In 2008 the Early Prevention of Obesity in Childhood (EPOCH) Collaboration was formed. This involves investigators from four randomised controlled trials (RCTs) of early childhood obesity prevention interventions underway in Australia and New Zealand. The trial interventions were implemented from late pregnancy or early infancy, to age two years and the results of these individual studies are listed below. A prospective meta-analysis of these trials is progressing.
Wen LM, Baur LA, Simpson JM, Rissel C, Wardle K, Flood VM. Effectiveness of home based early intervention on children’s BMI at age 2: randomised controlled trial. BMJ. 2012;344(e3732).
Daniels LA, Mallan KM, Nicholson JM, Battistutta D, Magarey A. Outcomes of an Early Feeding Practices Intervention to Prevent Childhood Obesity. Pediatrics. 2013;132(1):e109-e118.
Campbell KJ, Lioret S, McNaughton SA, et al. A parent-focused intervention to reduce infant obesity risk behaviors: a randomized trial. Pediatrics. 2013;131(4):652-660.
Taylor BJ, Gray AR, Galland BC, et al. Targeting Sleep, Food, and Activity in Infants for Obesity Prevention: An RCT. Pediatrics. 2017, 139(3) e20162037; DOI: 10.1542/peds.2016-2037.
Lisa Askie (lead), Louise Baur, Chris Rissel, Karen Campbell, Kylie Hesketh, Rachael Taylor, Alison Hayes, Marj Moodie, Li Ming Wen, Lynne Daniels, Anthea Magarey
To determine the longer term effects - at 3.5 and 5 years of age - of early intervention programs in Australasia which are aimed at preventing childhood obesity
To determine which components of the complex interventions tested are more or less effective in preventing childhood obesity, and which interventions work best for which sub-groups.
To establish a framework for data sharing and collaborative analyses of future Australasian and international early childhood obesity prevention trials
We will continue the collaboration established as part of the Early Prevention of Obesity in Childhood prospective meta-analysis (EPOCH-PMA). The EPOCH-PMA is unique internationally in looking at interventions to prevent obesity in early childhood. The four Australasian trials in early childhood obesity prevention – Healthy Beginnings, NOURISH, InFANT and POI.nz - agreed to pool data via an individual participant data prospective meta-analysis, under the leadership of Lisa Askie. EPOCH’s Phase 1 work was funded by NMHRC (#1028555; 2012-2014). The protocol for this analysis is published at: http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-10-728
Just recently, the initial pooled analysis data (n=2196 participants) became available, and will be published in later 2016. That work looked at outcomes at age 18-24 months.
Extending this work to determine the effects at 3.5 and 5 years (i.e. between 3 to 3.5 years post-intervention), and to examine which components of interventions are more or less effective, and for whom, will be crucial to developing effective intervention programs with sustained effects.
We are aware that other studies in this age group are planned, or just underway, in other countries. Our EPOCH CRE team, under Lisa Askie’s leadership, will work with others to develop a framework for data sharing and collaborative analyses of these and other early childhood obesity prevention trials.
This stream will provide important new information about:
Stewart Trost and Rebecca Golley (co-leads), Louise Baur, Karen Campbell, Kylie Hesketh, Rachael Taylor, Li Ming Wen, Lynne Daniels, Anthea Magarey
Poor diet, inadequate sleep and insufficient activity are key obesity-related behaviours, even among infants and young children. The ability to monitor population trends, evaluate scaled-up intervention programs and make informed policy and practice decisions, depends on the availability of suitable assessment tools and supporting resources. However, the lack of validated and ‘fit-for-purpose’ tools for use with infants, toddlers and preschool-aged children that are feasible for use in policy and practice settings limits research and evaluation potential in this area.
The reasons for this are varied. Firstly, assessment at this age is particularly complicated as a result of large variations in activity and diet across very brief time periods (i.e. months), such as from infancy to toddlerhood. The ideal tool is simple, yet precise and accurate, characteristics that become increasingly difficult to achieve because of these rapid developmental changes which limit the ability for consistent measures. Secondly, existing tools are cost- and time-intensive for users and are frequently mis-used, giving rise to poor data quality and interpretation. Quality assurance protocols and technology-assisted data collection and analysis are urgently needed to address these barriers and enhance research, particularly in policy and practice settings.
We will develop, pilot test, and validate rapid assessment tools for the measurement of physical activity, diet, sedentary behaviours and sleep for children under 5. The Stream will leverage from existing projects and datasets, including those outlined in Stream 1, to construct short form measurement tools that are immediately deployable in population level research, policy and practice settings. In addition we will modify and validate existing assessment tools used in older children for use in under 5s. The resultant short form measures will be particularly useful as tools to support the evaluation of scaled-up programs
Once the brief tools have been developed, we will develop and pilot test online front-end user experience for these tools. In consultation with end-users, we will develop automated back-end analysis and interpretation protocols to enhance data harmonization and quality potential. The final product will be tested with end users e.g. early childhood carers and child health nurses, evaluating acceptability and practicality. We will use qualitative methods such as focus groups, as well as opportunistic evaluation activities via established research partnerships and student projects
The upscaling of effective obesity prevention interventions (Stream 1) to influence population health (Stream 4) will require an evaluation framework that includes rapid, accurate and consistent assessment of outcomes in research translation and practice settings. We will produce a range of practical, validated measures of obesity-related behaviours in infants, toddlers, and preschool-aged children. We will build capacity in the application of such measures within evaluations of population-based scaled up versions of obesity prevention trials. The tools will be packaged for uptake in a variety of settings, and supporting documentation, training materials, and automated protocols for data processing and analysis will be made available to a variety of potential users.
The work is innovative because we will be the first to develop a suite of validated short-form assessment tools to measure obesity-related behaviours in children aged under 5 years that are purpose-built for translation and use in practice. The resultant measures will enable researchers, practitioners and educators to effectively monitor obesity-related behaviours in population-based surveillance and intervention studies.
Alison Hayes and Marj Moodie (co-leads), Lisa Askie, Louise Baur, Chris Rissel, Kirsten Howard, Rachael Laws, Stavros Petrou
It is not enough for policy makers to know the comparative effectiveness of one program measured incrementally against another when making decisions on the allocation of resources to obesity prevention programs. Decision-makers also want to know whether an intervention represents value for money. Evidence gaps exist around what may be cost-effective in this age-group, as very few preventive interventions aimed at children aged 0-5 years have been subject to economic evaluation.
The reasons for this vary - difficulties in obtaining health care cost data, the paucity of quality of life instruments appropriate to this age group for use in cost-utility analysis, the lack of validated models to project quality of life and BMI trajectories, coupled with the fact that benefits of obesity prevention in childhood will not be fully realised until many years into the future.
However, there is good evidence that rapid weight gain in early childhood tracks to later adolescent and adult obesity, so implementation of cost effective interventions in early childhood could be key to slowing down the progression of obesity. Furthermore, whilst there may be a long lead time to the realisation of reductions in obesity-related disease, early prevention will serve to mitigate the non-disease specific harm of obesity per se in children (such as stigma, bullying and loss of quality of life) at the population level.
We will develop a micro-simulation model for the early childhood age group as a standardised economic evaluation framework to aid decision makers in allocating resources to obesity prevention programs. This has not been done in the past. We will use both published data, and new analysis of existing datasets, to develop models to predict BMI trajectories, quality of life and healthcare cost trajectories, from early childhood to adolescence. These will be integrated to provide a platform for health economic modelling from early childhood to the start of adulthood.
We will determine the preferences of key stakeholders (e.g. policymakers, parents, practitioners, early childhood educators) for measures of benefit in early childhood obesity prevention using discrete choice and structured interview methods. This will build on a framework developed by CI Moodie and colleagues at Deakin University as part of the ACE (Assessing Cost-Effectiveness) studies. It will consider the following attributes of interventions, in addition to their cost-effectiveness: equity, affordability, implementation feasibility, acceptability, sustainability and scalability. We will derive a scoring matrix which will facilitate the ranking and prioritisation of different types of interventions in the early childhood space. This work will effectively provide a link between Stream 1 (which will identify effective intervention or intervention components) and Stream 4 (which will provide for the translation into practice and policy).
The innovation associated with this research Stream will be the development of an economic toolkit for the early childhood population which will capture the costs, outcomes and economic credentials of either single or multiple interventions, and account for the trajectory of health outcomes into adolescence and adulthood, quality of life losses, equity effects and broader considerations of benefit.
Outcomes will include a robust economic model and a standardised economic evaluation framework focused on the early childhood age group; constructive collaborations across the field especially with policymakers; and cost-effectiveness evidence for a range of interventions which will inform policy makers making investment decisions in early childhood obesity prevention.
Rachel Laws, Li Ming Wen, Karen Campbell and Chris Rissel (co-leads),
Louise Baur, Kylie Hesketh, Lisa Askie, Elizabeth Denney-Wilson, Lisa Bero, Adrian Bauman, Tim Gill, Lynne Daniels
There are now several individual examples of effective programs to prevent childhood obesity (37-39). However, less is known about how to scale up these programs to a point where they will have population health impact. Scaling up programs and translating research into practice requires good understanding of the policy context and available policy levers, and also an understanding of how to engage practitioners and consumers in this process.
Lead investigator: Chris Rissel
We will conduct a comprehensive mapping of current policies and service delivery in early childhood services related to obesity prevention. This will include ‘desktop review’ and key informant interviews to explore the policy/program response for early child obesity prevention, factors influencing the approach taken and scalability of any programs implemented. This will be guided by the Consolidated Framework for Implementation Research.
Lead investigators: Rachel Laws, Li Ming Wen
We will conduct evaluation of the existing translation efforts with the Healthy Beginnings and InFANT trials to identify leverage points for translation of effective programs into routine practice. This will involve interviews with those involved in implementation including practitioners, policy makers and researchers as well as parents attending such programs to enable development of recommendations to facilitate the reach and widespread implementation of early childhood obesity prevention programs.
Lead investigator: Rachel Laws
We will undertake a case series to identify features of early childhood research interventions that can be successfully scaled up and factors influencing this process. This will involve a systematic search to identify published obesity prevention intervention studies for children aged 0-5 years. A survey of chief investigators of these studies will be conducted to identify those that have been successfully scaled up and translated into routine practice. A case series will be conducted, purposefully sampling interventions that have been scaled up and those that have not moved beyond the research phase. Qualitative interviews will be conducted with research investigators and end users to explore factors influencing the translation and scaling up process. A realist review framework will be used to synthesis the data.
The application of new research findings into scaled up professional practice to prevent childhood obesity represents a unique and significant contribution to population health. Achieving this in the Australian context would be at the international forefront. Understanding the programmatic components of success and the systems for delivering interventions combined with influence over the policy levers are necessary to effect real change.