AReportforthePickYourPartners PartnershipsinHealthResearchGrant

ResearchAroundPracticein ChildhoodOverweight/Obesity
TheRAPICOIpswichModel

AnneA.Poulsen JoleenTirendi RobertBush DouneMacdonald GaryM.Leong JennyZiviani MatthewA.Brown RebeccaAbbott July2009

PreparedbytheHealthyCommunitiesResearchCentre,TheUniversityofQueensland

Acknowledgements This report was prepared by The Healthy Communities Research Centre (HCRC), in collaboration with The University of Queenslands (UQ) Diamantina Institute for Cancer, Immunology and Metabolic Medicine, Institute for Molecular Bioscience (IMB), School of Health and Rehabilitation Sciences, School of Human Movement Studies, and the Ipswich and West Moreton communities. The Pick Your Partners (PYP) steering committee provided advice, guidance and support in all aspects of the project. The steering committee members were: Professor Robert Bush Professor Doune Macdonald Dr Gary M. Leong Associate Professor Jenny Ziviani Professor Matthew A. Brown Dr Rebecca Abbott The PYP project team acknowledges the valuable contribution of the following practitioners and researchers who shared their clinical and research experiences in forwarding their vision to foster research-based practice at the genetic, family and community levels to decrease the risk of childhood overweight and obesity: Mr Jeremy Barker, The University of Queensland, Qld Facility for Advanced Bioinformatics, Institute of Molecular Bioscience Michael Beohm, Scouts Queensland Associate Professor Mark Brown, The University of Queensland, Faculty of Health Sciences Professor Helen Chenery, The University of Queensland, Faculty of Health Sciences Dr Gary Cowin, The University of Queensland, Centre for Magnetic Resonance Professor Lynne Daniels, School of Public Health, Queensland University of Technology Dr Patrick Danoy, The University of Queensland, Institute of Molecular Bioscience Associate Professor Peter Davies, The University of Queensland, Childrens Nutrition Research Centre Peter Doyle, Brassall State Primary School Russell Franklin, Scouts Queensland Helaine Freeman, Ipswich & West Moreton Division of General Practice Professor Graham Galloway, The University of Queensland, Centre for Magnetic Resonance Dr John Gavranich, Department of Paediatrics, Ipswich Hospital James Graham, BMedical Health Equipment Suppliers Dr Trish Glasby, Department of Education, Training & the Arts, Queensland Government Dr Mark Harris, Department of Endocrinology, Mater Childrens Hospital Marion Hogg, West Moreton South Burnett Health Service District Associate Professor Karam Kostner, Department of Cardiology, Mater Adult Hospital 1

Wendy Kastelein, Child Health, Ipswich Community Health Maurice Law, Scouts Queensland Associate Professor Amanda Lee, Health Promotion Unit, Queensland Health Dr David Marshall, The University of Queensland, Healthy Communities Research Centre Dr Mike McGill, Department of Paediatrics, Ipswich Hospital Dr Bob McGregor, Paediatrician, Ipswich Stacey Menear, The University of Queensland, Healthy Communities Research Centre Ken Millers, Scouts Queensland Associate Professor Geoff Mitchell, The University of Queensland, School of Medicine; and General Practitioner, Ipswich Professor George Muscat, The University of Queensland, Institute of Molecular Bioscience Sharon Oxenbridge, Ipswich & West Moreton Division of General Practice Liz Paul, West Moreton South Burnett Health Service District Noelene Schultz, Young Peoples Health, Ipswich Community Health Professor Michael Waters, The University of Queensland, Institute of Molecular Bioscience Associate Professor Jon Whitehead, The University of Queensland, Diamantina Institute for Cancer, Immunology and Metabolic Medicine Simon Wright, Education Queensland Dr Jim Varghese, Springfield Land Corporation Tom Yates, Ipswich Hospital Foundation Funding Funding was provided by The University of Queenslands Partnerships in Health Research Grant in 2008. The project team gratefully acknowledges the Faculty of Health Sciences and the Institute for Molecular Bioscience for providing seed funding to establish this partnership between the Faculty, Schools, Centres and Institutes. The Healthy Communities Research Centre provided infrastructure support to enable the project to be carried out in the Ipswich region of South-East Queensland.

The Authors Anne A. Poulsen PhD, BOccThy (Hons) The University of Queensland, Healthy Communities Research Centre, Ipswich, Faculty of Health Sciences Joleen Tirendi BA (Sociology) The University of Queensland, Healthy Communities Research Centre, Ipswich, Faculty of Health Sciences Doune Macdonald PhD, BHMS (Ed) (Hons) The University of Queensland, School of Human Movement Studies, Faculty of Health Sciences Robert Bush PhD, BA (Hons) The University of Queensland, Healthy Communities Research Centre, Ipswich, Faculty of Health Sciences Gary M. Leong MBBS, FRACP, PhD The University of Queensland, Institute for Molecular Bioscience; and Department of Paediatric Endocrinology and Metabolism, Mater Childrens Hospital, South Brisbane Jenny Ziviani PhD, BAppSc(OT), BA, Med The University of Queensland, School of Health and Rehabilitation Sciences, Faculty of Health Sciences Matthew A. Brown MBBS, MD, FRACP The University of Queensland, Diamantina Institute for Cancer, Immunology & Metabolic Medicine Rebecca Abbott PhD, B Nut Diet (Hons) The University of Queensland, School of Human Movement Studies, Faculty of Health Sciences

Contents

Acronyms Executive Summary Introduction Part I 1.0 Childhood overweight and obesity 1.1 The extent of the issue 1.2 Prevalence rates in Ipswich and West Moreton regions 1.3 Significance of the issue 1.4 Need for coordinated preventive, promotional and clinical actions 2.0 Levels of risk 2.1 Risk Profiles 2.2 Environmental risk factors 2.3 Child level risk factors Part II 3.0 Community-research partnerships 3.1 Program theory 3.2 Logic models 3.3 Benefits of a logic approach 3.4 Diffusion of Innovations 3.5 National campaigns and local initiatives 4.0 Research around Practice in Childhood Overweight/Obesity (RAPICO) 4.1 The RAPICO-Ipswich Model 4.2 Goal Hierarchy 4.3 Research Around Practice (RPM) Logic Wheel Part III 5.0 Summary of Recommendations References

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Figures Figure 1. Logic model for community-research partnerships Figure 2. RAPCIO-Ipswich goal hierarchy Figure 3. Research Practice Model (RPM) 21 25 27

Acronyms ABS AT BMI CCRE GP HCRC HPE IMB MVPA NHMRC NSW PYP RAPICO-Ipswich SES UQ WA WHO Australian Bureau of Statistics Active Travel Body Mass Index Clinical Centre of Research Excellence General Practitioner Healthy Communities Research Centre Health and Physical Education Institute for Molecular Biology Moderate to Vigorous Physical Activity National Health and Medical Research Council New South Wales Pick Your Partners research grant Research around Practice in Childhood Obesity Ipswich Socioeconomic status The University of Queensland Western Australia World Health Organisation

Executive Summary This report describes the rationale, evidence and modelling of multi-level crosssectoral responses to obesity prevention and interventions for children in local communities. It advocates for interventions to be informed through a strong alliance between practitioners and researchers. The field work for this report was undertaken in the City of Ipswich although the research around practice model presented has wider application. The issue of childhood overweight and obesity is complex and requires coordinated responses from multiple cross-sectoral partners. It is estimated that up to 7600 children in the Ipswich region are overweight or obese. This is not an isolated health problem confined to Ipswich. Currently, there is a national effort to reduce obesity throughout Australia. Indeed, throughout the developing world today, there is increasing recognition that isolated strategies to prevent unhealthy weight gain in children are inadequate. Cumulative risk factors, such as genetic and lifestyle factors, as well as low socioeconomic status (SES) and a range of environmental, ethnic and cultural factors are associated with increased likelihood of unhealthy childhood weight gain. Thus, there is a need for coordinated multi-pronged, local responses to this public health issue. Systemic actions based on solid scientific evidence are required so that children at low, medium and high risk of overweight and obesity are all included in targeted interventions that focus on a continuum from prevention to treatment. In this way, population health risk factors and clinical service responses will be developed that are consistent with local social and cultural environments. This is important because weight, child-care and socialisation are contextually and culturally bound experiences. Intervention strategies need to enhance childrens lives at every level and be positively focused so that adverse consequences, such as social stigmatisation, do not occur. A coordinated response is an essential element of a management plan to address and ameliorate childhood overweight and obesity in the Ipswich community. This should be directed towards reducing individual- and environment- level risks, and by building community capacity and resilience to risk factors. No single program or isolated action is sufficient to respond to this significant health issue. Community-research partnerships can provide a firm foundation for the development of informed and comprehensive strategic responses. Local participation and building on the knowledge and awareness of local peoples needs, expertise and vulnerabilities, are integral to any research-practice endeavours involving the development of community responses. This report describes how solid partnerships between community and research partners can enhance the provision of sustainable local responses that meet the overall aim of achieving healthy diets, increasing physical activity engagement, decreasing sedentary behaviour and weight maintenance for all children living in the Ipswich and West Moreton regions. 7

Introduction Approximately one in five children in Queensland is estimated to be overweight or obese (Abbott, Macdonald, Mackinnon, Stubbs, Lee, Harper & Davies, 2007). The multiple, long-term health consequences of obesity are significant and represent an economic and disease burden that will increasingly impact on all Australians over the coming decades (Access Economics, 2008,Department of Health & Ageing, 2003). Community actions to ensure that all children have sufficient physical activity and balanced diets will contribute to a healthier population of growing children and a future generation of healthy adults. Childhood overweight and obesity is associated with a multitude of adverse health outcomes, including liver, cardiovascular and endocrine problems that emerge in late childhood, adolescence or young adulthood (Baker, Olsen & Srensen, 2007). The impact on everyday functioning can be both extensive and pervasive. The World Health Organisation has classified obesity as a chronic disease that is life limiting (WHO, 2007), as well as life changing. Research to identify preventive actions and successful interventions must consider a wide range of contributing factors and multiple actions to ameliorate childhood overweight and obesity. Despite childhood overweight and obesity being increasingly recognised as a public health issue, it remains unclear what strategies are the most appropriate and effective in combating the problem. Clarifying which strategies or combination of strategies are effective requires attention to risk and protective factors not only for each child, but also for families, the more immediate social network, within settings such as the schools, and the wider environment. Since physical activity and diet are determined by familial, lifestyle and environmental factors, it makes sense to seek holistic, community-based actions that target children at low, medium and high levels of risk for obesity. Such an approach will help ensure the improved health of current and future generations of Australian children. Coupling a community-based approach with information from robust research about bio-molecular factors represents a significant and vital approach to tackling this complex health issue. This type of research collaboration, where practical strategies are evaluated alongside focused research about underlying factors and contributing influences, is called a bench-to-fieldwork approach. Lessons learnt about strategies developed from bench-to-field research provide feedback to further develop effective and targeted endeavours to improve health for all children. This approach has greater potential to provide sustainable improvements in the general health of children who are at risk. Systematic research to explore practical means of identifying and changing multiple risk factors must be grounded in crosssector partnerships that link community expertise with research know-how. This is termed research around practice.

Why adopt a research around practice model? What makes a research around practice model relevant, strategic and advantageous in developing responses to childhood obesity? Currently, there is not a strong evidence base to identify best practice responses to childhood overweight and obesity. Working with practitioners and community organisations in all facets of the research cycle helps generate and apply research knowledge and skills where it counts: at the coal face. This is strategic because overlapping, uncoordinated and under-reported practical strategies that are shown to be effective can be put in place as soon as evidence is known and reported. Why do we need multiple partners across research and practice sectors? A comprehensive portfolio of accessible, sustainable and multi-pronged initiatives will be more likely if multiple partners work together to address this multi-system health issue. It is well recognised that no single approach is likely to work in isolation and that coordinated efforts are essential. What partners would be involved? Health and education ambassadors at all levels of the community are necessary. These will include practitioners from the public and private heath sectors at primary and tertiary levels. Individuals, families and community members will partner with government and non-government organisations, professional associations, the private business sector, the philanthropic sector and academia. How will this be funded? There is a need for future initiatives to be based on scientifically rigorous evaluations and comprehensive, coordinated actions. This will require research funding support as well as financial support from community partners. What are the benefits to the Ipswich community of adopting a coordinated approach to childhood obesity that considers multiple layers of risk? A coordinated systems response based on estimated level of risk for childhood overweight/obesity will have immediate and long-term impacts across the whole community. An approach that considers responses to high, medium and low risk of overweight or obesity will include both preventive and intervention responses. Basic and applied science research will sit alongside best practice in clinical and community research that will inform future responses in the Ipswich region and further afield. This is considered to be a tiered risk-linked response. What are the broader benefits to the wider national and international community? The monitoring and evaluation of local initiatives will inform national and international research, practice and training of practitioners. RAPICO-Ipswich, an acronym for Research around Practice in Childhood Overweight/Obesity, Ipswich and described hereafter, will be linked with other national and international centres dedicated to the development and evaluation of strategies to ameliorate overweight/obesity in children. It is envisioned that RAPICO Ipswich will, through its research and network actions, be a repository of information on best evidence and have the capacity to influence policy and practice. 9

Research around Practice in Childhood Obesity (RAPICO) - Ipswich RAPICO-Ipswich represents an example of research around practice in childhood obesity in the Ipswich region of South East Queensland. RAPICO-Ipswichs vision is to foster researchbased practice at the bio-molecular, family and community level to decrease the risk of childhood overweight and obesity. RAPICO-Ipswich was initiated through a successful application for a development grant called Pick Your Partners (PYP) from The University of Queensland. This grant provided the stimulus funds to develop RAPICO-Ipswich. It also supported the development of a consortium of Schools, Centres and Institutes from The University of Queensland (UQ) to advance an application for a Clinical Centre of Research Excellence (CCRE) in Childhood Obesity to be based in Ipswich. The PYP grant was designed to encourage working relationships between Faculty Schools and Centres with Institutes so that health-related research in areas of high national importance can be achieved. These initiatives, with their respective research and evaluation efforts, along with more fundamental research undertaken at the Institute for Molecular Bioscience and the Diamantina Institute for Cancer, Immunology and Metabolic Medicine, formed the basis of a benchtofield approach to childhood obesity. The establishment of the Healthy Communities Research Centre (HCRC) at Ipswich along with strong and emerging links between primary and tertiary health care centres and schools in the region provided the basis for establishing a field trial site in this location. The Ipswich and West Moreton region has several significant features that make it an important site for evidence to action community research in child obesity. These include: (i) A significant proportion of the regional population is in the lowest SES quartile of the Australian population (ABS 2006a) and it is this quartile that has the highest proportion of risk factors for, and prevalence of, child obesity. If evidence to action research is to benefit children, then it needs to succeed in this group. (ii) A mix of urban and rural populations (ABS, 2006c) and other social environments providing different types and levels of community capacity to support obesity interventions. The region has the capacity to test interventions in a variety of settings with different resource levels and arrangements. (iii) A wide variety of ethnic and cultural groups with higher than average prevalence of child obesity, for example, Pacific Islanders, (ABS, 2006b) live in the region. The research trial site thus has the potential to determine what changes or additions to programs are necessary to be effective with different populations.

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(iv) An active and research-oriented Division of General Practice supported by an active paediatric service with solid local support for applied research in the primary school community is already established within the region. (v) Existing links between the HCRC and local agencies are established and provide the necessary infrastructure to activate applied research without long relationship building and expensive lead times. (vi) The increasing high profile of the HCRC within the national health scene means that a group such as RAPICO-Ipswich will have ready access to the latest information about health policy and reform and will be able to contribute to future developments at this level. The RAPICO-Ipswich consortium brings together pioneering bio-molecular, proteomic and metabonomic studies and expertise with clinical and communitybased interventions and education practices to predict, prevent and ameliorate the metabolic, mental health and cardiovascular complications of child and family obesity. PYP seed funding has enabled the consolidation of a research around practice community-linked multi-disciplinary team to further these aims. Expert knowledge creation and sharing across research and practice areas provides the platform to invite further successful ongoing partnership formation to stimulate ongoing and collaborative research. This report discusses the rationale and process behind the formation of the RAPICOIpswich consortium. Part I explores the extent, aetiology and prevalence rates for childhood overweight and obesity and the need for coordinated preventive, promotional and clinical actions to address associated risk factors. Part II describes the processes underpinning the formation of community-research partnerships using program theory and logic model development to guide goal formation and plan diffusion of innovations arising from these partnerships. Part III considers future directions for the community-research partnership RAPICOIpswich.

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Part I. 1.0. Childhood overweight and obesity 1.1 The extent of the issue Childhood overweight and obesity is a health issue of local, national and international concern. In Australia, the proportion of children who are overweight or obese significantly increased during the decade 19851995 (ABS, 1998). Prevalence rates for Australian children are high, with approximately one in five children falling into the category of being overweight or obese (Magarey, Daniels & Boulton, 2001). The International Obesity Taskforce standard definition of overweight and obesity for children is linked to the adult cut-off points of 25 and 30kg/m2 respectively (Cole, Bellizi, Flegal & Dietz, 2000). The World Health Organisation (WHO, 2000) has described obesity as a global epidemic and a significantly neglected public health problem. There is continued public debate as to whether rates of childhood obesity and overweight are rising. This has contributed to confusion about the severity of this public health issue but has also emphasised the need for carefully grounded evidence and ongoing scientific rigor in monitoring prevalence rates (Gill et al, 2009). To date, national data from surveys conducted over the past decade indicate that the prevalence of childhood obesity in Australia is settling (Olds, Ferrar, Tomkinson & Maher, 2009). Although the levelling out of rates of obesity and overweight appears promising, the health goal of achieving optimal health for all children in relation to childhood overweight and obesity remains an important target. The recent state-wide survey of anthropometry, physical activity and nutrition behaviours in Queensland children found 21% of children aged 5 to 17 years were overweight or obese; 19.5% of boys and 22.7% of girls (Abbott et al., 2007). The Queensland data found that prevalence of adiposity, as measured by Body Mass Index, increased with age. The prevalence of childhood overweight and obesity in Queensland has increased since 1995 when the last national data was collected (ABS, 1998). These figures are slightly different from those reported for children who live in other states of Australia, demonstrating the importance of obtaining local prevalence data. Abbott and colleagues (2007) reported that within most age groups, Queensland children had lower proportions of overweight and obesity than children of similar ages in NSW and WA. Currently, while there are small data sets describing trends across Australian states, there is no local data available for the Ipswich and West Moreton region. There is thus a need for ongoing research to collect regionally specific data. 1.2 Prevalence rates in Ipswich and West Moreton regions In the absence of published data reporting prevalence rates of childhood overweight and obesity in the Ipswich and West Moreton regions, a cautious estimate of prevalence based on known risk factors is presented. Based on the 2008 Ipswich 12

child resident population figures, it is estimated that at least 3800 children are currently overweight or obese, with approximately twice this number affected in the broader Ipswich and West Moreton regions. This is likely to be an underestimation of true prevalence given the higher than average levels of socio-economic disadvantage in Ipswich compared to the rest of Queensland (ABS, 2006b). These are known risk factors associated with childhood overweight and obesity. For example, given that the relative rate of obesity in Australian children from low SES groups is 2.4 times higher than that reported for children from high SES backgrounds (ODea, 2008), then prevalence rates may be even higher than estimated. Compared to the state average, the Ipswich region also has a higher proportion of children aged 5-12 years living in this locality, with 18,107 resident children (ABS, 2006a). The Ipswich and West Moreton region features a unique ethnic and cultural composition, with a higher than state average of Indigenous persons as well as a significant overseas born population, particularly from the Oceania regions of New Zealand, Polynesia, Melanesia and Micronesia (ABS, 2006c). The combined impact of socio-economic disadvantage, cultural and linguistic diversity, and a rapidly growing population within the Ipswich region (Queensland Department of Local Government, Planning, Sport & Recreation, 2005:62) raises estimated numbers of childhood overweight and obesity in this region. 1.3 Significance of the issue Currently, obesity is considered to be one of the most common chronic health problems in childhood with widespread long term impacts, including both physical and psychosocial co-morbidities. Physical health complications associated with obesity range from orthopaedic and gastrointestinal problems, sleep and metabolic abnormalities (such as pre-diabetes), and asthma and respiratory problems (Leung & Robson, 1990). Cardiovascular risk factors, including high blood pressure, abnormal lipids (Figueroa-Colon, Franklin, Lee, Aldridge & Alexander, 1997), and atypical physical findings and biomarkers (Goran, Ball & Cruz, 2003; Weiss et al., 2004) are also associated with obesity. Psychosocial problems associated with being overweight or obese are considerable. Negative stigmatization (St-Onge, Keller, & Heymsfield, 2003), bullying and peer aggression (Janssen, Craig, Boyce, & Pickett, 2004), peer rejection (Bell & Morgan, 2000) and negative prejudicial treatment are perceived as early as 5 years of age by preschoolers who are obese (Ebbeling, Pawlak, & Ludwig, 2002). The growing media attention surrounding parenting practices, eating and physical activity energy expenditure of children who are overweight has increased public awareness but may have inadvertently contributed to stigmatisation concerns for children who are overweight or obese, and their families. The need for sensitive understanding of the multiple factors contributing to mental as well as physical health problems for children who are overweight or obese is underscored when one considers the far-reaching impact of unhealthy weight gain and the inadequacy of current measures to comprehensively address this issue. Given the number and diversity of serious diseases and adverse health 13

consequences associated with childhood obesity, it is not surprising that children who are obese have an increased risk of heart disease, diabetes and premature death in adulthood (Baker et al., 2007; Mamun, Cramb, OCallaghan, Williams & Najman, 2009); (Magarey, Daniels & Boulten, 2001; Neovius, Sundstrm & Rasmussen, 2009). Obese children are approximately eight times more likely to become obese adults, particularly for females (Venn et al., 2007). The Queensland Minister for Health reported that overweight and obesity contributed to 8.6% of the burden of premature death and multi-system disability in Queensland during 2006 (Abbott et al., 2007:8). This represents a considerable economic burden for communities and the nation more broadly, as well as significant social and quality of life costs for the individual. 1.4 The need for coordinated preventive, promotional and clinical actions It is important that preventive actions are taken early in a childs life, addressing nutrition and physical activity as early as possible, and are not confined to medical management. Adopting a community-based approach obesity prevention approach is seen as a core part of a range of government prevention strategies aimed at protecting and promoting health in Australian children (King & Gill, 2009). The Federal Governments initiative to provide GP-based healthy child checks for all fouryear-old Australian children represents a window of opportunity for the delivery of preventive interventions. Further research is needed to develop universal preventive practices for overweight/obesity in preschool children as current actions have not demonstrated broad effectiveness (Wake & McCallum 2004). It has been recommended that a more comprehensive approach is required that emphasises collaboration and better coordination between health care and other service providers, facilitated at both the service policy level and the administrative sector (Hearn, Miller & Campbell-Hope, 2008) Obesity is one of the most common problems in paediatric practice and yet 80% of GPs and paediatricians report discomfort, frustration & low self-perceived competence in managing childhood obesity (Elliott, Horn, Dettori, Kadash & Leong, in press; Jelalian, Boergers, Alday, & Franck, 2003). There is a pressing need to design and implement intervention programs that are not only practical, transferable, sustainable, and have demonstrated efficacy, but will be readily utilised by primary care providers. Doing so will address significant practitioner concerns about a troublesome, neglected area of practice. Significant barriers to effective weight management by GPs include low acceptance of existing models of care because of low evidence for effective and sustainable weight management interventions, lack of time and inadequate resources. Concerns about parental perceptions of stigma or denial of weight-related issues represent another barrier to identification. Perceived social rather than medical causes for a childs weight status contribute to decisions to refer to other service systems for lifestyle management (King, Loss, Wilkenfeld, Pagnini, Booth & Booth, 2007). For the majority of children, schools provide a significant avenue for learning about health and engaging in health promoting practices such as healthy food choices and 14

daily physical activity (Abbott et al., 2007). School design and access to schoolbased resources provide an opportunity for children from households with different income and educational levels to have equitable opportunities to health-enhancing physical activity. Underpinning a raft of health-related policies in schools is the compulsory Health and Physical Education (HPE) key learning area taught by both specialist and generalist teachers. More recently, under the rubric of the Queensland Governments Eat Well Be Active campaign, schools have been required to implement Smart Choices, a traffic light system that applies to school canteens, fund-raising and special events with the goal of promoting healthy food choices. The Smart Moves program has also been initiated which requires all primary school children to undertake at least 30 minutes of moderate to vigorous physical activity (MVPA) daily during curriculum time in addition to HPE and school sport. Schools may also choose to become involved with active transport initiatives such as Active After School (Australian National Audit Office, 2008) and sport development programs to name a few. However, it is of interest that, while schools are often highly engaged with policies and practices that make a positive contribution to the reduction of overweight and obesity, schools frequently do so with minimal interaction with other agencies or organisations that lie outside education systems (Marks, Macdonald, Abbott & Ziviani, 2006-2009). Beyond the school gate, local communities have many attributes that may act in preventive ways but also in ways that create a risk environment for childrens nutrition and physical exercise (Malone, 2009). These are often described as the social determinants of health (Evans, Barer & Marmor, 1994; WHO, 2008). It is now evident that the physical structure of local communities influences nutrition and physical activity (Frank, Andersen & Schmid, 2004; Popkin, Duffey & Gordon-Larson, 2005). Further, normative beliefs and culture also impact upon levels of risk and protection in health more generally (Bush & Baum, 2001). Creating environments that give inhabitants the best opportunities to address health promoting actions requires a range of upstream interventions (Marmott & Wilkinson, 2006). These are concerned with policy making and regulation that provides an environment for health and wellbeing as well as social marketing that assures good health literacy and a more conducive social environment for health (Alcalay & Bell, 2000). Moreover, epidemiological evidence on community participation shows that a wide and vibrant range of local social groups, organisations, events and activities are necessary to provide opportunities for social action in health (Baum et al., 2000). 2.0 Levels of risk 2.1 Understanding risk profiles for childhood overweight and obesity There is increasing recognition that there is no single factor which can be readily identified for childhood overweight/obesity. Rather, complex solutions to address multiple causal pathways are required to either (i) modify energy imbalance equations by addressing energy expenditure or energy intake levels for individual children and their families, or (ii) develop a situation-specific approach influencing both individual-level risk factors and environment-level factors, as well as addressing individual-environment interactions. The need to consider a tiered risk profiling 15

system is underscored by emerging knowledge about obesogenic energy intake factors that encourage excess energy consumption or discourage energy expenditure. These may be physiologically or genetically predetermined and further modified by socio-cultural factors. A range of social, environmental and motivational factors have been identified as contributing significantly to the aetiology of childhood overweight and obesity. Understanding of the need to adopt risk profiling for children at low, medium and high risk of obesity is emerging as a strong direction for future research and practice (Spear et al., 2008). This has already occurred in other health areas where risk profiling for osteoporotic fractures and cardiovascular disease has been supported by publication of National Health and Medical Research (NHMRC) guidelines (e.g. NHMRC, 2009). The American Academy of Pediatrics (Krebs & Jacobsen, 2003) has published stratification of interventions based on clinical risk profiling using BMI, and other indicators of risk for childhood obesity. In Australia, the NHMRC clinical practice guidelines for the management of overweight and obesity in children and adolescents published in 2003 are under revision. The identification of modifiable risk factors in the general population will give impetus to community-based actions that have the potential for widespread impact. These will have an impact for at-risk children, in terms of reducing prevalence rates by making individual interventions easier to sustain, and through the wider environment due to greater preventive factors and reduced risk more globally. 2.2 Environmental risk factors Abundant evidence exists concerning the contribution and complex interactions between environmental, social and family factors on levels of risk for childhood overweight or obesity. Drugs, environmental toxins and chemicals, viruses and modifications to the food system are posited as potential contributing factors (Ebbeling et al., 2002). Nutrition education and family practices surrounding mealtimes, food portion sizes, leisure-time physical activity behaviour and industry regulations for advertising, food labelling and production are additional environmental agents. There is a growing body of evidence regarding the situation-specific contribution of multiple environmental risk factors (Ebbeling et al., 2002). These environmental influences cannot be considered in isolation from other mechanisms of action such as individual genetic susceptibilities. Conflicting evidence of rates of overweight/obesity are reported for children from different SES groups in high-, medium- and low- income nations. There are higher prevalence rates in children from lower SES backgrounds who reside in medium- and high-income nations (Stamatakis, Primatesta, Chinn, Rona, & Falascheti, 2005). Ready availability of affordable high-density food, low participation in structured physical activities such as expensive sports programs, and high use of electronic media are proposed as amplifying factors in an already obesogenic environment. More recently, attention has focussed on the adverse weight consequences of globalisation. Increasing child obesity rates and prevalence of metabolic syndrome in 16

children living in developing countries such as Northern Africa, Central and South America, India and the Middle East (Kelishadi, 2007) show a positive relationship between industrialisation, urbanisation, Westernisation and unhealthy weight gain (French, Story & Jeffrey, 2003; Prentice 2006). Increased wealth and technological influences, access to a broader food repertoire and more urban and sedentary livelihoods are associated with increased consumption of high density, calorie-rich foods and reduced physical energy expenditure (Reddy, Prabhakaran, Shah & Shah, 2002). The outcomes of this phenomenon are two-fold since, not only do populations as a whole gradually become overweight, but those who are genetically susceptible to weight gain can become excessively obese (Freidman, 2003). American randomised controlled trials have shown a positive correlation between television viewing behaviours and body fatness (Robinson 2001). In a longitudinal study of New Zealand children, Hancox and Poulten (2006) found that BMI and prevalence of overweight at all ages were significantly associated with mean hours of television viewing reported in the assessments up to that age. Australian national guidelines stipulate that more than two hours television viewing per day is associated with moderate levels of risk for childhood overweight while more than five hours of viewing per day is associated with increased risk of obesity (NHMRC, 2003). However, many Australian children do not meet these screen time guidelines (Salmon, Timperio, Telford, Carver & Crawford, 2005). A sustainable way of enhancing childrens physical activity is through their participation in habitual forms of everyday physical activity such as active travel (AT) (Duncan, Duncan & Schofield, 2008). The most common forms of AT are walking and bicycle riding. Although a relationship has not always been demonstrated (see for example, Meltcalf, Voss, Jeffrey, Perkins & Wilkin, 2004), it has been found that children who use AT to and/or from school are generally more physically active, have higher levels of energy expenditure and are more likely to meet physical activity guidelines than children who are driven (Timperio et al., 2006). While there has been a long standing interest in the factors that promote AT in adults, attention has been more limited for children (Pont, Ziviani, Wadley, Bennett & Abbott, 2009). Findings highlight the importance of socio-cultural and physical environment influences and point to the impact of local community characteristics. 2.3 Child level risk factors At the individual level, there is considerable evidence of a genetic disposition and physiological basis to childhood obesity. More than 20 genes have now been identified with a common variation which affects weight. While these genes still only explain a small proportion of the overall variation in weight, they do confirm epidemiological findings that the majority of inter-individual variation in body mass is due to genetic effects. For example, it has been found that monogenic forms of obesity are caused by a single gene mutation (Farooqui & O-Rahilly, 2005), syndromic forms of obesity arise from genetic defects or chromosomal abnormalities (Bell, Walley & Froguel, 2005), and polygenic obesity results from gene-gene and gene-environment interactions.

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Data from twin, adoption and family studies suggest that energy variables and obesity phenotypes such as BMI and fat mass are strongly heritable (Nirmala, Reddy & Reddy, 2008). Parental obesity is a strong risk factor for future obesity (Stettler et al., 2002). A preschooler with one parent who is overweight has a four- to five-fold increased chance of being obese (Whitaker, Pepe, Wright, Seidel & Dietz, 1998). Having more than one family member who is overweight or obese increases the level of risk for a target child (Rice, Perusse, Bouchard & Rao, 1999). Ethnicity is a risk factor for obesity in children and adolescents. Pacific Islanders are characteristically taller and more muscular than people of European descent (Swinburn, Ley, Carmichael & Plank, 1999) and are considered genetically susceptible to severe weight gain (Friedman, 2003). A high risk of obesity and an increase in type-2 diabetes is found in Aboriginal and Pacific Islander children and among Middle Eastern youth (ODea, 2008). Other child-level risk factors include weight gain early in postnatal life (Stettler et al., 2002), hypothalamic damage and endocrine disorders (Lustig, Post, Srivannaboon, Rose, Danish et al., 2003) and various pharmacotherapeutic agents (Schwartz, Nihalani, Jindal, Virk & Jones, 2004). Early adiposity rebound is another factor implicated in childhood overweight and obesity (Whitaker, Pepe, Wright, Seidel & Dietz, 1998). The preschool and school entry years represent a period where childrens body fat declines to a minimum level or adiposity rebound point before increasing again into adulthood. Hence a rise in prevalence rates for overweight or obesity at this stage of life may impact on future weight status.

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Part II. 3.0 Community-research partnerships 3.1 Program theory Program theory has been proposed (Rogers, 2008) as a means of evaluating complicated and complex aspects of interventions. In addition, this approach offers a platform to guide translational research at the basic science and community levels. This ensures that actions are effective, replicable and deliverable to children and families at low, medium and high risk of obesity and have the greatest immediate and long term impact across multiple levels. Translational research around best practice can be actioned using a program logic map developed through collaborative goal setting. Program logic is well suited for complex health issues such as childhood overweight and obesity. The multi-faceted nature of this health problem requires a diverse, interwoven network of change agents to achieve long term improvements for children and their families. Part of an effective program logic map includes a diffusion of innovations plan. Findings from research about what works and what does not work can then be widely and effectively disseminated across all sectors. In this way, sustainable changes to dietary habits and physical activity energy expenditure for individuals from low to high risk can be planned for all community sectors. 3.2 Logic models Program logic models make sense of complex and sometimes incomplete scientific data, as well as site-specific knowledge to inform future actions. Practical logic maps display vast amounts of information about how to best achieve goals that have been collaboratively identified. As such, they represent a guiding framework that shows how to galvanise, direct and coordinate actions. Childhood overweight and obesity is a health issue that is well suited to logic mapping. The complexity of this health problem in relation to aetiology, management and local development of targeted responses is acknowledged (Ludwig, 2007). However, it is unclear which responses are best suited for individual children and their families. Uncertainty also exists about which energy intake or energy expenditure strategy is most effective in different settings and whether practices that have been shown to work in one situation can be adapted to fit unique local conditions. Evidence to inform practice and contribute to understanding about interrelated factors across bio-molecular, physiological, behavioural, and community levels is emerging. However, the nature of these relationships is unclear (Glouberman & Zimmerman, 2002). No single solution or recipe is currently available to solve childhood obesity. Indeed, no collection of simple solutions can be currently recommended to address this issue. Rather, a coordinated effort is essential. Program logic is a tool that aims to link the various contributing factors and resources into a process system. A map to 19

coordinate research-practice endeavours across the community and research sectors must incorporate diverse, multi-level factors including dietary practices, parenting behaviours, physical activity energy expenditure, leisure patterns, transport and travel behaviour, education practices, food advertising and other social, environmental, cultural and individual factors, including genetic and metabonomic markers. In a complex system, interconnectedness between factors and their properties of self-organisation and evolution requires responses that are more than just an assembly of simple actions. 3.3 Benefits of a logic approach A logic model approach overcomes a reductionist view where simple solutions alone, or a collection of many simple solutions, are insufficient for long-term actions embedded in real world practice. Developing local partnerships, and drawing on the wisdom and practical knowledge of community members who understand the unique local conditions and social ecology of the area is critical to success (Rogers, 2005). A logic model incorporating research expertise has the added advantage of injecting the latest empirical evidence from a broad range of research sectors, including basic and applied science, into this equation. This means merging both top-down perspectives, where social planning from experts is utilised, and bottom-up grass roots approaches, where community inputs and responses are able to provide key reference points to inform the logic plan (Roussos & Fawcett, 2000). However, the approach must go beyond building a relationship based on understanding and communication and requires more than simply an interaction between two worlds of knowledge practice and research. Rather, a merged world of practice and research, with a fused network of committed partners, must be created. This fused network or consortium of partners will be ready to implement bench-tofield activities in a field trial site. The consortium will be able to guide research endeavours, support program development and evaluate changed or novel practices. The benefits for complex health issues, such as childhood obesity, are considerable. The consortium will act as an engine to address current needs and have the ability to assist change uptake in the local community. The individual, family and community readiness to adjust behaviours and habits, adopt innovative practices and engage in change programs will be implicitly grounded if a merged consortium has been developed over time (Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004). In the case of childhood obesity, the time taken to develop working partnerships is particularly important. The process of developing workable, evidence-based solutions requires more than knowledge transference alone. Because evidence about effective practices is fragmented and not always locally applicable, a primed consortium that can act on new evidence and can determine local applicability is essential. Developing a research-practice consortium represents the first step in moving research into practical opportunities within the community. It is a strong, forward moving approach that has widespread potential in addressing childhood obesity. A logic model for progressing research-practice partnership formation to diffuse information about consortium innovations in the area of childhood obesity is presented in Figure 1. 20

RAPICO Research Around Practice in Childhood Obesity

RESEARCH

NETWORK IDENTIFICATION People Resources

PARTNERSHIP DEVELOPMENT Collaboration Coordination Planning

CONSORTIUM ACTIONS Achieve goals Strengthen partnerships

DIFFUSION OF INNOVATIONS Disseminate knowledge Develop 'best practice' models

IMPACT Healthy lifestyles for children

COMMUNITY

Figure 1. Logic model for Community-Research Partnerships

3.4 Diffusion of Innovations Diffusion of innovations refers to the process by which new practices, products or ideas are implemented through (i) passive, unorganised or peer-mediated, informal spread, (ii) active and planned dissemination of innovations, (iii) active and planned mainstream implementation, and (iv) sustainability actions (Greenhalgh et al., 2004). A well established research-practice consortium has the capacity to identify and utilise resources, and advance knowledge and skills by drawing on resources from inter-sectoral partners (Roussos & Fawcett, 2000). In community-research partnerships, purposeful sharing of knowledge is planned from the outset using social networking, tailored messages to reach diverse audiences, advertising and the utilisation of recent technological advances. Active dissemination of knowledge can occur in multiple ways, including through scientific and technological publications aimed at professional audiences, government bodies and industry partners. Different methods of innovations diffusion are necessary for primary health service providers, educators, community members, private organisations and non-private operators. There may be ideological resistance from non-professionals where scientific evidence may be viewed as a privileged form of knowledge, as well as 21

paradigmatic differences in terms of what constitutes valued knowledge across the professions. It is important to consider that innovations can become stuck at boundaries between professions, organisations or other key stakeholders. Communication mechanisms that consider differential power and status, alongside environmental and social factors such as resource capacity, supply and demand factors and available capital, ensures viable diffusion of innovations (Fitzgerald, Ferlie, Wood & Hawkins, 2002). Currently, the issue of childhood obesity is considered to be a complex health issue with poor interdisciplinary and intersectoral coordination of action plans (Bell, Simmons, Sanigorski, Kremer & Swinburn, 2008). Diffusion of innovations based on evidence from community approaches to weight management allows communityresearch partnerships to deliver practical, relevant solutions. Government task forces, commissions of inquiry and peak bodies of professional expertise are being formed upstream from the coal face. For example, the Healthy Weight 2008 Australias Future: The National Agenda for Young People and their Families; The National Agenda on Early Childhood; and Healthy Children Strengthening Promotion and Prevention across Australia (National Obesity Taskforce, 2008) is a recent nationwide endeavour that requires local adaptation and support to improve uptake and adherence. It has been noted (Bell et al., 2008) that achieving integrated multi-strategy, multi-setting interventions at a state or national level cannot be achieved without strong partnerships and sophisticated coordination. However, local conditions are an under-recognised consideration when diffusing these innovative ideas and responses in different contexts. Similar action needs to be encouraged at the community level. 3.5 National campaigns and local initiatives The application of national campaigns within local communities require policy makers, researchers and local practitioners to work together to develop targeted responses that are socially and culturally relevant. In the United States, one of the first collaborative community-based participatory research initiatives was Shape Up Somerville: Eat Smart, Play Hard. This study took a collaborative approach to research-partnerships that considered local conditions. Evaluation of the study found a demonstrated effectiveness in decreasing weight gain in children living in three culturally diverse urban communities who were at high risk for obesity (Economos et al., 2007). In particular, it was noted that the up-front investment in partnership building for collaborative community-based participatory programs reaped measurable rewards for child health outcomes. However, the total cost, in terms of time and labour costs, was high. In fact, it took over 12 months to establish effective research-practice relationships that could build an effective plan that met the community needs. Careful attention to the initial planning process allowed the growth of community support and encouraged strong collaborative relationships to ensure a rapid and seamless introduction of multiple community strategies for healthy weight initiatives. The establishment of a coordinated partnership of stakeholders throughout the development, implementation and

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evaluation of multi-pronged strategies was an integral factor behind the success of this project (Economos et al, 2007). Here in Australia, Be Active Eat Well (BAEW) was a multi-faceted community capacity-building program promoting healthy eating and physical activity for schoolaged children residing in the town of Colac, Victoria (Sanigorski, Bell, Kremer, Cuttler & Swinburn, 2008). BAEW was designed to build the communitys capacity to create its own solutions to promoting healthy eating, physical activity and healthy weight in children aged 412 years and their families. The intervention program was designed, planned and implemented by the key organisations in Colac, including Colac Area Health, Colac Otway Shire and Colac Neighbourhood Renewal, with Deakin University providing support, training and evaluation. The action plan was developed by agencies and stakeholders in 2002 and implemented from 2003 through to 2006. The main objectives were capacity building, increasing awareness of the project messages and evaluation. The capacity-building objective included broad actions around governance, partnerships, coordination, training and resource allocation. Five objectives targeted evidence-based behaviour changes (reducing television viewing, reducing sugar drinks and increasing water consumption, reducing energy dense snacks and increasing fruit intake, increasing active play after school and weekends, increasing active transport to school), and each objective had a variety of strategies (such as social marketing, programs and policies). Over the three year period, BAEW was effective at slowing the rate of weight gain (by about 1 kg) and waist gain (about 3 cm) in primary school-aged children. The authors attributed the success of the intervention to it being derived through a community-capacity building approach. However, more rigorous research designs that are capable of identifying the causal pathways for success are needed. In New Zealand, the APPLE study (A Pilot Programme for Lifestyle and Exercise) is a community based intervention focussing on increasing physical activity both within and outside of school through a community-based activity program (Taylor et al, 2006). The first-year results showed a significant reduction in BMI-z score, although a reduction in the prevalence of overweight/obesity was not seen. The above community-based examples demonstrated how research around practice can inform local responses within the Ipswich and West Moreton regions. They also serve as stimulus points for further research highlighting the significance of the development of sound research design.

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4.0 Research around Practice in Childhood Overweight/Obesity (RAPICO) 4.1 The RAPICO-Ipswich model Evidence from the community-based childhood obesity prevention initiatives described earlier provides a positive sense of direction for other community-research approaches. The mounting evidence that no single solution alone has been found to ameliorate childhood overweight or obesity can leave a community feeling uncertain about how best to tackle this issue. Rather, the findings that community-research partnerships can successfully address uncertainty about how to best approach this problem cannot be underestimated. The Research around Practice in Childhood Overweight/Obesity Ipswich (RAPICOIpswich) model was developed to guide future actions to holistically and comprehensively address childhood overweight and obesity within the Ipswich and West Moreton regions of South-East Queensland. Rather than simply collating evidence to coordinate a series of isolated approaches to solve separate pieces of the childhood overweight/obesity puzzle, a map grounded in partnership development to collaboratively address the issue was developed. The importance of understanding the connections between the pieces of the puzzle using resources from community and research sectors to provide the most current, practical and grounded information was a priority. In this case, the truism that the whole is more than the sum of its parts was paramount. The recent establishment of the HCRC within the Ipswich and West Moreton region, and the provision of seed funding to support partnerships development stimulated a holistic research-around-practice approach. This partnership produced a guiding logistic plan to collate evidence from contemporary basic and applied science, and to create future diverse, workable actions that will provide sustainable, context-specific, relevant community responses through coordinated actions. 4.2 Goal Hierarchy The RAPICO-Ipswich model employed backward mapping (Elmore, 1980) to plan the specific inputs, actions and outcomes for a series of goals identified by community and research partners (see Figure 2). The process involved the development of a goal hierarchy that was initially framed by an overarching goal to achieve healthy lifestyles for children at risk of overweight or obesity. The next stage involved working backwards to tease out a series of carefully stepped goals to achieve the enhanced health of each child.

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Achieve healthy lifestyles for children at risk of overweight/obesity

Implement comprehensive and coordinated policy for achieving sustainable healthy lifestyles

Diffusion of innovations (i) Document evidence-based best-practice responses (ii) Disseminate knowledge on evidence to practice community and clinical trial outcomes (iii) Increase community knowledge and awareness of successful strategies (iv) Establish a trained and educated workforce of practitioners and researchers grounded in evidence-based research

Develop innovative and practical strategies to decrease the risk of childhood overweight/obesity

Develop risk profiling tools to evaluate child-, family-, and community-levels of risk for overweight/obesity

Identify child-environment factors contributing to low, medium and high risks of childhood overweight/obesity

Identify and strengthen resources, networks, and partners that support healthy lifestyles Figure 2. RAPICO Ipswich goal hierarchy Healthy lifestyles was defined as healthy eating and exercising, adequate sleep, low levels of sedentary behaviours and full participation in health-enhancing in-school and out-of-school activities. This would be determined by life conditions (resources), life chances (structural-based probability of correspondence of lifestyle and life situation) and life conduct (patterns of behaviour) (Rtten, 1995). It was acknowledged from the outset that no single narrative of healthy living could encompass the diverse range of influences on families and children living in the 25

Ipswich and West Moreton regions. Rather, a holistic view of healthy living was employed. This was determined by numerous individual- and environmental-level factors as well as interdependent relationships between these elements. As such, the need to incorporate the perspectives of prospective partners across every sector of the community was paramount. Building relationships between research and community partners was therefore incorporated as a key aspect of the goal hierarchy. Himmelmans theory (1996) was employed for the progressive building of the consortium. First, networks of people and resources were identified. Second, partnerships were advanced and formalised. Next, strong consortium development was sought to enable actioning of responses using top-down and bottom-up strategies consistent with scientific research perspectives and grass roots approaches. Although goals were initially outlined in a logical and hierarchical order, the practicalities of achieving goals in an orderly and predictable manner in the real world precluded the application of a linear working framework. It was implicitly acknowledged that goal achievement was not expected to proceed in a progressive ordered manner. Rather, multiple goals could be simultaneously addressed in a circular, interactive and occasionally recursive arrangement. The development of a logical map of expected goals was necessary to ensure that markers of best community-research practice were flagged from the outset. Thus, progress could be identified towards achieving the ultimate goal of healthy lifestyles for all children living in the Ipswich and West Moreton regions who are at risk of overweight of obesity. 4.3 Research Practice Model (RPM) logic wheel The circularity of the research-practice interactive process was recognised in the formation of a diagrammatic representation of the goal hierarchy that had meaning for community members. The contributions of the various linked partnerships and the need to build and strengthen these partnerships was conceptualised via a hubandspoke wheel network model (MacRae et al., 2005; Nobilio & Ugolini, 2003). The RPM (see Figure 3) was viewed by community members as a meaningful, grounded representation of the numerous features and connections required to achieve momentum in tackling an issue that was multi-faceted and complicated.

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Figure 3. Research Practice Model (RPM)

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Part III. 5.0 Summary of Recommendations RAPICO Ipswich brings together community expertise and leadership to implement trials that develop through evidence-based research with key interdisciplinary partners to reduce and ameliorate the risk of overweight and obesity for children residing in the Ipswich and West Moreton regions. Frameworks for translating evidence into community-based action require research with high levels of internal validity, as well as broader based socio-cultural, organisational and grass roots inputs from key community stakeholders to ensure external validity and contextual relevance (Swinburn, Gill & Kumanyika, 2005). Community involvement is central to the vision and success of RAPICO Ipswich. Recommendation 1 1.1 Research practice partnerships will be built with the following characteristics: a shared vision for partnerships in research around practice in childhood overweight and obesity; a set of principles and practical strategies to guide partnership development; key indicators of effective partnership implementation to ensure sustainability, accessibility and reproducibility; and governance arrangements. Partnerships will be geared to conduct clinical trials, share evidence-based information and link services across all sectors. This is important because: clinical trials and interventions must be able to run smoothly without the need for lengthy (and costly) relationship building periods; widely disseminated, shared evidence-based information about strategies for dealing with issues and barriers will facilitate the adoption of sustainable healthy physical activity engagement and eating habits for children in our community; and linkage of services across all sectors will ensure the seamless transitions between services for children, adolescents and adults with special consideration for family-linked service provision. The RAPICO-Ipswich consortium will be built so that it can provide the community with information about: existing networks and partnership arrangements; referral pathways and contact points to healthy community initiatives; regular monitoring and feedback about current resources, upcoming events and success/barriers to implementation of recent initiatives (delivered to RAPICO partners via a quarterly email newsletter); and practical means of networking with individuals and groups where there is a range of expertise and resources.

1.2

1.3

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Recommendation 2 2.1 Baseline documentation of regionally specific prevalence rates of childhood overweight and obesity will be collated so foundation data to evaluate the success of preventive and intervention strategies is readily available. Collecting information about levels of risk in relation to physical activity levels and healthy eating habits at the individual, family and community levels will be prioritised because this is considered to be equally as important as surveying and classifying obesity prevalence and incidence using a measure, such as BMI. There is a justified concern that labelling children as overweight, obese or morbidly obese can lead to stigmatisation and subsequent low uptake of community-based initiatives aimed at reducing risk levels through monitoring physical activity and improving nutritional intake of children and families. Collected data will be: non-discriminatory; age-related so that key ages are consistently assessed; voluntary, with adult- and child-consent obtained prior to collection, consistently collected across all community sectors; and family-centred so that all members of the family are included in a wholeof-family approach. The consortiums efforts to document and collate this information will be directed towards further development of a monitoring/data management system that will enable RAPICO Ipswich to: provide a minimum level of information to enable monitoring of population changes over time; evaluate the effectiveness of programs and policies by tracking changes; and systematically collect and analyse data to support applications for future initiatives and inform policy development.

2.2

2.3

2.4

Recommendation 3 3.1 Sound research designs will be formulated by RAPICO Ipswich community and research partners to enable translation of innovative research ideas into research designs so that best practice outcomes occur. Best practice outcomes will be evaluated on the following criteria: measurable; replicable; cost-effective; and sustainable. 3.2 A comprehensive portfolio of evidence-based initiatives for children at all levels of risk is required. These strategies will include policy and regulatory 29

approaches, social marketing campaigns and community wide programs, including active parks, walking and cycling tracks. Additionally, it is recommended that approaches that are applicable to clinical settings as well as promoting healthy school environments and youth programs, which focus on healthy physical activity and sound nutrition through modification of dietary habits, be adopted to ensure a comprehensive approach. This will include a consideration of a range of factors, such as urban and building design, inschool physical education programs and screen and physical activity guidelines. This is because no single strategy to address childhood overweight/obesity has been shown to be successful to date. Recommendation 4 4.1 Empirical findings will be distributed widely. RAPICO Ipswich will publish empirical findings of local research endeavours in the national and international literature. Population-based information about community-based interventions requires further sound research to establish clear guidelines and direction to improve the reach and impact of efficacy and evidence-based initiatives. This is critical in evaluating the effectiveness of programs that support prevention and intervention of overweight and obesity in all children.

Recommendation 5 5.1 A trained and educated workforce of practitioners, professionals and academics to address childhood overweight and obesity is required. This will underpin the provision of more readily and widely available, affordable and effective education and service provision for all members of the community, including children and their families.

Recommendation 6 6.1 Dissemination of innovations will occur through active and passive modes. A practical reservoir of resources and accessible consultative personnel regarding effective practice will facilitate diffusion of innovations, taking the intervention to interested community members. Referrals and practical partnership linkages could be facilitated through such a provision.

Recommendation 7 7.1 RAPICO Ipswich will become involved in policy decisions through responses to calls for submissions, government inquiries and representation on committees addressing issues, such as: legislation to restrict food advertising and marketing of unhealthy foods; development of a national front of pack nutritional labelling system; adoption of nutritional labelling systems for fast food outlets; government assistance to offset high cost of fruit and vegetables;

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 7.2

encouragement of supermarkets to implement healthy food choice promotion; increased Medicare rebate for preventative health initiatives; increased access and decreased costs of physical activity programs and leisure facilities; and the development of a national food and nutrition policy.

A whole of government, long-term strategy requires input from sound research around practice that is informed by partnerships across federal, state and local government, health and education sectors, community and non-government organisations, businesses, families and individuals. RAPICO Ipswich will link with other key partners and communities where holistic, coordinated action to ensure effective implementation of coordinated responses can occur.

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