Is monitoring childhood obesity in Wales feasible?

1. Is monitoring childhood obesity in Wales feasible? Dr C Humphreys

2. 60% popn. could be obese by 2050 ‘Obesogenic environment’ Life course component Early growth patterns (weeks/months) may affect later risk of obesity & disease Generational component Parents weight are greatest predictor of obesity Obesity Foresight Tackling Obesities: Future Choices – Project report UK Government Foresight programme. Image reproduced with permission.

3. “Global public health crisis”1 Consequences include2 Social and psychological, low self esteem affecting future physical and mental health risk factors for heart disease:  blood pressure, cholesterol, blood sugar Persistence into adulthood  rates of ill-health / death than those obese as adults only Type 2 diabetes in children & adolescents Childhood obesity Foresight report 1 Knai C, Lobstein T, Mckee M (2005) “Childhood obesity: the case for binding international legislation”, European Journal of Public Health, 15(6):559-563. 2 Storing up the complications, RCP, RCPCH, FPH 2002, Royal College of Physicians: London.

4. Prevalence of excess body weight WHO Europe Scotland England Wales Prevalence of excess body weight and obesity in children and adolescents. Copenhagen, WHO Regional Office for Europe, 2007:2-3 (ENHIS Fact Sheet No 2.3) Reproduced with permission of WHO Regional Office for Europe Self Reported Heights and Weights. 2001/2.

5. Current measures

6. Feasibility study • Assembly request for pilot 08/09* • Pre-existing measuring systems • NCMP, England (age 4/5 & 11/12) • Legal powers; e.g. giving parents BMI results • Requirement • Local level information – population coverage • Piloting across specific Trusts • To inform standardised national programme *HPV vaccine also introduced

7. Aim: to inform a standardised national study • National programme would • monitor population trends in (primary school) childhood growth • including obesity and underweight • inform strategies / service development; • assess effectiveness of population based interventions • be basis for epidemiological research • Surveillance not screening • Outcomes relate to • Quality of data • Coverage • Acceptability • Cost

8. The study • Participants • Reception (NCMP) & Year 4 (COSI) • State schools in 5 former Trust* areas • Pembs & Derwen; North East Wales; Powys; North Glamorgan; Swansea (part) • 30% of Wales population of age groups • Randomisation • Cluster (school) randomised for consent (year 4) • Opt in versus Opt out, to assess effect on uptake of measures • Ethical approval obtained • Feedback on request • Three of five Trusts *Including Powys Teaching LHB

9. The study • Measurement • Community/school nursing services • Training, instruments • Data recording • Community Child Health 2000 System (empty fields) • National Community Child Health Database • Qualitative study • Children, Parents, staff Image reproduced with permission from parent & child

10. Results • 14,100 children measured • 457 schools • Quality of data – mostly very high • School code & exam date ≥ 99.7% all areas • Dob/gender 100% all areas • Ethnicity <50% all areas (0.7% in one Trust) • Data from one Trust (N Wales) missed cases • Some of those not consenting to measurement • Height & weight data quality • Very good quality • ≥ 99.4 had BMI within plausible range

11. Height - normal distribution Reception Year 4 Weight - positively skewed distribution

12. Uptake: % eligible children measured

13. BMI status by age group, boys (%) - IOTF BMI status by age group, girls (%) WHS: 19% overweight (not obese); 7% obese using IOTF

14. % overweight or obese by WIMD fifth of deprivation, Year 4

15. Interviews with children, parents & staff • Qualitative study: semi-structured interviews • 10 children • 10 parents • 12 staff • Interviews took place after measurement phase • All interviews recorded, transcribed and analysed according to standard qualitative research methods

16. Qualitative study: key results 1 • Some children were comfortable with being measured, others less so. Areas for improvement: • Privacy including avoiding use of ‘holding area’ • Being accompanied by a familiar adult • Awareness of reasons why measured • Children not aware • Parents and staff mostly aware that it was about population monitoring • Difficulty separating such a programme from taking measures to manage individual children

17. Qualitative study: key results 2 • Staff more concerned about consent method than parents • Parents and children expressed interest in knowing the results of measurements • Staff found programme was work intensive – especially providing results to parents

18. Feedback of results • 1,722 results returned (41% of 4,202) • 70% of opt-in v 27% of opt-out (N Wales) • 70% ‘normal weight’; 29% overweight/very overweight* (Pembs) • Dedicated phone line & website (hosted by NHS Direct) • 11 calls (4 answered) • 7 website hits • GP survey (Pembs) • No impact on service (75% response) • Nursing service – 1 enquiry relating to results Using clinical cut offs rather than IOTF

19. Some key conclusions • It is feasible to measure ht & wts in primary schools • It is feasible to use CCH2000/NCCHD • Data quality good • But changes required to CCH2000/NCCHD • Opt-out had large impact on uptake • Effect on measured obesity may vary by deprivation • Programme acceptable • But communication, especially with children, could be improved

20. Next steps • Report to Assembly to inform Minister • June 2009 • Included 28 recommendations • Ministerial submission expected • Oct 2009 • Recommendations from Assembly

21. Children Parents Nathan Lester (contributed to slides) Other NPHS staff Angela Jones Thriveni Beerenahally Sharon Hillier Judith Greenacre Trust staff Anne Farr, Sandra Jones, Lesley Taylor, Yvonne Harding, Susan Jones, and Helen Jones and Paula Davies Swansea University Rhys Williams Centre for Child Health Research: Justine Howard, Helen Elton HSW esp Louise James, David Jones NHS Direct Thanks