Attrition in paediatric weight management: a review of the literature and new directions

Paediatric obesity continues to be one of the most important health issues facing children and families today, and there remains a need for effective treatment options. There are a few reports in the literature demonstrating high rates of attrition from paediatric weight management programmes, ranging from 27% to 73%. While some studies show that racial/ethnic minorities, the economically disadvantaged and those with higher levels of obesity are at risk, other studies do not. There is some consistency in reasons given by families for attrition from treatment, most often scheduling issues and programmes not meeting family needs or expectations. This review highlights identified contributors to attrition from paediatric weight management and provides a framework to study this problem, based on models of adherence to paediatric medical regimens.     

Strategies to reduce attrition in weight loss interventions: A systematic review and meta‐analysis

The primary objective of the study was to identify the effect of intervention strategies on attrition within a weight loss programme among adults aged 18 to 65 years. The secondary objective of the study was to assess the impact of such intervention strategies among female‐only weight loss programmes. The literature search was performed in Ovid (CINAHL Plus, MEDLINE, EMBASE, Cochrane [Cochrane Database of Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register], and PsycINFO). Studies must have identified weight loss as the main aim and compared the primary weight loss programme alone (control) with the primary weight loss programme coupled with an additional intervention strategy (intervention). Papers must have had a mean participant age between 18 and 65 years and available in English. Fifty‐seven trials met the inclusion criteria and were included in the meta‐analysis. Strategies that successfully reduced attrition included the incorporation of financial incentives (n = 8), a multicomponent approach (n = 13), and use of self‐monitoring technology (n = 4). The majority of studies were of low to moderate methodological quality because of insufficient reporting. A limited number of female‐only trials were found (n = 13). Implementation of financial incentives, multicomponent interventions, and self‐monitoring technology help reduce attrition among adult weight loss programmes. Further studies are required to identify the impact of intervention strategies on attrition in women.     

Immersion treatment of childhood and adolescent obesity: the first review of a promising intervention

Obese children have attended weight loss camps and residential programmes for more than 40 years. This paper provides the first systematic review of the effects of those programmes. Twenty‐two studies met inclusion criteria (targeted and assessed change in weight status, minimal stay of 10 days and nights). Similar components across programmes included controlled diet, activities, nutrition education, and therapy and/or education regarding behaviour change. Participants lost substantial amounts of weight in all 22 studies, as measured by reductions in per cent‐overweight during intervention. Eleven programmes included long‐term follow‐up evaluations. Compared with results highlighted in a recent meta‐analysis of out‐patient treatments, these immersion programmes produced an average of 191% greater reductions in per cent‐overweight at post‐treatment and 130% greater reduction at follow‐up. Furthermore, mean attrition rates were much lower when compared with standard out‐patient treatment. Inclusion of a cognitive–behavioural therapy (CBT) component seemed especially promising; follow‐up evaluations showed decreased per cent‐overweight at follow‐up by an average of 30% for CBT immersion programmes vs. 9% for programmes without CBT. Explanations for the potentially greater impact of immersion relative to out‐patient treatments are presented, including possibly differential effects on self‐efficacy for both children and their parents.     

Childhood obesity and school absenteeism: a systematic review and meta‐analysis

Regular school attendance is a key determinant of student's academic achievement and psychosocial development. Obesity may affect children's school attendance through its detrimental impact on their physical and mental health. A literature search was conducted in the PubMed, Web of Science and Cochrane Library for articles published until April 2017 that examined the relationship between unhealthy body weight and school absenteeism among children and adolescents. Thirteen studies total (10 cross‐sectional and three longitudinal) conducted in seven countries were identified. The mean and median sample sizes were 24,861 and 3,113, respectively. Ten studies objectively measured children's height and weight, and three were based on parents' self‐report. Four studies measured absenteeism using school administrative data, and nine administered questionnaires on children's parents. Among them, 11 reported a statistically significant positive association between childhood overweight/obesity and school absence, whereas two reported null effect. The meta‐analysis found that the odds of being absent from school was 27% and 54% higher among children with overweight and obesity than among their normal weight counterparts, respectively. Future studies should adopt an experimental study design and accurate measures on school attendance and delineate the underlining pathways linking childhood obesity to school absenteeism through obesity‐related illnesses and psychosocial problems.     

Parenting beliefs and practices of opiate-addicted parents: concealment and taboo

The lifestyle associated with opiate dependence, including drug taking, the buying and selling of drugs, and contact with other drug users, carries potential risks for the safety and well-being of children of drug-using parents. Based on a qualitative interview study conducted with 50 opiate-dependent parents in Dublin, Ireland, the parenting beliefs and practices in relation to children's exposure to drugs and the associated lifestyle are described. Parents saw their lifestyle as potentially risky for their children and their families. The most common strategy adopted by parents was to conceal their drug-related activities and maintain a strict family taboo about these activities. Intervention programmes should be offered to support effective family communication about parental drug dependence.     

Dietary and lifestyle interventions for weight management in adults from minority ethnic/non‐White groups: a systematic review

Minority ethnic/non‐White populations are more prone to weight gain and more susceptible to obesity‐related complications. The objective of this study was to systematically review dietary and lifestyle interventions for weight management in minority ethnic groups. Electronic databases and reference lists of original studies and reviews were searched for studies on dietary and lifestyle weight management interventions published. Randomized clinical trials with ≥6‐month duration were included. Nineteen studies met the inclusion criteria. Fourteen studies involved African–Americans, one in non‐White Hispanics, one in Japanese Americans and three in both African–Americans and non‐White Hispanics. Most of the interventions proved relatively effective. However, significant drawbacks were noted for several of these studies, such as small sample size, high attrition rates and lack of follow‐up data. Better quality and long‐term trials are required in order to investigate in detail the effectiveness of lifestyle changes for weight management in these populations and eventually support evidence‐based recommendations.     

The Pre‐dialysis Experience ‐ Are individual needs being met?

The pre‐dialysis experience is a time of change. Individuals and their families are able to adapt to this change and altered lifestyle if their specific needs are met. This qualitative study aims to gain an understanding of the patient's perspective and identify how they manage the pre‐dialysis experience. This knowledge will enable renal unit teams to plan effective holistic programmes, which meet the needs of the individual. The emergent theory identified that predialysis patient's and their families have to accept a different view of life before they can move forward and make a decision regarding treatment. The adoption of a model for good practice aids the transition.     

Employees' perceptions of the Aid-for-AIDS disease-management programme,South Africa

It is estimated that 18–20% of South Africa's more than 5 million HIV-positive individuals are formally employed. Disease management programmes for these employees vary in scope and sophistication, with services provided by the employer, or third-party specialist disease managers, or through medical aid schemes. This study surveyed 215 HIV-positive employees in two organisations contracted to the Aid for AIDS (AfA) disease management programme through their in-house medical aid schemes. The two organisations differed in their overall approach to HIV and AIDS: one mainly relies on on-site access to voluntary counselling and testing (VCT) and AfA's management of registered HIV-positive employees, while the other has invested in and actively developed a comprehensive programme that also extends to families and the community as well as links employees to the AfA programme. Responses received from 28 of the 215 employees surveyed indicate that fear of disclosure of one's HIV status and of stigmatisation are reasons for late registration with the AfA programme or non-utilisation of other available support programmes. Respondents mentioned that confidence in the employer's ability to maintain confidentiality was also an issue. Respondents' important suggestions for change included: a) on-site educational and awareness programmes for management personnel and staff in order to reduce HIV discrimination and stigmatisation; b) information directed at HIV-positive employees publicising the benefits and effectiveness of medical treatment; c) support groups for HIV-positive employees; and d) management personnel to engage with HIV-infected employees who are willing to take an active role in staff education and the development of workplace policies and programmes.     

Community perception of school-based delivery of anthelmintics in Ghana and Tanzania.

This paper presents the results of an evaluation of community perception of two large-scale, government-run, school-based health programmes delivering anthelmintic drugs to primary school children, in Ghana (80 442 children in 577 schools) and Tanzania (110 000 children in 352 schools). Most teachers (96% in Ghana and 98% in Tanzania) were positive about their role in the programme, including administration of anthelmintic drugs, and parents and children fully accepted their taking on this role. The benefits of the programme were apparent to teachers, parents and children in terms of improved health and well-being of the children. Over 90% of parents in both Ghana and Tanzania indicated a willingness to pay for the continuation of drug treatment. The evaluation also highlighted areas that are critical to programme effectiveness, such as communication between schools and parents, the issue of collaboration between the health and education sectors, parents' perception of the importance of helminth infection as a serious and chronic health problem (compared with more acute and life threatening illnesses such as malaria), and who should pay for treatment of side-effects.     

Systematic review of the use of data from national childhood obesity surveillance programmes in primary care: a conceptual synthesis

This study reviewed the use in primary care of national surveillance data for children to determine the data's potential utility to inform policy and practice decisions on how to prevent and treat childhood obesity. We reviewed the 28 countries identified by the World Obesity Federation as having high‐quality comparable body mass index data for children. Literature published from any period up to December 2013 was included. Peer review literature was searched using Web of Science (Core Collection, MEDLINE). Grey literature was searched using the Internet by country name, programme name and national health and government websites. We included studies that (i) use national surveillance obesity data in primary care, or (ii) explore practitioner or parent perspectives about the use of such data. The main uses of national surveillance data in primary care were to identify and recruit obese children and their parents to participate in school and general practice‐based research and/or interventions, and to inform families of children's measurements. Findings indicate a need for school staff and practitioners to receive additional training and support to sensitively communicate with families. Translation of these findings into policy and practice could help to improve current uses of national child obesity surveillance data in primary care.     

Social influence in childhood obesity interventions: a systematic review

The objective of this study is to understand the pathways through which social influence at the family level moderates the impact of childhood obesity interventions. We conducted a systematic review of obesity interventions in which parents' behaviours are targeted to change children's obesity outcomes, because of the potential social and environmental influence of parents on the nutrition and physical activity behaviours of children. PubMed (1966–2013) and the Web of Science (1900–2013) were searched, and 32 studies satisfied our inclusion criteria. Results for existing mechanisms that moderate parents' influence on children's behaviour are discussed, and a causal pathway diagram is developed to map out social influence mechanisms that affect childhood obesity. We provide health professionals and researchers with recommendations for leveraging family‐based social influence mechanisms to increase the efficacy of obesity intervention programmes. © 2016 World Obesity     

Are field‐based exergames useful in preventing childhood obesity? A systematic review

Exergames have started to find their way into field‐based settings, such as schools, communities and homes, as a possible solution to curbing physical inactivity and childhood obesity. However, a clear view of the effects of field‐based exergaming on children's obesity‐related outcomes is lacking. Hence, a systematic review on this topic is warranted. This review synthesizes the impact of field‐based exergames on children's physical and psychosocial outcomes. A total of 34 articles conducted in field‐based settings were identified from 104 peer‐reviewed publications that investigated the effects of exergames. Upon screening, these articles met the inclusion criteria and a high inter‐rater agreement for inclusion was reached between the authors. The effects of field‐based exergames on children's habitual physical activity (PA) and obesity‐related outcomes (e.g. weight loss, body composition) remain unclear due to design problems, measurement issues and other methodology concerns. In addition, exergame is appealing to children, although strategies are warranted to sustain their interests. In summary, exergames are desirable as a promising addition to promote PA and health. Professionals may integrate exergames at field settings to promote a physically active lifestyle among children with the goal of curbing childhood obesity.     

Children's and parents' opinions on the sport‐related food environment: a systematic review

Sport is a key setting for interventions to address child obesity given its obesogenic nature. Understanding children's and parents' opinions on the sport‐related food environment is critical in developing effective programmes and policies to improve children's health. This systematic review synthesizes quantitative and qualitative research examining children's and parents' opinions on the sport‐related food environment. During July 2016, a range of electronic databases of academic and grey literature were searched. Thirty‐two publications (11 including children, 17 parents and 4 both) were included for review. The publications were assessed using the Analysis Grid for Environments Linked to Obesity framework to categorize the sport‐related food environment into the physical, sociocultural, economic and political environments. The literature available investigating children's and parents' opinions of the sport‐related food environment suggests that many children and parents consider the environment neither conducive to nor supportive of children's healthy food behaviours or wider health and well‐being. Both groups would likely support actions to change and improve it. This systematic review found that original research specifically investigating children's and parents' perspectives on almost all aspects of the sport‐related food environment is limited. Thus, there is scope for further investigation into this important part of children's food environments.     

Evaluating commercial weight loss programmes: an evolution in outcomes research

The increasing prevalence of obesity has been mirrored by a parallel increase in the number of commercial weight loss programmes. Research evaluating these programmes is meagre, however, compared to the numbers treated. Reluctance of commercial weight loss programmes to meaningfully evaluate their weight loss efficacy may arise from fear that competitors will use the results against them. Evaluation of commercial weight loss programmes usually progresses from testimonials, often by famous people who were successful, to uncontrolled studies of past participants evaluated either by the programme itself or by an outside entity. The gold standard, however, is a scientifically rigorous, controlled study of the programme conducted by an independent entity. Such a study, published in a peer-reviewed journal, can gain credibility for a programme, as it did with Slim Fast, if the results are positive, or herald the end of the programme, as it was with Simeons human chorionic gonadotropin injection clinics. This review of the evolution of the evaluation process of commercial weight loss programmes leads us to conclude that consumers are likely to demand greater scientific rigour in the future, a change that will favour informed choice and discourage the practice of unrealistic advertising that raises false hopes.     

Socioeconomic factors related to attendance at a Type 2 diabetes screening programme

Aims The prevalence of diabetes is increasing, and screening of high‐risk populations is recommended. A low attendance rate has been observed in many Type 2 diabetes screening programmes, so that an analysis of factors related to attendance is therefore relevant. This paper analyses the association between socioeconomic factors and attendance for Type 2 diabetes screening. Methods Persons aged 40–69 years (n = 4603) were invited to participate in a stepwise diabetes screening programme performed in general practitioners’ offices in the county of Aarhus, Denmark in 2001. The study was population‐based and cross‐sectional with follow‐up. The association between screening attendance in the high‐risk population and socioeconomic factors was analysed by odds ratio. Results Forty‐four percent of the estimated high‐risk population attended the screening programme. In those with known risk for Type 2 diabetes, attenders were more likely to be older, to be unemployed and to live in the countryside than non‐attenders. The risk for Type 2 diabetes was unknown for 21% of the study population; this group was younger and less likely to be cohabitant, skilled, or employed and to have middle or high income than the study population with known risk score for diabetes. Conclusions A low attendance rate was found in this screening programme for Type 2 diabetes. No substantial socioeconomic difference was found between attenders and non‐attenders in the high‐risk population. Further research is needed to uncover barriers to screening of Type 2 diabetes in socioeconomically deprived persons.     

Effectiveness of web‐based interventions in achieving weight loss and weight loss maintenance in overweight and obese adults: a systematic review with meta‐analysis

The objectives of this systematic review are to evaluate the effectiveness of web‐based interventions on weight loss and maintenance and identify which components of web‐based interventions are associated with greater weight change and low attrition rates. A literature search from 1995 to April 2008 was conducted. Studies were eligible for inclusion if: participants were aged ≥18 years with a body mass index ≥25, at least one study arm involved a web‐based intervention with the primary aim of weight loss or maintenance, and reported weight‐related outcomes. Eighteen studies met the inclusion criteria. Thirteen studies aimed to achieve weight loss, and five focused on weight maintenance. Heterogeneity was evident among the studies with seven research questions examined across interventions of varying intensity. Seven studies were assessed for effectiveness based on percentage weight change, with four studies deemed effective. Although the four meta‐analyses suggest meaningful weight change, it is not possible to determine the effectiveness of web‐based interventions in achieving weight loss or maintenance due to heterogeneity of designs and thus the small number of comparable studies. Higher usage of website features may be associated with positive weight change, but we do not know what features improve this effect or reduce attrition.     

Impact of male‐only lifestyle interventions on men's mental health: A systematic review and meta‐analysis

Despite rising mental health problems worldwide, engaging men to seek mental health support is challenging. Male‐only lifestyle interventions have shown promise for improving men's physical health, but the overall impact of these programs on psychological outcomes is unclear. This review aimed to evaluate the impact of male‐only lifestyle interventions on men's mental health and to identify if any study or intervention features were associated with effectiveness. A systematic literature search with no date restrictions was conducted across four databases and returned 15 946 citations. Nine studies were eligible for inclusion, representing 1427 participants. Risk of bias was generally low across studies, although none were specifically powered to detect changes in mental health. Overall, significant group‐by‐time effects were reported for 26% of mental health outcomes examined. In the fixed‐effects meta‐analyses, small‐to‐medium intervention effects were observed for mental health–related quality of life (SMD = 0.24), self‐esteem (SMD = 0.51), and positive affect (SMD = 0.58). Insights into effective study or intervention features were limited because of the low number of heterogeneous studies. Although male‐only lifestyle interventions have improved men's mental health in some circumstances, studies that are specifically powered to detect long‐term changes are urgently required, particularly in groups with pre‐existing mental health concerns.     

Quality of Life and Technology: Impact on Children and Families With Diabetes

Ensuring quality of life (QOL) while maintaining glycemic control within targets is an important challenge in type 1 and type 2 diabetes treatment. For children with diabetes, QOL includes enjoying meals, feeling safe in school, and perceiving positive, supportive relationships with parents, siblings, and friends. Yet many treatment-related and psychosocial barriers can interfere with a child??s QOL and their ability to manage diabetes effectively. Diabetes management also imposes considerable lifestyle demands that are difficult and often frustrating for children to negotiate at a young age. Recent advances in diabetes medications and technologies have improved glycemic control in children with diabetes. Two widely used technologies are the insulin pump and continuous glucose monitoring (CGM) system. These technologies provide patients with more flexibility in their daily life and information about glucose fluctuations. Several studies report improvements in glycemic control in children with type 1 diabetes using the insulin pump or sensor-augmented pump therapy. Importantly, these technologies may impact QOL for children and families with diabetes, although they are rarely used or studied in the treatment of children with type 2 diabetes. Further, emerging closed loop and web- and phone-based technologies have great potential for supporting diabetes self-management and perhaps QOL. A deeper understanding and appreciation of the impact of diabetes technology on children??s and parents?? QOL is critical for both the medical and psychological care of diabetes. Thus, the purpose of this review is to discuss the impact of new diabetes technologies on QOL in children, adolescents and families with type 1 diabetes.     

Cardiac rehabilitation programmes: predictors of non-attendance and drop-out.

BACKGROUND: Despite evidence of its benefits, attendance at cardiac rehabilitation (CR) programmes is poor. Past studies to identify predictors of non-attendance have been limited by their small sample size, particularly for female patients. The present study was designed to identify socio-demographic and clinical predictors of non-attendance and drop-out separately for men and women automatically referred to CR programmes. METHOD AND SUBJECTS: Prospective study of CR programme attendance amongst 808 patients consecutively admitted over an 11-month period to one of two hospitals in Melbourne, Australia, after acute myocardial infarction (AMI), or to undergo coronary artery bypass graft surgery (CABGS) or percutaneous coronary intervention (PCI). RESULTS: Of the 652 eligible patients, 573 (88%) were successfully tracked at 4 months. Of these, 284 (49.6%) had attended a CR programme, while 272 (47.5%) had not. Using logistic regression, the significant predictors of programme non-attendance among men were having had a PCI, being a non-driver, and being aged 70 or more. The only factor predictive of non-attendance for women was being aged 70 or more. Amongst attenders, 67 (23.6%) patients discontinued the programme. Being a smoker, having diabetes and being unemployed at the time of hospital admission were predictive of programme drop-out by men. Being physically inactive at admission was predictive of programme drop-out by women. CONCLUSIONS: The present study demonstrated a relatively high rate of CR programme attendance. Special attention needs to be directed towards males who are older, PCI patients, smokers, unemployed or non-drivers, and females who are older or inactive.     

Interventions that involve parents to improve children's weight‐related nutrition intake and activity patterns – what nutrition and activity targets and behaviour change techniques are associated with intervention effectiveness?

Parent involvement is an important component of obesity prevention interventions. However, the best way to support parents remains unclear. This review identifies interventions targeting parents to improve children's weight status, dietary and/or activity patterns, examines whether intervention content and behaviour change techniques employed are associated with effectiveness. Seventeen studies, in English, 1998–2008, were included. Studies were evaluated by two reviewers for study quality, nutrition/activity content and behaviour change techniques using a validated quality assessment tool and behaviour change technique taxonomy. Study findings favoured intervention effectiveness in 11 of 17 studies. Interventions that were considered effective had similar features: better study quality, parents responsible for participation and implementation, greater parental involvement and inclusion of prompt barrier identification, restructure the home environment, prompt self‐monitoring, prompt specific goal setting behaviour change techniques. Energy intake/density and food choices were more likely to be targeted in effective interventions. The number of lifestyle behaviours targeted did not appear to be associated with effectiveness. Intervention effectiveness was favoured when behaviour change techniques spanned the spectrum of behaviour change process. The review provides guidance for researchers to make informed decisions on how best to utilize resources in interventions to support and engage parents, and highlights a need for improvement in intervention content reporting practices.