, the Department of Health initiated the National Child Measurement Programme (NCMP) to identify schoolchildren in Reception (typically aged 4–5 years) and Year 6 (aged 10–11 years) who are overweight or obese in England.4 Since its inception, results from the NCMP have indicated high levels of overweight and obesity in both age groups—the most recent findings (school year 2010/2011) identifying 22.6% and 33.4% of Reception and Year 6 children as overweight or obese, respectively. Surveillance programmes have evolved into screening programmes with a high proportion of UK primary care trusts choosing to inform parents of their child's weight status. Although this practice is controversial, it is also the case that identification may be a trigger for parents to initiate lifestyle change and/or seek professional support.5
Research has indicated that there may be an effectiveness gradient with regard to the impact of child obesity treatment with age.6 Generally, earlier treatment is associated with better outcomes following programmes that are less intensive. To be effective, it is recommended that interventions are multicomponent and include age-appropriate nutrition and physical activity with behaviour change strategies that are developmentally appropriate to the cognitive abilities of the child and the nature of relationships in the family life cycle.7 ,8 Although the availability of treatments is steadily increasing, there are significant disparities in the availability of treatments across the developmental continuum. In the UK, only 8 of 45 weight management schemes cover the 5–7 age range9 and only 4 of the 13 Department of Health approved Child Weight Management programmes are suitable for children under the age of 7.10 To our knowledge, there are no published, peer-reviewed weight management trials or service level evaluations for children aged 5–7 in England. This leaves a gap in the understanding of the outcomes that it is possible to achieve for overweight and obese children in this age range in a UK setting.
The aim of this study was to report outcomes from the UK service level delivery of MEND 5-7 (Mind, Exercise, Nutrition... Do it!), a multicomponent, community-based healthy lifestyle intervention designed for overweight and obese children aged 5–7 years and their families.
Families were recruited between 2009 and 2011 using a variety of techniques. MEND provides recruitment resources such as posters, flyers and letters that can be used within local networks to support the recruitment process. In addition, support is also provided, detailing the effective use of these resources. Children were eligible if they were classified as overweight or obese (body mass index (BMI) ≥91st percentile) according to the UK 1990 reference data11; had no apparent clinical conditions, comorbidities, physical disabilities or learning difficulties that would interfere with programme engagement and were aged between 5 and 7 years with at least one parent/carer who was able to attend each of the programme sessions.
The study employed an uncontrolled repeated measures design evaluating changes in the anthropometric, psychosocial, physical activity and nutritional outcomes. This study reports the outcomes of participating children with complete preintervention and postintervention data when delivered in UK community settings under service level conditions.
The MEND 5-7 programme is a comprehensive, multicomponent intervention designed to tackle obesity in childhood. The programme supports families by providing information on child nutrition (based on government healthy eating guidelines), active play and parenting practices to help parents practically integrate these recommendations into everyday life. The programme uses a non-diet approach to prevent unduly restrictive eating which can lead to problematic eating behaviours.7
MEND 5-7 is based around key principles in health-related behaviour change and behavioural parent training programmes. These methods are drawn from evidence-based practices in child psychology and parenting interventions.12
Reviews of behavioural treatments for childhood obesity show that group-based interventions are the most commonly used delivery formats and that they are more effective than individual treatment sessions.13 Groups are more efficient, provide greater opportunity for therapeutic interactions between participants, improve attendance rates and are cost-effective.13 Community groups provide greater access to minority ethnic groups, counter stigma, provide a social support network and aid the therapeutic process of problem-solving.14 These factors improve the understanding of the condition, adherence to the intervention and implementation of changes in behaviour. Recognising the importance of family involvement for behaviour change, the programme requires a parent or carer to attend all sessions.
Structure and content
The programme consists of 10 (1 h and 45 min duration) weekly group-based sessions delivered by two trained leaders and one optional assistant. The programme is held in community settings such as sports centres and schools for groups of 8–15 children and their parents/carers. The first and last sessions are allocated as introductory and graduation sessions, respectively, incorporating measurements and parental/carer questionnaire completion.
Each session has four components: ‘Power Time’ (20 min), ‘Healthy Families’ (25 min), ‘Active Play’ and ‘Parent/carer Workshop’ (during this time, children take part in 60 min of physical activity and parents/carers attend a workshop). ‘Power Time’ is a joint parent/carer and child snack time designed to help parents incorporate evidence-based food exposure techniques into their daily routines to increase their child's preferences for healthier foods. ‘Healthy Families’ is also a joint parent/carer and child session that focuses on educating and promoting skills for everyday play, active family lifestyles and healthy family eating in the home environment. ‘Active Play’ is a child-only play session that takes place while the parents/carers are in their workshop. The focus is on fun and active participation. The aim is to provide children with positive experiences of being active in a supportive setting.
The parent/carer workshops include interactive activities and discussions focusing on nutrition, activity and behaviour change. Five of the parent/carer workshops focus on healthy eating and nutrition-related topics. Group discussions include practical training on understanding food and drink labels, fat and sugar content of foods and drinks, portion sizes and managing fussy eating. The remaining workshops focus on family rules and routines, reducing screen time and overcoming barriers to physical activity.
The MEND 5-7 programme is delivered by community-based health, education and physical activity professionals who attend a 2-day, face-to-face training course. The training is derived from established competency-based skills training methods15 and includes direct teaching, role-play, guided discussion and multiple choice assessments. After training, all staff are required to complete an online assessment to gain certification to deliver the programme and pass an enhanced CRB (Criminal Records Bureau) check.
Following successful completion of the training, delivery teams are provided with four manuals, two for programme delivery, one for programme management and one for physical activity. These resources provide full details of session plans, objectives, direct teaching notes, desired outcomes, set-up and delivery requirements and all aspects of the physical activity programme component.
Socioeconomic status was determined based on home ownership,16 grouped as ‘owner occupied’, ‘private rented’, ‘social rented’ and ‘other’. Ethnic background was based on the UK census categorisation as outlined in the National Obesity Observatory Standard Evaluation Framework for weight management interventions.16
Physical activity and inactivity
Physical activity level and sedentary behaviours were assessed using items adapted from the ‘outdoor playtime checklist’.17 Physical activity was assessed by asking ‘How much time did your child spend playing outside in the yard or street of your house (or the house of a friend, neighbour or relative), or at the park, playground or outdoor recreation (eg, swimming pool, zoo or amusement park), including while at day care or preschool?’ Television viewing time and time spent playing computer/console games were assessed by asking ‘How much time would you say your child spends watching television (including videos and DVDs), including time spent watching TV in other people's houses?’ and ‘How much time did your child spend playing Play-Station/X-box/Nintendo/Computer games (including watching a friend/brother/sister/adult play, and at other people's houses)?’ Total sedentary activity was calculated from the addition of TV viewing time and time spent playing computer/console games. Answers were given in hours and minutes per day, based on typical days in the last month. Separate estimates were provided for weekday and weekend days.
Body weight (kg) and height (cm) were measured using standardised procedures18 and body mass index calculated as body weight (kg)/height (m2). Waist circumference (cm) was measured 4 cm above the umbilicus.19 BMI and waist circumference z-scores were calculated from UK national reference data11 ,20 using LMS growth software.21
Fruit and vegetable consumption
Levels of child and parent fruit and vegetable consumption were assessed by the daily frequency of portions consumed.22 Questions were measured on a 7-point Likert scale (less than 1/week, 1/week, 2–3/week, 4–6/week, 1/day, 2/day or 3 or more per day).22
Parenting self-efficacy was measured using the subscales of ‘Play and Enjoyment’, ‘Discipline and Boundary Setting’ and ‘Learning and Knowledge’ taken from ‘TOPSE’ (Tool to Measure Parenting Self Efficacy).23
Strengths and Difficulties Questionnaire
The Strengths and Difficulties Questionnaire (SDQ)—Parent's Version24 is a widely used measure of emotional distress in children and adolescents. The measure consists of 25 statements referring to behaviours associated with emotional difficulties, such as ‘often has temper tantrums or hot tempers’ and ‘often lies or cheats’. Parents are asked to indicate how ‘true’ each statement is of their child on a 3 point Likert scale (not true, somewhat true, certainly true). A ‘total difficulties’ score is generated, with higher scores indicating greater levels of emotional distress. Measures of psychological distress were included to evaluate the impact of the intervention upon the children's well-being and to ensure that physical health outcomes were not achieved at the expense of well-being.
Data cleaning and statistical analysis
Owing to the data being collected under service level conditions by non-researchers, comprehensive cleaning procedures were undertaken to ensure data quality. Outliers for anthropometric measurements were identified from a visual analysis of histograms and scatterplots. Visual analysis enabled the identification of seven observations that were inconsistent with other observations in the data set. After comparison to reference growth charts, these seven data sets were excluded due to biologically unlikely increases in height of over 5.5 cm over the course of the premeasurement and postmeasurement sessions. Participants were excluded from the activity analysis if the addition of reported daily physical activity and sedentary behaviour exceeded 16 h, resulting in seven data sets being excluded.
Variable distribution was checked using the Kruskall-Wallis test for normality. Paired sample t tests were employed to assess mean differences in the outcome variables from baseline to 3 months (end of intervention). Changes in the proportions for fruit and vegetable intake from baseline to the end of the intervention were assessed using McNemar's test. Baseline differences for those who did and did not complete postprogramme measurements were examined using independent sample t tests. Similarly, effects of gender pre–post programme were examined using independent sample t tests. Statistical significance was set at p<0.05. All analyses were conducted using SPSS V.18.0 for Windows (SPSS, Chicago, Illinois, USA).
Four hundred and forty children participated in MEND 5-7 programmes across 37 UK locations.
Baseline demographic and anthropometric characteristics
Fifty-eight per cent were women and 79% of participants were obese (BMI ≥98th centile). Thirty-three per cent of children were from non-white ethnic backgrounds with 57% reporting that they did not own their home (table 1).
Completers versus Non-completers
There were no significant differences in baseline demographic and anthropometric characteristics between children with complete sets of measurement data and those without. Significant differences were evident in baseline comparisons of physical activity levels (15.0±8.9 h/week completers vs 19.3±13.7 h/week non-completers, p<0.01). All other outcome measures were not significantly different at baseline.
Attendance and retention
Attendance data were available for 81% of participants. Mean attendance for the programme was 73% and retention rate (based on children attending at least 7 sessions) was 70%.
Within-subject differences in anthropometric, psychosocial and activity measures preintervention and postintervention are shown in table 2. Significant reductions in BMI, BMI z-score, waist circumference, waist z-score and child total difficulties score (all p<0.0001) postintervention were noted. Positive changes were also observed for TV time, sedentary activity (p<0.0001) and physical activity (p<0.01). Significant increases were observed in all parenting self-efficacy domains and the proportion of children and parents eating at least five fruit and vegetables per day (all p<0.0001). There were no gender differences in any of the study outcomes.
This study examined outcomes following participation in the MEND programme for children aged 5–7 years. Positive changes were observed for children's weight status, diet and activity levels and emotional well-being. Parents also reported an increase in self-efficacy in relation to their parenting role.
Most of the outcome literature on child weight management programmes has been reported under trial conditions. Outcomes reported in studies of general practitioner-led behavioural treatment of individual families (LEAP (Live, Eat and Play) intervention25) and in generic parenting programmes unmodified to deal with the specific needs of obese and overweight children (Triple P) have shown no significant reductions in measures of degree of obesity. A version of the Triple P programme specifically adapted for obesity (Lifestyle Triple P) showed a reduction of −0.11 at 20 weeks,26 the HICKUPS study of a multicomponent group-based parenting intervention reported a reduction of −0.36 at 6 months and the PEACH study of a parent-only group intervention showed a reduction of −0.26 at 6 months.27 ,28
In the current study, children with complete sets of measurement data had a significant reduction in BMI z-score of −0.20 after 10 weeks. The results presented here were similar to the unpublished 3 month data (−0.20) for children taking part in the randomised controlled trial of the MEND programme for 7–13-year-old children29 and its national service level evaluation (−0.18).30 Although not directly comparable to the treatment effects reported in experimental studies using intention-to-treat analysis, this study suggests that community level interventions delivered under conditions of normal service delivery may achieve similar results to those obtained in clinical trials.
Generally, interventions that produce greater treatment effects are more intense and involve relatively higher levels of contact time.31 The US preventive services task force (USPSTF) concludes that low-intensity interventions—defined as those involving less than 25 h direct professional contact time—are insufficient to have a positive impact on weight status in obese and overweight children. The MEND 5-7 programme consists of 17.5 h of face-to-face contact time and demonstrated significant reductions in zBMI for 62% of children with complete sets of measurement data. Contrary to USPTS> recommendations, this suggests that clinically meaningful outcomes may be achievable by low-intensity interventions.
MEND 5-7 has been designed to be delivered by community-based, non-obesity specialists, in contrast to other studies that have used highly skilled professionals to deliver the intervention.27 ,28 A large proportion of childhood obesity interventions employ intensive programmes involving specialist dieticians and other health professionals.32 Childhood obesity interventions are significantly more expensive when skilled professionals and additional contact hours are employed. In an increasingly resource-constrained public-sector environment, these factors might limit the potential reach of evidence-based programmes.32 The development of a clinically effective, low-intensity programme using non-specialist, community-based delivery staff could be a crucial strategy to meet the needs of younger children who are already overweight. The present results suggest that clinically meaningful outcomes may be achievable by low-intensity interventions delivered by non-specialist staff. Further research would be desirable to explore whether these initially promising data could be independently replicated under service level conditions.
The UK Department of Health physical activity guidelines specify that children and young people (5–18 years old) should engage in 60 min of activity per day while minimising sedentary behaviours.33 Sedentary behaviours—in particular, time spent watching television—are associated with metabolic risk factors in children34 and have been shown to predict BMI in early adulthood.35 Independent of TV viewing time, higher levels of sedentary behaviours have been shown to lower levels of physical activity in children.36
There is also evidence that participation in physical activity leads to health benefits37 and lowers levels of overweight and obesity in children.38 In this study, participation in MEND 5-7 was associated with significant, positive changes in physical activity levels (p<0.01), TV viewing time and sedentary activity levels (p<0.0001). Parents reported that children on the programme had reduced sedentary behaviour by an average of 4.1 h, of which 3.4 h was television viewing, and increased their physical activity levels by 2.9 h per week. Such reductions in sedentary activity and increase in physical activity during participation in the programme is very encouraging.
Some limitations of the study should be acknowledged. Only 62% of participants who started the programme completed postprogramme measurements. This level of completion is not atypical for a pilot study or reports of service-level implementation39 ,40 but may be a source of bias that could lead to an overestimation of treatment effect. Statistical analyses revealed that there were limited differences between those participants who completed the programme and those who did not. The data presented here are uncontrolled data representing the short-term impact of the intervention for children with complete sets of measurement data. Controlled studies of the impact beyond the 10 week programme are needed to establish whether the present results are sustained and more effective than no or an alternative intervention. While it is well documented that subjective measures of physical activity over-report when compared to more accurate, objectively measured physical activity,41 subjective measurement can be a useful and cost-effective tool when employed in a community-based programme if it is not feasible to obtain objective measurements.42 The improvements found in physical activity and sedentary behaviours require supporting evidence using objective measurement.
Participation in the MEND 5-7 programme was associated with beneficial changes in physical, behavioural and psychological outcomes for children with complete sets of measurement data, when implemented in UK community settings under service level conditions. The findings presented warrant further evaluation in a formal trial to establish if the observed outcomes would have occurred in the absence of intervention, are replicable across varying ethnic and socioeconomic groups, are sustainable and are cost-effective. Further, process evaluation of programme implementation will also establish if the delivery model, using non-obesity specialists, can provide a scalable and suitable care pathway for families of overweight and obese children on a national level.
We would like to thank Dr Venediktos Kapetanakis for his statistical advice. We would also like to thank all the families who took part in the MEND 5-7 programme.
Contributors LRS performed statistical analysis and contributed to the writing of the paper. PC co-developed the intervention and contributed to the writing of the paper, as well as the interpretation and analysis of results. DR contributed to the writing of the paper and statistical analysis. MK critically reviewed all parts of the paper and assisted in the interpretation and analysis of the results. CSG contributed to the interpretation of the results and critically reviewed all parts of the paper. JR co-developed the intervention and critically reviewed all parts of the paper. PS co-developed the intervention, contributed to the interpretation of the results and writing of the paper and critically reviewed all parts of the paper. All authors approved the final draft of the paper.
Funding This evaluation received no specific grant from any funding agency. Researchers (authors) were all funded as employees of MEND Central Ltd. Programmes were primary funded by the UK Primary Care Trusts and Local Authorities (approximately 80% and 10%, respectively). Additional programmes were funded from a variety of sources including local Leisure Providers and Private Sector Companies.
Competing interests LRS, DR, CSG and JR are employed full-time at MEND. Dr PC is currently employed part-time as Clinical Director at MEND. MK is employed part-time at MEND. PS is currently employed as a Senior Research Fellow at the UCL Institute of Child Health as well as the Chief Research and Development Officer at MEND. VK serves as a consultant statistician to MEND.
Ethics approval This study is a service evaluation and is not within the remit of the UK Ethics Committee governance. Parents consented to take part in the study and for use of their anonymised data.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
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