Two-year effects of the community-based overweight and obesity intervention program Gezond Onderweg! (GO!) in children and adolescents living in a low socioeconomic status and multi-ethnic district on Body Mass Index-Standard Deviation Score and quality of life

Abstract

Background: In most childhood obesity interventions, disadvantaged groups are underrepresented, and results are modest and not maintained. A long-term collaborative community-based approach is necessary to reach out to children from multi-ethnic backgrounds and achieve sustainable behavior change, resulting in sustained Body Mass Index-Standard Deviation Score (BMI-SDS) reductions. The objective is to determine the effects of GO! on BMI-SDS and Health-Related Quality of Life (HRQoL) for children and adolescents having overweight or obesity.

Methods: A prospective, longitudinal cohort study was used to collect two-year follow-up data from November 2014 to July 2019. Children and adolescents (4-19 years old) from the low socioeconomic status and multi-ethnic district of Malburgen in the Dutch city of Arnhem were included. 178 children having overweight or obesity were recruited, with 155 children measured at baseline and after two years as a minimum, while 23 were lost to follow up. Participants attending the program for over six months were defined as completers (n=107) and participants attending the program for less than six months were defined as non-completers (n=48). The child health coach (CHC) acts as a central care provider in the collaborative community with healthcare providers from both medical and social fields. This coach coordinates, monitors and coaches healthy lifestyles, while increasing self-management for both children and parents. This is done in a customized and neighborhood-oriented manner and provided by all the stakeholders involved in GO!. The main outcomes are the change in BMI-SDS scores and HRQoL scores reported by participants.

Findings: After 24 months, completers showed a decrease in BMI-SDS of -0·32 [95% CI: -0·42, -0·21], compared with -0·14 [95% CI: -0·29, 0·01] for non-completers (adjusted for gender and ethnicity; P=0.036). While 25% suffered from overweight and 75% from obesity at the start, following the intervention 5% showed normal weight, with 33% overweight and 62% with obesity. HRQoL reported by participants improved over time, showing no differences between completers and non-completers, gender and ethnicity after two years.

Interpretation: Our results suggest that the GO! program might be effective in reaching out and reducing BMI-SDS for participants in a low socioeconomic status and multi-ethnic district over a two-year period. We noticed also trends to beneficial shifts in obesity grades. HRQoL improved regardless of the participation rate, gender and ethnic background. In light of the study limitations, further studies are needed to corroborate our observations.

Funding: Dullerts-foundation, Nicolai Broederschap foundation, Burger en Nieuwe weeshuis foundation, Rijnkind foundation, Arnhems Achterstandswijken foundation, Menzis-foundation, the municipalities of Arnhem, Rheden, Overbetuwe and Lingewaard, the Association of Dutch municipalities, and Province of Gelderland.

Keywords: BMI-SDS; Childhood obesity; Collaborative community-based intervention; Health-related quality of life; Multi-ethnicity; Socioeconomic status.

Figure 1

Flow chart GO! showing the follow-up of participants over two years of time. Two groups were formed ‘completers’ and ‘non-completers’.

Figure 2

Description of the GO! intervention GO! schematically The GO! approach focuses on three levels: a) participants and parents level (individual level): in which the child health coach (CHC) acts as a central care provider aiming to increase self-management of both participants and parents, b) community level: in which healthcare professionals from both the medical and social fields work closely together to offer “on demand” personalized help. The CHC coordinates this process, c) neighborhood level: in which stakeholders in the direct environment of the participants and their parents adapt and stimulate a healthy lifestyle and develop activities such as cooking workshops and physical activity programs aimed at improving healthy eating and physical activity. Management and organization of GO! GO! lasts for two years and is free of charge for all participants. The implementation of GO! in a new community starts with a stakeholder analysis in close collaboration with local policymakers to identify potential collaborators in the (para)medical and social fields, and locally embedded activities stimulating healthy behavior. Suitable professionals are selected and trained for the GO! program during three sessions: referral criteria, communication (“how to talk about obesity”) and treatment protocols of the different disciplines are discussed. Emphasis is laid on network orientation and collaboration. Program team In each community, a local ambassador, two local coordinators - preferably from the paramedical and social field - and a CHC are selected. Either a “child” mayor or public role model in the field of sport/cooking may fulfill the local ambassador role. The local coordinators are responsible for promoting GO! in the community and organizing program team meetings during which the professionals and community stakeholders discuss the progress and points for improvement. Child health coaches CHCs are specifically selected and trained for their communicative and coaching skills and are responsible for signaling and tackling underlying problems that are often associated with obesity and hinder the adoption of a healthy lifestyle. During the first consultation with the CHC, the CHC explains the program and interviews the participant and the parents extensively to identify multi-problems in five areas: child factors, parental factors, environmental factors, healthy lifestyle and coping strategies. Motivational interviewing techniques play a pivotal role in referring participants to personalized, desired help. Subsequently, the CHC develops an appropriate plan of action in collaboration with the participant and his/her parents and professionals in the middle circle, depending on what is needed. The CHC also monitors whenever the timing is right for healthy lifestyle coaching. Lifestyle coaching Itself is fully customized. The CHCs use the child friendly and appealing handbook in which both the theoretical framework and practical tools for the topics healthy food, physical activity, rest and sleeping habits and cognitive behavior techniques are depicted. All consultations are held in the direct surrounding of the participants. At the start, the CHC meets face to face on a weekly basis, then every two weeks, then monthly and - if successful - quarterly. During the second year, the CHC monitors the maintenance of behavioral changes. Multi-disciplinary consultation (MDC) Complex cases that are unable to reach their healthy lifestyle goals, or where there is a suspicion of multi-problems, are discussed by the CHC according to a protocolled format during a multi-disciplinary consultation, preferably in the presence of the parents (four times a year). Underlying causal problems are mapped and a plan of action is made. After six months, evaluation takes place.

Figure 3a

Shifts in obesity grades of the completers at T24, compared to T0. Overweight is defined as an adult equivalent BMI≥25 and obesity grade 1,2,3 as respectively adult equivalent BMI ≥ 30, 35 and 40. 1 grade up means for example a shift from overweight to grade 1 or a shift from grade 1 to obesity grade 2.

Figure 3b

Shifts in obesity grades of the non-completers at T24, compared to T0. Overweight is defined as an adult equivalent BMI ≥25 and obesity grade 1,2,3 as respectively adult equivalent BMI ≥ 30, 35 and 40. 1 grade up means for example a shift from overweight to grade 1 or a shift from grade 1 to obesity grade 2.

Figure 4a

BMI-SDS values presented over time for girls and boys in the completers and non-completers, including the standard error. Results are presented as predicted means plus standard errors based upon the fitted mixed linear model for BMI-SDS. All values are adjusted for ethnicity. *Significantly different compared to the measurement at 0 months (T0) (p<0.05).

Figure 4b

Reported total Health Related Quality of Life by girls and boys in the completers and non-completers at five different timepoints. Results are presented as predicted means plus standard errors based upon the fitted generalized linear mixed model for HRQoL. For boys in the non-completers group no data was available at T3 and T6. *Significantly different compared to the measurement at 0 months (T0) (p<0.05).