Getting Our Active Lifestyles Started! (GOALS), Obesity in Liverpool

Themes this local practice example relates to:

  • Families, Parents and Carers
  • General resources

Priorities this local practice example relates to:

  • Improving the safety, health and wellbeing of children through improving the physical and mental health of mothers, fathers and carers

Basic details


Organisation submitting example

Liverpool John Moores University (in partnership with Liverpool PCT, Liverpool City Council, University of Salford and Royal Liverpool Children’s NHS Foundation Trust)

Local authority/local area:

Liverpool


The context and rationale

In 2003, partners from higher education, the local authority and primary and secondary care came together with the idea of developing a community-based lifestyle change intervention for obese children and their families; Getting Our Active Lifestyles Started (GOALS)

GOALS was founded in response to growing local concern regarding provision for children who were already overweight or obese in Liverpool. School health teams were receiving referrals for obese children for whom there was no service available and community paediatricians were expressing concern about the volume of families seeking medical support for their child’s obesity, which in the majority of cases required a lifestyle solution; something that paediatric teams had neither the capacity nor the context to provide. 

The need for GOALS was further highlighted by the Liverpool SportsLinx project, which is a multi-faceted programme that focuses on the fitness, eating habits, physical activity and health of children across Liverpool. SportsLinx has collected data on fitness and body composition of children reaching back to 1998, and data showed an increase in childhood obesity between 1998 and 2003, when figures rose to over one third of 9-10 year old Liverpool children being overweight or obese. Prevalence has since levelled off but childhood obesity levels remain high and there has been no reduction to pre-2003 prevalence. SportsLinx data has also shown a continuing decline in cardiovascular fitness in Liverpool children from 1998 to the present year, which is of great concern given the importance of fitness to future health and life expectancy. 

We aimed to support families with obese children, particularly those from deprived backgrounds, to make small, sustainable changes to their lifestyles. Our focus was multidisciplinary, with the aim of managing children’s weight and improving their long-term health prospects through a physically active lifestyle and eating a healthy balanced diet. We hoped to equip families with the knowledge and skills to manage a healthy lifestyle in the long-term and through doing so also improving their wellbeing and quality of life. 

Although GOALS targets children who are obese, the focus of GOALS throughout has been on helping the whole family become more physically active and make healthy changes to their diet. We believe strongly in role-modelling, and reinforce this through the intervention whereby adults and healthy weight siblings take part in everything the obese child does; they are weighed and measured, they set their own personal goals and they all join in the physical activity sessions together.

The first phase of GOALS involved a year-long action research phase through which sessions were developed week by week according to the needs of the families taking part. The iterative development of the intervention was further informed by qualitative data from focus groups, family interviews and observations. 

Following this pilot phase, we developed an 18-session intervention that has been gradually refined and implemented across the city of Liverpool. 
This feasibility phase (ongoing) has allowed us to:
• explore recruitment, retention and attendance rates
• identify the most effective intervention components
• explore the acceptability of the intervention to families and staff
• measure the potential impact of the intervention. 

The intervention has been refined throughout according to this ongoing evaluation.

The practice

Partners
GOALS is managed and evaluated by Liverpool John Moores University in partnership with Liverpool City Council, Liverpool PCT, Royal Liverpool Children’s NHS Foundation Trust and the University of Salford. The project is directed by a strategic management team with representatives from all organisations, and led on a day to day basis by a Project Manager/Principal Researcher. The development and delivery team consists of a nutritionist, a physical activity specialist, a health behaviour specialist, an administrator and 12 delivery staff. 


Current intervention
The GOALS intervention has seen many developments since it was founded in 2003, and the details below refer to the intervention as it operated during the 2010-2011 funding year. The aims, ethos and framework of the intervention (ie. Fun Foods, Target Time, Move It) have remained the same throughout. Further planned developments to the intervention are described in section 3.

Structure
The GOALS intervention currently consists of 18 x 2-hour group sessions over three 6-weekly modules (each spanning approximately half a school term), followed by 6 x once a month follow ups. Sessions are run during term-time only at local schools, mostly between 5.30pm and 7.30pm. As some interventions run either side of the summer holiday period, the time it takes to run 18 sessions varies with season (sessions starting in April last approximately 7 months, sessions starting in September and November last approximately 5 months). Sessions are planned around three sections: Fun Foods (nutrition), Target Time (behaviour change and wellbeing) and Move It (physical activity)

Theoretical basis
The GOALS intervention follows a social cognitive approach to behaviour change, acknowledging the many influences on a child’s behaviour from their environment, their family and their own thoughts and behaviour. A number of behavioural change techniques are used throughout the intervention, among others self-monitoring, goal setting, and reinforcement. 

Participants
Families may take part if they have at least one child aged 3-16 who is medically classified as obese (over the 98th%ile BMI for age and sex). Interventions currently operate for 3-7 year olds, 8-12 year olds and 13-16 year olds. The minimum family unit is one child plus one adult guardian, but siblings and other family members are encouraged to join. In certain circumstances, a family which has not met the eligibility criteria (e.g. if their child is overweight rather than obese) may be permitted to join the intervention if they demonstrate a high need and motivation to change. 

Recruitment
Participants are recruited to GOALS through multiple referral pathways. These include identification via SportsLinx, referral from health professionals and self-referral in response to promotional activities (e.g. press articles, posters, leaflets, health events etc). 

Personal mentors
Prior to the first GOALS session, all families are invited to attend a lifestyle assessment, which involves a 40 minute chat to gain an insight into the family’s current diet and physical activity patterns. Each family is then assigned a personal mentor at the outset of GOALS. The personal mentor has responsibility for setting weekly goals with the family, and tracking their progress throughout the intervention. 

Childcare
During the early GOALS interventions a free on-site crèche was offered to those families who needed it. Due to the low take-up of this service, this was replaced by an offer to provide a childminder service. Over the past year, younger siblings have joined in the intervention, with staff members taking them aside for more age-appropriate activities where necessary.

Outcome measures
The following measures were collected at baseline, post-intervention, and one year post-baseline:
- Height, weight, abdominal circumference (all participating family members)
- Lifestyle questionnaire exploring physical activity and dietary habits (all participating family members, separate child and adult versions)
- 4 subscales from Harter’s (1985) Self-Perception Profile for Children: Social Acceptance; Athletic Competence; Physical Appearance; Global Self-Esteem (children over 8 only)

Process measures
- Focus groups were conducted with adults and children during week 6 of the intervention to explore its acceptability and what they perceived to be facilitators and barriers to change.
- Qualitative feedback questionnaires have been used to explore self-reported change post-intervention.

Evidencing your practice has made a difference to children, young people and families

Children who completed the GOALS intervention became less overweight for their age and sex.

The following data relates to child cohorts who completed GOALS between 2006 and 2009 (58 families). A child cohort is defined as a cohort where the average age was <12 years (Oude-Luttikhuis et al.,Cochrane Review, 2009). We have had fewer adolescent participants, but all three of our most recent adolescent cohorts have showed a median reduction in BMI SDS of at least -0.08 pre- to post- intervention.

Child BMI SDS (Body Mass Index Standard Deviation Score) 
Weight was recorded to the nearest 0.1kg and height to the nearest 0.1cm. To account for change in children’s ages from baseline, BMI (weight (kg)/height(m)2)was converted to Standard Deviation Scores based on the 1990 UK Growth Reference curves. 

Mean child BMI SDS change was -0.08 pre- to post- intervention (sd 0.17, p<0.01). In the 36 children who attended follow up, change pre- to post-intervention was slightly higher (-0.09, sd 0.19 (p<0.01)) and was maintained at 12 months (-0.09, sd 0.26 (p<0.05)). There appeared to be a gradual (though non-significant) improvement in the proportion of children that reduced BMI SDS over the three funding years (50%, 66.7% and 81.5% respectively). 

Child self-esteem
Self-esteem increased pre- to post-intervention in all four domains, though none of these changes reached significance.

Families who participated in the GOALS intervention are leading healthier lives following changes to their physical activity levels, dietary habits, psychosocial wellbeing and family relationships. 

Relationship between child BMI SDS change and adult BMI change
For the children who attended with an adult for whom BMI change data was available (n=51), there was a significant positive correlation between pre- to post-intervention BMI SDS change and adult BMI change (r =0.479, p<0.001). In the follow up group (n=29), the positive correlation between pre- to 12-month child BMI SDS change and adult BMI change was stronger (r =0.65, p<0.001). Child BMI SDS change was significantly greater (p<0.05) in those whose attending adult family member also reduced their BMI (n=23, BMI SDS change -0.14, sd 0.15) than those whose attending adult family member maintained or increased their BMI (n=28, BMI SDS change -0.02, sd 0.17); thus suggesting a whole family approach to weight loss is beneficial. 

Qualitative feedback questionnaires
Of 36 adults, 35 reported their child’s physical activity levels to have improved during the intervention, and 34 reported their family’s diet to have improved. 
Examples of physical activity changes focussed either on 
• new activities taken up 
e.g. “now goes to football, rides bike frequently, also goes to badminton and swims”; “does more walking, plays out more”
• a change in the child’s attitude towards physical activity 
e.g. “she is more aware of the balance between what she eats and her activity levels”; “tries much harder, doesn't give up as quickly”; “both more active & confident, will join more clubs”
• behavioural diet changes
e.g. “stopped eating at night”; “eat breakfast all the time, never did before”; “eat more fruit on regular basis, switched to skimmed milk, trying more vegetables, trying more recipes”
• attitudinal changes
e.g. “children more prepared to try different foods”; “read labels more”; “more aware of portion size”

Since we started running the intervention in Liverpool, we have made continuous refinements according to the ongoing evaluation. Examples of such changes include
• providing feedback on adults’ as well as children’s BMI, and setting weight targets for adults
• piloting different exit strategies to provide ongoing support after the intensive phase of the intervention finishes
• changing the way personal goals are set and rewarded.

Since April 2011, we have been piloting some further changes aimed at improving the cost-effectiveness of the programme. The most notable of these is a change in the structure of the intervention from an 18-session “closed group” to a rolling programme with an “open group” format. Through these structural changes we hope to reduce waiting times, increase capacity and improve effectiveness through offering the flexibility to stay with the programme with differing durations depending on family need and circumstances. 

We also plan to pilot a school-based version of GOALS for adolescents. There will still be a family focus to this, but different ways of involving parents (other than their required attendance every week) will be piloted. Again, it is hoped this format will allow us to reach more adolescents and increase the capacity and effectiveness of the intervention. 

Over the past two years, we have conducted a research project looking at improving the cultural relevance of GOALS for Black and Racial Minority (BRM) Groups (funded by MerseyBEAT, now Liverpool Institute for Health Inequalities Research). Through this research we have learned important messages about engaging and working with BRM populations that have resulted in changes to the way GOALS is marketed, and the way some of the sessions are run. The project identified a need for healthy living programmes for Muslim populations that are accessible through local community centres, and we hope in the future to implement GOALS programmes along these lines. 

GOALS has been piloted as a model of best practice in three other Primary Care Trusts in the country: Sandwell, Walsall and (currently underway) Blackburn with Darwen. Each of these collaborations has been bespoke to the local area, and mutual learning has occurred (and continues to occur) that has fed back into the development of the core GOALS programme in Liverpool. Feedback from PCT clients has been extremely positive, with the main benefits of working with GOALS being our recognition of local expertise and our flexibility in allowing others to tailor the programme to the needs of their local area. 

We have also drawn on what we have learned through the SportsLinx and GOALS research to provide educational messages through the media. The most notable example of this was Channel 4’s Generation XXL, through which seven obese children came into Liverpool John Moores University for health checks as part of a longitudinal observational documentary. Further information on the programme can be found athttp://www.channel4.com/programmes/generation-xxl 

Within the ongoing changes we are making (see previous section) we will maintain the elements of GOALS that we have identified through our qualitative research to be key. These include the group support, the whole family approach, the multidisciplinary model (Fun Foods, Target Time, Move It) with visual, interactive & fun sessions, the non-judgemental ethos and the focus on gradual, realistic lifestyle change. 

The impact of the structural changes will be fully evaluated and changes maintained / disregarded according to the findings. 

Whilst our findings are promising, we acknowledge the limitation of having no control group with which to compare them. This is often a challenge for short-term funded child weight management interventions (our funding has been issued one year at a time) as it would be unethical to have a “waiting-list control” for whom we could not guarantee there would be an intervention at a future stage. We have however submitted research funding applications to conduct a controlled trial of GOALS (thus far not successful) and will continue to seek funding for this crucial next step of our research. 

It is very important also to explore the long-term impact of child weight management interventions. Over the next six months, we will be revisiting families who attended GOALS several years ago to explore whether the children have maintained any reduction in BMI SDS and explore the family characteristics associated with sustained lifestyle change. 

Measuring change in physical activity and dietary behaviours continues to be a challenge, and our main evidence to date has been drawn from self-report questionnaires and qualitative focus groups. It would be beneficial to conduct a study using objective measures of physical activity such as accelerometers.

Sustaining and replicating your practice

We have produced several evaluation reports, including a summary for the feasibility period 2006-2009, an evaluation of the Sandwell PCT pilot and an evaluation of the Walsall PCT pilot. Key data from the feasibility period (highlighted in section 3) is currently being written up for peer-reviewed publication and we have published a paper discussing the relationship between adult and child BMI change (Watson PM, Dugdill L, Pickering K, Bostock S, Hargreaves J, Staniford L & Cable NT (2011) A whole family approach to childhood obesity management (GOALS): relationship between adult and child BMI change. Annals of Human Biology, 38 (4), 445-452.)
We have also presented on the GOALS development and implementation process at over 10 national conferences and published case studies of GOALS in Dugdill L, Crone D and Graham R (eds), 2009 Physical Activity and Health Promotion: Evidence-based Approaches to Practice. Wiley-Blackwells.

During the most recent year, we have been evaluating progress against pre-determined outcomes from our commissioning body (Liverpool PCT). . 

Progress towards outputs 2010 - 2011
• With 21 referrals during Q4, this brought our total for the 2010-2011 year to 113 families and within the region of the agreed 120 family target.
• All non-starters were offered an information pack.
• A total of 57 families started GOALS during the 2010-2011 funding year 
• 31 families completed GOALS during the 2010-2011 funding year. 

Qualitative feedback from families has also been collected 
“Really enjoyed whole experience. The programme makes you think about your diet & lifestyle without dictating what you need to do. Enjoyed the Move It sessions & the way the exercise varied every week. Staff extremely cheerful & boosted us every week. Thanks.” 
(mother, adolescent girls’ programme)

“Pleased to have changed some eating habits. Have tried when spare time available to eat regular meals. I think I have achieved original goals i.e. 34" waist and touch toes - don't know about weight loss yet.” 
(father, adolescent girls’ programme)

More comments can be seen here.

Funding for GOALS has been provided by the Area Based Grant, Liverpool City Council and Liverpool PCT.

Hot tips

Over the past 8 years, we have learned a lot about the development and implementation of a child weight management intervention. Below are some key messages we pass on when we train other areas to deliver. 

1. Implementing a family-based child weight management intervention is a complex process that takes time.
2. Recruitment is one of the biggest challenges, particularly in the early days. 
3. To make the whole family approach work, careful consideration must be given to practicalities. 
4. Talking about weight is important. 
5. Every child, every family, every group will be different. 
Further discussion around these tips is provided here.

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e. contactus@C4EO.org.uk

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