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Article: Lauren McGovern, Jonathan N. Johnson, Remberto Paulo, Allison Hettinger, Vibha Singhal, Celia Kamath, Patricia J. Erwin, and Victor M. Montori Treatment of pediatric obesity. A systematic review and meta-analysis of randomized trials J Clin Endocrinol Metab 2008; 0: jc.2006-2409v1 [Abstract]

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The gap between research and the experience of clinical practice

Sue Channon, Bethan Phillips, Sue Channon, Justin Warner, Jacqui Lowden, and Non Thomas   (23 June 2009)

The gap between research and the experience of clinical practice 23 June 2009
Sue Channon, Consultant Clinical Psychologist Cardiff and Vale NHS Trust, Bethan Phillips, Sue Channon, Justin Warner, Jacqui Lowden, and Non Thomas Send letter to journal: Re: The gap between research and the experience of clinical practice Sue.Channon{at}Cardiffandvale.wales.nhs.uk Sue Channon, et al.	As a group of clinicians who have recently delivered what can only be described as an unsuccessful group for obese adolescents and their parents, we read with interest the recently published guidelines and meta-analysis on the treatment of pediatric obesity (1) . What can we learn from this paper to help us think about what went wrong and what to do next time? As stated in the conclusions of the meta-analysis "the available evidence should inform the practice of evidenced based obesity treatment in children". This we did, implementing a combined lifestyle intervention, offering diet, activity and psychological support to 11-15 year olds with a BMI < 2 SDS .We made every effort to make it convenient, fun, and a safe place away from medical institutions. However, with an attrition rate after 6 sessions of 80%, with no significant changes in BMI, it can only be described as a failure in terms of the specified outcomes. So why is the experience of clinical practice so different to the story presented in the published research? Is it the nature of the participants? Our families were not self-selecting volunteers who have reached a point of action but adolescents on a dietetic waiting list when often it is the practitioners' agenda that has brought them there. Furthermore, they were not subjected to a randomized study, but invited to attend the program. There were complex psychosocial issues for many of our families, as illustrated by the fact that two of the original group of 11 were placed on the Child Protection register within a year of the project finishing. Such families have complex psychological needs and weight loss is often not high on their agenda. The concepts of motivation and readiness to change which seem critical in practice are rarely measured in studies. Is it shortage of resources? The work was funded by a grant from Welsh Assembly Government and was delivered out of normal hours so participants would not have experienced it as routine care. Practitioners were all experienced including a Consultant Paediatric Endocrinologist and Clinical Psychologist, a Senior Dietician and Sports Scientist and two trainee Psychologists. Is there a "good" age-group to work with? In the review there is evidence that working with younger children may be more effective, and certainly from our perspective it felt as if participants were at exactly the wrong age: too young to be making all their own choices about food and activity, too old to be wanting to conform to any family shift in lifestyle. All these factors may have made a difference and are in part answered by the meta-analysis but there seems to be so much more to learn. There is a danger in this area that the interventions become more complicated to try and rise to the challenge. However even in the high quality trials presented, the complexity of the clinical work is missing and maybe there is a need for more qualitative, process based work to start to unpick the intricacies of the field. Reference 1. McGovern L, Johnson JN, Paulo R, Hettinger A, Singhal V, Kamath C, Erwin PJ, Montori VM. 2008. Treatment of Pediatric Obesity: A Systematic Review and Meta-Analysis of Randomized Trials J Clin Endocrin Metab 93:4600-4605