Early intervention to prevent childhood obesity: Healthy Beginnings – a RCT
HEALTHY BEGINNINGS is a randomised control trial funded by the National Health and Medical Research Council. It involved an early family-focused intervention addressing the prevention of overweight and obesity in early childhood. The study aimed to compare the effect of an intensive, home-based early intervention for first-time mothers of newborn babies, versus usual care, on child and family eating patterns, television viewing, opportunities for physical activity and anthropometric measures.
From March 2007 – March 2008 first time mothers who elected to have their babies at Campbelltown and Liverpool Hospitals were approached through antenatal classes and antenatal clinics, informed of the project, and asked if they would like to participate. Posters and flyers were also used as part of the recruitment process. All aspects of the program were explained to the participant and if interested in participating, they verbally consented to a home visit for informed consent, randomisation, initial data collection and intervention.
The intervention group consisted of eight home visits from a specially trained research nurse delivering a staged intervention beginning in the antenatal period, and then at one, three, five, eight, 12, 18 and 24 months. The timing of the visits was designed to coincide with early childhood developmental milestones, particularly with regards to feeding practices, nutrition and physical activity, and parent-child interactions.
The control group families received the usual childhood nursing service as provided by SSWAHS, comprising one home visit by a community nurse within a month of birth plus possible baby clinic visits. However, for study participants in the control group there were additional visits at 12 and 24 months for the purpose of data collection only, they also received injury prevention information.
To assess the effectiveness of the project, data collection took place on four occasions during the two years of the program. Data was collected on various nutrition measures (breastfeeding, introduction of solids, serving size and food intake, parent-child feeding interaction, the continuation of offering milk in a bottle beyond 12 months, the provision of high sugar fruit juices or soft drinks), physical activity, parent’s knowledge of and attitudes towards childhood obesity, partner and family support, family functioning and demographics. The weight, length and waist circumference of the child were also measured.
The unique aspects of the study are that it was the first randomised controlled trial (RCT) anywhere to look at the effect of Intensive Home-Based Intervention delivered by a nurse on outcomes at two years relevant to overweight and obesity in young children.
The development of the intervention was informed by a pilot program. This pilot program was based on existing clinical practice of home visiting nurses and a literature review of the epidemiology of overweight in early childhood and also dietary intake and physical activity in young Australian children. This highlighted key risk factors to address.
Also informing the intervention was expert advice and direction from a planning reference group consisting of all chief and associate study investigators and input from researchers with critical experience in delivering nurse-based home interventions, nutrition expertise, psychologists, occupational therapists and other external experts.
Key guiding documents and web sites included:
- Australian Breastfeeding Association
- Australian Parenting website
- Department of Health and Ageing
- Food Standards Australia and New Zealand
- National Health and Medical Research Council
- The Dietary Guidelines for Children and Adolescents in Australia NHMRC 2003
- The Dietary Guidelines for Adults in Australia NHMRC 2003
- World Health Organisation
- Zero to Three: National Center for Infants, Toddlers and Families 2009
A literature search informed the play component of the program and was developed in consultation with Occupational Therapists. For more information see the study protocol.
Nurse training for the project
Nurses were trained in a number of areas prior to commencing the home visits with study participants. These included:
- Project orientation, research protocol, evidence based practice, qualitative data collection, open ended questioning
- Family partnership training, which was essential as the delivery of the intervention closely followed the fundamental principals of this training, developing a respectful partnership between the parents and nurse which is fundamental in facilitating any change
- Tresillian training including: a review of early brain development, overview of attachment, review of infant states, infant cues, state modulation making links to feeding and sleep behaviour, strategies to work with parents
- Performing anthropometric measurements
- Nutrition, including: infant feeding, introduction of solids, water as main other drink, cup feeding, serving sizes, fruit & vegetables, family food, reading labels, healthy snacks
- Australian breastfeeding association guidelines
- Grief and loss in the peri natal period
- Play training
- Child protection
- Food security
- Pre and postnatal exercises with physiotherapist
- Physical activity training including stages of change model and motivational training
Delivery of intervention
At each home visit, the research nurses addressed four key areas:
- infant nutrition
- your baby and physical activity
- your physical activity and nutrition
- social support
Each visit consisted of a set of standard information with key discussion points for each area and appropriate resources to reinforce the information. A checklist for each visit was developed to ensure all information was covered.
The visits took place face to face in the participant’s home and ranged in length from 45 – 90 minutes. At each visit, the research nurse engaged the participant in a number of key discussion areas. There was no set order for discussion, each visit was participant led. If discussion was outside the project protocol this information was recorded and any necessary referrals would take place.
Five key messages were developed:
- “Breast is best”
- “No solids for me until 6 months”
- “I eat a variety of fruit and vegetables everyday”
- “Only water in my cup”
- “I am part of an active family”