13. Personalised Approach to Obesity Management in Children

Cardiovascular diseases (CVDs) are a leading cause of death, comprising approximately half of all non-communicable disease (NCD) deaths (Benziger, Roth and Moran, 2016[1]). One of the primary determinants of CVD is obesity, as well as its associated comorbidities (diabetes, hypertension). In 2018, almost 60% of people in OECD countries were overweight, and 25% were obese (OECD, 2019[2]). The adoption of unhealthy behaviours leading to the development of CVD risk factors takes place in early childhood (Peñalvo et al., 2013[3]). However, obesity is largely preventable, highlighting the importance of effective health promotion early on in the life course.

The PAOMC intervention in Estonia is a family-based paediatric obesity intervention targeting children aged 7-17 years with pre-obesity (i.e. overweight) or obesity. The study included 58 children in Tallinn and the surrounding Harju County, and largely took place in the Tallinn Children’s Hospital outpatient clinic. During the intervention, families received education materials, and a personalised assessment of both the parents’ and children’s lifestyle behaviours, as well as of their willingness to change. Moreover, the children received personal counselling, physical activity (PA) assessments and sessions (such as hikes, outdoor exercise activities and gym training), attended bi-weekly education sessions (PA and diet), and set lifestyle goals for a 12 month period.

Children were referred to PAOMC through their family doctor (general practitioner (GP)), general paediatricians, and endocrinologists or by other family initiatives.

This section analyses PAOMC against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence-base and Extent of coverage (see Box 1.1 for a high-level assessment of PAOMC). Further details on the OECD Framework can be found in Annex A.

The PAOMC intervention was generally successful in improving participants’ anthropometric measurements and PA levels. Prior to the intervention, 93% of the children selected for the intervention lived with obesity (BMI ≥ 95 percentile) and 7% with pre-obesity (BMI 85-95 percentile) (Suurorg et al., 2017[4]). Two years after the intervention, 42% had decreased their BMI category, 58% had experienced weight loss, 70% had shown participation in PA sessions, 94% had seen improvements in their sit-up tests and 65% in their six-minute walking test. Nonetheless, 27% did not experience any weight change and 15% saw an increase in weight (Suurorg et al., 2017[4]).

While a comparison can only be carried out at the high-level, given that studies may have used different methodologies and that, across studies, target populations an activities within the intervention may not be fully comparable, the results from the PAOMC intervention seem to be greater than those of similar family-based clinical childhood obesity interventions. Indeed, the Families for Health trial in the United Kingdom, a family-based childhood obesity treatment intervention in a primary care setting, did not result in significant differences in BMI z-score at 12 months between the intervention and control groups (Robertson et al., 2017[5]). Moreover, the High Five for Kids study (also a primary care-based childhood obesity prevention intervention) in the United States was shown to have non-significant change in participants’ BMI (p = 0.15) (Wright et al., 2014[6]). These results point to the potential of the PAOMC programme and underline the importance of comprehensive, family-based and personalised obesity interventions in childhood.

Drawing upon OECD analysis, the potential impact of expanding PAOMC to the national level can be estimated. Specifically, OECD’s 2019 obesity report shows that PA and nutrition interventions targeting school-children could avoid over 65 cases of CVD and 149 cases of diabetes in Estonia between years 2020-50 (OECD, 2019[2]). An additional 0.11 life years (LYs) and 0.98 disability-adjusted life years (DALYs) could also be gained in Estonia per 100 000 people annually from 2020-50. These figures might provide an indication of the potential of the PAOMC programmed if scaled-up in Estonia to a national level. However, the results focus on school-based obesity programmes, rather than on family-based, clinical paediatric obesity interventions, and therefore a range of precautions must be taken in interpreting results.

Publically available information on the costs of operating PAOMC show the intervention’s overall budget is approximately EUR 25 000 (USD PPP 36 547) per year (Kramer and Suurgorg, 2017[7]). However, it is unclear how many children this covers, therefore a cost per participant is not available.

An analysis of school-based programs designed to reduce rates of overweight and obesity by the OECD can shed light on the potential effect of interventions such as PAOMC. OECD estimates that heathy lifestyle programs targeting school-aged children lead to health expenditure savings of USD PPP 0.01 (EUR 0.01) per capita in health expenditure annually, during the first 30 years after implementation (OECD, 2019[2]). The main reason behind this result is that health care expenditure for NCDs is small in children and young adults due to low incidence rates. Across the whole population, this translates into annual health expenditure savings of USD PPP 12 113. It is expected that in the long term, when children targeted by the intervention reach their 50s’, the impact of the intervention may become larger. Finally, caution should be taken when interpreting these results given PAOMC is implemented in a primary-care setting while OECD analysis relies on findings from school-based interventions.

PAOMC does not directly target a priority population group however it addresses a health issue that disproportionately affects children from lower-income households. In Estonia, the proportion of children with pre-obesity or obesity was 26% for those in the poorest quintile compared to 18% in the highest quintile (OECD/European Union, 2018[8]). Nevertheless, obesity interventions delivered in a primary care setting may be less likely to reach children living in less affluent families which risks widening existing health inequalities (OECD, 2019[9]). For example, analysis by OECD estimates that after adjusting for needs, in Estonia, 64% of people in the lowest income quintile accessed a GP in the past year compared to 72% in the highest quintile (OECD, 2019[9]).1

It is unclear from the available information whether specific efforts were made to ensure other disadvantaged groups, such as children from different ethnic backgrounds or with a low socio-economic status, accessed PAOMC.

A cross-sectional, observational study was used to evaluate PAOMC. Measures were taken for anthropometric markers (BMI, height, weight, waist circumference) and physical fitness levels (6-minute walking test and sit-up test), although no information is available on the mediums used. The childrens’ and parents’ desire for behavioural lifestyle change was assessed by the WHO Visual Analogue Scale (VAS) and self-reported questionnaires. Dietary and PA behaviours were determined through assessments led by physicians, surveys and the Yale food addiction scale, a self-reported questionnaire (Suurorg et al., 2017[4]). The use of these tools by qualified health professionals increase the reliability and validity of the evaluation results. For these reasons, the data collection methods used to evaluate PAOMC are considered “strong” against the Quality Assessment Tool for Quantitative Studies framework (see Table 1.1) (Effective Public Health Practice Project, 1998[10]).

The method used to evaluate PAOMC also performed well in regard to the study design as well as reducing selection bias. However, similar to many public health interventions, neither participants nor researchers were blinded, therefore the study is considered “weak” in this area. Further, it was unclear if researchers controlled for confounders.

There is no publically available evidence to measure participation or dropout rates for PAOMC. However, data on the probability of visiting a GP in the last 12 months is available, which provides a conservative insight into how many children could access PAOMC if it were scaled-up across the whole of Estonia (given children and adolescents can be referred by their GP to PAOMC).

By multiplying the probability of a GP visit in the last year2 by the number of children aged 7-17 years with pre-obesity or obesity, it is estimated that 18 776 children could be referred to PAOMC via their GP if it were scaled-up across the country (out of 30 285 who are eligible) (Statistics Estonia, 2020[11]; WHO, 2016[12]; Eurostat, 2019[13]).3

The PAOMC intervention fits many of the overarching best practice criteria in terms of clinical, family-based childhood obesity programmes. The trial is a comprehensive programme involving the family and wider support networks, which strongly targets both diet and PA. Moreover, it focuses on behaviour change at the family and individual level.

Literature on best practices in this field underlines the importance of obesity counselling, education and behavioural therapy in addition to nutrition and exercise (Mead et al., 2017[14]). However, it is important to note that many of these policies fall outside the responsibilities of programme administrators and instead require input from higher-level policy makers (e.g. at the national level). Nonetheless, in upscaling or adapting this intervention, further emphasis on motivational interviewing (MI), positive reinforcement, monitoring, and cognitive restructuring could be considered to enhance effectiveness (Davis et al., 2007[15]). Indeed, a systematic review of the treatment of paediatric obesity found that multicomponent interventions targeting not only diet and PA, but which also included a strong emphasis on behavioural therapy and education achieved the most significant outcomes in terms of reductions in systolic and diastolic blood pressure, BMI, and triglycerides (Rajjo et al., 2017[16]). Moreover, a meta-analysis of the effectiveness of MI concluded that this practice could lead to up to 51% improvement rates in the treatment of problem behaviours (Burke, Arkowitz and Menchola, 2003[17]). MI can help induce behaviour change through guiding individual reflection, as participants are more likely to accept and act on opinions, which they have voiced themselves. Furthermore, shifting participants’ thinking patterns and managing their expectations can lead to higher adherence to dietary change (Burke, Arkowitz and Menchola, 2003[17]).

Efficiency is calculated by obtaining information on effectiveness and expressing it in relation to inputs used. Therefore policies to boost effectiveness without significant increases in costs will have a positive impact on efficiency.

To enhance equity, to the extent possible, programme administrators are encouraged to undertake a review to determine whether the intervention should be adapted to meet the needs of priority population groups. In order to better understand how different groups of participants benefit from the intervention, future evaluations should break down key indicators, for example, by family socio-economic status and ethnicity. Finally, additional effort to recruit families and children from groups which have lowers level of access to health care is important, particularly if these groups have higher rates of obesity (as outlined under “Efficiency”, nearly 40% of children in the lowest income quintile won’t access a GP and therefore have the opportunity to be referred to PAOMC).

To enhance the evidence-base, future evaluations could consider using a blinded randomised study design if considered ethical in order to better understand the true effect of PAOMC. A longer follow-up would also improve the validity of evaluation results, for example, by collecting data 12 months after the intervention has finished. Moreover, alternatives to questionnaires could be considered to assess dietary and PA habits, as well as behaviour change willingness. Indeed, in order to assess the long-term impact (e.g. after 10 years) of PAOMC on rates of obesity and overweight, it is necessary to gather data according to the same measures, and when possible, with the same individuals (i.e. panel data). Longitudinal panel data is deemed to be the “gold standard”, given that it reduces bias by accounting for differences amongst individuals. However, as this requires long-term funding and support, responsibility for this option lies with high-level policy makers, rather than with the PAOMC study group.

Given limited information on the extent of coverage for PAOMC, specific polices to boost uptake have not been included. However, in general, efforts to boost health literacy amongst children and parents are likely to increase motivation to participate in programs such as PAOMC.

This section explores the transferability of PAOMC and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publically available data; and 3) additional considerations for policy makers interested in transferring PAOMC.

To date, PAOMC has not been transferred outside of Estonia, however various personalised obesity intervention targeting children and adults exist. For example, Sweden’s Prescription on Physical Activity (see Chapter 4) intervention is in the process of being transferred to several EU countries.

The following section outlines the methodological framework to assess transferability and results from the assessment.

Details on the methodological framework to assess transferability can be found in Annex A. Indicators from publically available datasets to assess the transferability of PAOMC are listed in Table 1.2. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.

Results from the transferability assessment of PAOMC in Estonia to OECD and non-OECD EU countries are in Table 1.3. Overall, PAOMC is likely to have political support from countries given nearly all countries have a specific strategy targeting childhood obesity. In addition, most countries with available data (77%) have either implemented or foresee implementing programs to support physical activity counselling by health professionals indicating greater levels of workforce acceptability of PAOMC (i.e. given the health profession will be more accustomed to providing this service). Data on remaining indicators shows mixed results, further, for these indicators there are high levels of missing data in non-European countries.

To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 13.3. Countries in clusters with more positive values have the greatest transfer potential. For further details on the methodological approach used, please refer to Annex A.

Key findings from each of the clusters are below with further details in Figure 1.1 and Table 1.4:

  • Countries in cluster one have population, sector specific, economic and political arrangements in place that support transferring PAOMC, and therefore are less likely to experience implementation barriers.

  • The majority of countries fall under cluster two, which have political policies in place that support PAOMC. However, prior to transferring PAOMC, countries may wish to consider increasing funding for primary care to ensure the intervention is affordable in the long term. It is important to note that Estonia, which currently operates PAOMC, is in this cluster, indicating although ideal, high levels of spending on primary care is not a pre-requisite for transferring PAOMC.

  • Remaining countries are in cluster three, where spending on primary care is high, yet changes to the population, sector specific and political contexts may need to be addressed to ensure a successful transfer. For example, by ensuring health professionals receive training on how to lead a healthy lifestyle in countries such as Greece.

Data from publically available datasets is not ideal to assess the transferability of PAOMC. Therefore, Box 1.2 outlines several new indicators policy makers should consider before transferring PAOMC.

Over the course of the past three decades, there has been a significant increase in the prevalence of overweight and obesity worldwide. The adoption of inadequate lifestyle behaviours leading to situations of obesity or overweight takes place in early childhood (Peñalvo et al., 2013[3]).The PAOMC intervention seeks to counter such behaviours through a personalised, family-based, paediatric obesity programme in a primary care setting.

The results from this study show that the intervention was successful in positively impacting anthropometric measurements and PA levels amongst children. Details on the intervention’s efficiency were not publically available, however, previous OECD analysis indicates obesity management interventions targeting school-aged children are cost-effective, but produce a population-level impact only in the long-term. The data used to evaluate the effectiveness of PAOMC was derived from a cross-sectional, observational study, which is rated as weak evidence. PAOMC did not directly target a priority population group, nevertheless, it has the potential to reduce health inequalities given it targets a risk factor which disproportionately affects lower-SES children.

PAOMC includes many characteristics considered essential for a successful family-based, clinical obesity interventions in primary care settings. However, further changes, such as incorporating additional behaviour therapy and obesity counselling sessions, could be considered to achieve the intervention’s core objective: reducing obesity and overweight, and improving overall lifestyle behaviours among children in Estonia.

Finally, PAOMC addresses childhood obesity, which is of key political interest, further, it is likely to be supported by health professionals as they are accustomed to providing this type of treatment. Nevertheless, the success of PAOMC in the target setting will depend on a range of contextual factors, in particular, the willingness and ability of GPs and paediatricians to provide children and their parents with obesity related advice.

Box 1.3 outlines next steps for policy makers and funding agencies regarding the PAOMC intervention.


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← 1. Data is for the adult population, parents and non-parents. Nevertheless, it has been used as it is assumed parents, in most cases, are responsible for their child’s health care appointments.

← 2. Data is only available for those aged 15-19 years.

← 3. Estimated population aged 7-17 in Estonia = 156 106 * proportion of children with pre-obesity or obesity in Estonia = 19.4% * the probability of visiting a GP in the past year = 62%. Population data is only available by age groups which don’t identically align with 7-17, therefore the average was used.

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