A pragmatic evaluation of a family-based intervention for childhood overweight and obesity
Authors: Law Catherine , Cole Tim , Cummins Steven , Fagg James , Morris Stephen , Roberts Helen 
Published: October 2014

BackgroundChildhood overweight is unequally distributed by ethnicity and socioeconomic circumstances. Weight management interventions are moderately effective under research conditions. We evaluated the Mind, Exercise, Nutrition, Do it! (MEND) 7–13 programme, a multicomponent family-based intervention for children aged 7–13 years who are overweight or obese. The programme was tested in a randomised controlled trial (RCT) and then delivered at scale under service conditions.ObjectivesThe aims of this study were to describe the characteristics of children who take part in MEND, when implemented at scale and under service conditions; assess how the outcomes associated with participation in MEND vary with the characteristics of children (sex, socioeconomic circumstances and ethnicity), MEND centres (type of facility, funding source and programme group size) and areas where children live (in relation to area-level deprivation and the obesogenic environment); examine the cost of providing MEND, per participant, to the NHS and personal social services, including how this varies and how variation in cost is related to variation in outcome; evaluate the salience and acceptability of MEND to those who commission it, those who participate in full, those who participate but drop out and those who might benefit but do not take up the intervention; and investigate what types of costs, if any, are borne by families (and by which members) when participating in MEND, and in sustaining a healthy lifestyle afterwards.Data and methodsWe compared the sociodemographic characteristics of all children referred to MEND (‘referrals’,n = 18,289), those who started the programme (‘starters’,n = 13,998) and those who completed it (‘completers’,n = 8311) with comparable overweight children in England. Associations between participant, programme and neighbourhood characteristics and change in body mass index (BMI) and other outcomes associated with participation in MEND 7–13 were estimated using multilevel models. Economic costs were estimated using published evaluations in combination with service data. We used qualitative methods to explore salience and acceptability to commissioners (n = 27 interviews) and families (n = 23 family interviews and eight individual interviews), and costs to families.FindingsLess than 0.5% of children eligible for MEND were referred to, participated in or completed the programme. Compared with the MEND-eligible population, proportionally more MEND 7–13 starters and completers were girls, Asian or from families with a lone parent, and lived in social or private rented rather than owner-occupied accommodation, in families where the primary earner was unemployed, and in urban and deprived areas. Compared with the MEND-eligible population, proportionally less MEND 7–13 starters and completers were white or from ‘other’ ethnic groups. Having started the programme, boys and participants who were psychologically distressed, lived in socioeconomically deprived circumstances, or attended large groups or groups whose managers had delivered several programmes were less likely to complete the programme.Multilevel multivariable models showed that, on average, BMI reduced by 0.76 kg/m2over the period of the programme (10-week follow-up). BMI reduced on average in all groups, but the reduction was greater for boys, as well as children who were of higher baseline BMI, younger, white or living in less socioeconomically deprived circumstances, and for those who attended more sessions and participated in smaller programmes. BMI reductions under service and RCT conditions were of a similar order of magnitude. Reported participant self-esteem, psychological distress, physical activity and diet improved overall and were also moderated by participant-, family-, neighbourhood- and programme-level covariates.Based on previous studies the cost per programme was around £4000. The mean cost per starter is £463 and the mean cost per completer is £773. The estimated costs varied according to costs associated with local programmes and MEND Central (the organisation which sells MEND interventions to commissioners and delivery partners), and the number of participants per programme.Commissioners liked the fact that the programme was evidence-informed, involved families and was ‘implementation-ready’. However, recruitment and retention of families influenced their view on the extent to which the programme offered value for money. They wanted longer-term outcome data and had concerns in relation to skills for delivery to diverse populations with complex health and social needs.At least one individual in every family felt that participation in MEND had been beneficial, but few had managed long-term change. Most families had self-referred via the mother on the basis of weight concerns and/or bullying and anxiety about the transition to secondary school. Exercising with others of a similar build, tips for parents and cooking lessons for children were all valued. Less positively, timings could be difficult for parents and children, who reported competing after-school activities, and feeling tired and hungry. Getting to venues was sometimes difficult. Although families described liking the facilitators who delivered the programme, concerns were expressed about their skills levels. Engagement with the behaviours MEND recommends was challenging, as were the family dynamics relating to support for participants. The costs families mostly associated with the programme were for higher quality food or ‘treats’, time and transport costs, and the emotional cost of making and maintaining changes to lifestyle behaviours generally unsupported by the wider environment.ConsiderationsFurther research should focus on the sustainability, costs (including emotional costs to families) and cost-effectiveness of behaviour change. However, weight management schemes are only one way that overweight and obese children can be encouraged to adopt healthier lifestyles. We situate this work within a social model of health with reference to inequalities, obesogenic environments, a lifecourse approach and frameworks of translational research.FundingThe National Institute for Health Research Public Health Research programme.