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project reports the follow-up of a 30-month study carried out between 2004 and 2009 ... in Fiji and Tonga), thus the evaluation process in these sites was greatly ...
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doi: 10.1111/j.1467-789X.2011.00924.x

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R. Uauy1, C. Corvalan2 and J. Kain2

1

London School of Hygiene and Tropical

Medicine, University of London, London, UK; 2

Institute of Nutrition and Food Technology

(INTA), University of Chile, Av El Líbano 5524 Santiago, Chile

Address for correspondence: Professor R Uauy, London School of Hygiene and Tropical

Re-use of this article is permitted in

Medicine, University of London, London

accordance with the Terms and Conditions set out at http://wileyonlinelibrary.com/

WC1E 7HT, UK. E-mail: [email protected]

obesity reviews (2011) 12 (Suppl. 2), 1–2

The Pacific Obesity Prevention in Communities (OPIC) project reports the follow-up of a 30-month study carried out between 2004 and 2009 in four countries (Australia, New Zealand, Fiji and Tonga). Adolescents from eight ethnic/cultural groups with a high adult obesity rate were selected to participate in this community-based obesity prevention intervention. It was a large and complex intervention which included 18,000 secondary school children (aged 12–18 years), 300 stakeholders and partner organizations, 60 multi-professional research staff and 27 higherdegree research students. Investigators from Australia and New Zealand provided training and supported research teams in Fiji and Tonga on experimental design, quality control, data acquisition and processing. Team meetings were held 2–3 times per year with additional monthly teleconferences in order to monitor and review progress. This extraordinary multidimensional research had a common intervention plan for all sites; however, implementation was adjusted to local conditions. Community participation served to define local action plans developed after holding ANGELO workshops with broad community representation, including adolescents. These workshops guided the final action plans based on identification of the potentially critical socio-cultural factors associated with obesity in the specific settings. The fact that each of the intervention sites adapted the project according to local conditions was important as part of a participatory process. Local characteristics were clearly different in terms of food and activity environments, economic situations,

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obesity prevalence, research capability and technical resources. These differences proved to be critical in the implementation of the intervention in some sites (especially in Fiji and Tonga), thus the evaluation process in these sites was greatly compromised. Outcome measures were uniform across intervention sites. The main primary outcome were changes in anthropometry and body composition, while the secondary outcomes were changes in behaviours, knowledge, quality of life, body size perceptions and community capacity. The design was quasi-experimental; the unit geographic district. Theoretically, this design is clearly the best for carrying out ‘real-life’ experiments because in the real world it is seldom possible to randomly allocate interventions given political, administrative and economic concerns. This design brings us as close to reality as possible but blurs the measurement of impact, because, by design, potential confounders of the association are not equally distributed between groups and thus, they have to be controlled for in the analyses. The study design allowed for each site to define the particular components of their intervention; however, by doing this the homogeneity of the intervention was lost. Differences among sites included multiple other factors beyond the intervention, thus limiting the comparison of the findings. The only statistically significant result in the primary outcome, body mass index for age, that could be ascribed to the intervention was documented in Australia (It’s Your Move). A significant reduction in weight gain over the study period was found in

© 2011 The Authors obesity reviews © 2011 International Association for the Study of Obesity 12 (Suppl. 2), 1–2

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2 Obesity prevention in the Pacific Islands

R. Uauy et al.

students from the intervention schools; on all other sites no significant changes in terms of the primary outcomes were found. The lessons from this research were mainly in the qualitative components and in defining additional factors that need to be addressed to secure impact. These are: • It is especially important to identify values, attitudes and beliefs that influence what adolescents eat and how active they are. As the authors point out, it is desirable that the determination of these behavioural aspects be obtained beforehand, so as to increase the probability of a positive effect on obesity. • An important consideration is that attrition rates at follow-up can be high. For example, in Tonga, the number of participants with anthropometric data at follow-up was significantly greater than those with behavioural ones. These questions were not collected in students who left school, because they only related to school days and dropout rate was high. In Fiji, the number of participants in the intervention group was half of that in the comparison one, in New Zealand, less than 50% of the students had both baseline and follow-up data. In Australia, those followed up were different from those not followed up in some demographic characteristics. Standardized body mass index of students who dropped out was higher. • Building research capacity, especially in the lowerincome countries where it is limited, was a very important outcome of the study, and although there were few higher degrees achieved it occurred significantly at the community level, mostly through workshops targeting stakeholders. • Another important aspect that should be taken into account when targeting schools is the difficulty in integrating teachers as participants in the process, as academic achievement is the priority in all schools and an intervention is almost always considered as an additional burden. As has been demonstrated in other studies, commitment to the intervention is largely dependent on the support of the school principal and other senior personnel. • The action plan, although uniform in all sites, had to be flexible which meant that the intensity of the activities varied considerably. It is important to stress the fact that recommending increasing intensity has to take into account the real possibility of achieving it. Sometimes, this recommendation is offset by the barriers that limit the desire to do more. • The intervention in this case included a ‘policy component’ which is remarkable, because in general most

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studies do not consider this component, which as stated above can make all the difference between the impacts achieved in obesity prevalence. Researchers in this study identified existing policies within sectors such as trade, commerce, finance and agriculture and their influence on dietary intake (low fruit and vegetable consumption, price of beverages, etc.). Finally, a comprehensive list of possible policy interventions were developed in each country along with projected health and economic impacts, with the idea that future initiatives will be able to select from this list. Although this is no guarantee of success, it is clearly a step forward in the difficult task that involves progress from policy commitments to policy action. • While efforts to prevent obesity through behaviour change can produce some positive effects regarding diet and physical activity, a significant outcome will be achieved only when countries adopt policies which support healthy diets and promote physical activity. This is not an easy endeavour as ideally policy interventions need to engage multiple sectors beyond health. In summary, this large multidimensional participatory intervention, although it did not have a significant impact in terms of changes in obesity prevalence (except for the Australian site), the experience-based evidence on ‘sitespecific’ context accumulated, will be of great importance in guiding future efforts. Researchers involved in the public health prevention of childhood obesity need to face the reality of addressing site-specific factors which are of critical importance in defining what approaches might work best in addressing the critical barriers that need to be overcome before implementing an intervention. The obvious ones emerging from this study are socio-cultural issues and concerns, local capacity for programme implementation and evaluation and the real possibility of collaboration and participation by various stakeholders that are keys for success. Finally, it must be acknowledged that the best chances for success will be when the programmatic actions taken are in response to the demands of a community that is duly informed and has clearly defined the need for actions leading to control and prevention of childhood obesity as key to their human and social development. Ultimately, this becomes a political rather than a technical proposition. Engaging those that generate policies and the political actors that lead this process are clearly sine qua non for successful implementation and achieving a measurable impact. Scientists no matter how good they are ‘can not do it alone’.

© 2011 The Authors obesity reviews © 2011 International Association for the Study of Obesity 12 (Suppl. 2), 1–2