Prevention of obesity through home visiting up to the age of 2 yearsBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3931 (Published 26 June 2012) Cite this as: BMJ 2012;344:e3931
- 1Bar Ilan Faculty of Medicine in the Galilee, Israel
- 2University of Leeds and Leeds Community Healthcare Trust, UK
In the United Kingdom, a quarter of children are already overweight by the time they start school at the age of 5 years.1 Primary prevention therefore needs to start well before school age, particularly because heavy babies and rapid weight gain at this time are associated with the development of obesity later in life.2 Yet most research efforts are still focused on school aged children.3 In the linked study (doi:10.1136/bmj.e3732), however, Wen and colleagues have carried out a trial of an intervention programme aimed at infants.4
The study is important for two reasons: firstly, because the authors show that it is possible to engage young mothers, at least in Australia, in an obesity prevention programme during pregnancy; and, secondly, for the results they have achieved. They report that babies who participated in the intervention had lower body mass index (BMI) measures at the age of 2 years than those in the control group. They also found measurable differences in vegetable consumption, using food for reward, TV viewing, and mothers’ lifestyles.
The literature suggests that the medical model whereby health professionals instruct patients on a course of action is limited in its value as a motivator for change.5 Yet the programme used by Wen and colleagues—Healthy Beginnings—adopted a very structured approach where each visit followed a set agenda and parents were “taught” about healthy infant child rearing practices. The focus was on specific messages: “breast is best,” “no solids for me until 6 months,” “I eat a variety of fruit and vegetables every day,” “only water in my cup,” “I am part of an active family.” Parenting skills and style were not identified as key components, so whether the programme equips parents to face the challenges of maintaining a healthy lifestyle once children reach a more independent and opinionated stage of life is yet to be seen.
Despite its structured approach, the programme is one that cannot easily be taken “off the peg.” The training was extensive and provided the nurses with in depth expertise about early childhood development—emotional as well as psychomotor, a framework for observing infant behaviour, modulation techniques, and research methodology, as well as healthy family lifestyle behaviours.
It is no mean task to conduct a randomised controlled trial of this nature. More than 600 mothers were recruited in just 12 months from socially disadvantaged areas in Sydney; the 75% retention rate across both groups is an achievement in itself. The anthropometric findings, presented as change in BMI (rather than BMI z scores as is usual in children), are equivalent to less than half a centile space on the UK 1990 BMI charts. It is too early to say if this is clinically significant and whether the differences will translate into a long term reduction in obesity. Encouragingly, there was a trend towards fewer children in the intervention group being overweight or obese. Alongside the anthropometric measures, there were differences in eating behaviour and time spent watching TV or playing computer games, which are hugely important, because these early lifestyle habits track into later childhood and beyond.6
The study raises a number of questions. Several factors in pregnancy are now thought to be associated with child obesity,7 and some, such as nutritional quality of the diet, smoking, and weight gain, are potentially modifiable. Might we do better by starting to intervene even earlier in life? Pregnancy is a time when many women adopt healthier habits to benefit their unborn child, so programmes like Healthy Beginnings might consider yet earlier intervention. The researchers might also consider extending its remit beyond first time mothers. Contrary to expectation we have found that mothers with older children may be especially open to receiving support, particularly if their previous children have had excess weight gain or eating problems.8
The question of cost is important. Eight home visits over 24 months is not an insignificant call on resources. The UK Healthy Child Programme (the national health promotion programme) has been reduced to essentially three health reviews in the first two years.9 The concept of a universal programme offering eight home visits is far beyond the scope of current health visiting services. If nothing else, this trial indicates that tackling primary prevention of obesity requires considerable investment in time, training, and resources.
Wen and colleagues’ study shows that it is possible to conduct a randomised controlled trial of a home intervention and achieve promising results. Follow-up of the cohort in the long term is essential to see if the intervention results in a measurable reduction in obesity and morbidity. In the meantime, it is becoming clear that if we are to work towards primary prevention of obesity through interventions in the early years we need highly trained staff with adequate time and resources to work effectively with mothers of infants.
Cite this as: BMJ 2012;344:e3931
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; MR is academic lead for HENRY, Health Nutrition for the Really Young, a training organisation that aims to help community and health professionals work more effectively around obesity prevention, and she is co-principal investigator of EMPOWER, a specialist health visitor intervention for babies at high risk of obesity.
Provenance and peer review: Commissioned; not externally peer reviewed.