A Review of Primary Care-Based Childhood Obesity Prevention and Treatment Interventions

Dental-nutrition counseling for children with overweight and obesity: Evidence from a pilot study

BACKGROUND

Given the relationship between overweight and obesity (OV/OB) and poor oral health in children, paediatric dentists are uniquely positioned to provide educational interventions to children with OV/OB during dental visits.

AIM

To assess how an educational nutrition intervention delivered by dentists affected dental-nutritional behaviors and body mass index (BMI) percentile in children with OV/OB.

DESIGN

Retrospective analysis was performed using data collected on 217 patients with OV/OB aged 6-11 years who received nutritional counseling during dental visits at a Federally Qualified Health Center from September 1, 2021, through September 30, 2022. Data were collected on sociodemographic variables, oral health, and BMI percentile. Participants and their guardians were surveyed to measure the frequency of behaviors related to oral health and weight. Multivariable generalized estimating equations were constructed to determine the effect of the intervention on BMI percentile and reported dental-nutritional behaviors.

RESULTS

The intervention had no effect on the BMI percentile (p = .35). There were statistically significant reductions in the reported average number of sugar-sweetened beverages consumed daily (p < .001), reported average daily water intake (p < .001), and the reported frequency of brushing teeth (p < .001), the clinical significance of these reductions remains unclear.

CONCLUSION

Further research is needed to establish the efficacy of behavioral interventions at reducing weight and changing health behaviors.

Nutritional counselling and risk factors for obesity: an observational study in toddlers

BACKGROUND

Nutrition exerts a fundamental role in the prevention of obesity (OB). The aim of this study was to assess the extent to which well recognized risk factors for early OB can be associated to overweight (OW) or OB under a standardized nutritional approach and surveillance in toddlers.

METHODS

The eligible population was represented by 676 toddlers aged 24-36 months, assigned to 18 primary care pediatricians trained on nutritional issues who shared a standardized nutritional approach. Six-hundred-twenty-nine children (333 boys), mean age 27.8 ± 4.2 months were effectively included in this observational study. Parents received nutritional advice with particular emphasis to proteins and sugar composition supported by leaflets and reinforced at each visit. Body mass index was assessed at the age of 24-36 months. The following individual and family risk factors were considered: gestational age, birth weight, eutocic/caesarean delivery, milk feeding history, household smoking or antibiotics exposure, parents' weight, height and educational level. Prevalence of OW/OB was compared to a group of 742 toddlers (373 boys) under usual care.

RESULTS

Under a standardized nutritional counselling, 28.1% toddlers were classified as OW/OB compared to 36.9% toddlers under usual care (p = 0.005). In unadjusted models, parental OW/OB was significantly associated to OW/OB in toddlers (p < 0.01), while high birth weight did not reach statistical significance (p = 0.07). In adjusted models, including all the explanatory variables studied, only paternal OW/OB vs. normal weight was significantly associated to OW/OB in toddlers (OR 2.035, 95% confidence interval 1.206-3.436). No protective effect of exclusive breast feeding during the first 6 months of age was demonstrated.

CONCLUSIONS

Toddlers under a standardized nutrition counselling focused to limit protein and simple sugars, showed lower prevalence of OW/OB compared to usual care. Healthy promotion activities should take into account the influence of paternal BMI on the offspring adiposity.

Childhood obesity prevention in general practice: supporting implementation through co-ideation

BACKGROUND

Childhood obesity is associated with physical and psychological complications thus the prevention of excess weight gain in childhood is an important health goal. Relevant to the prevention of childhood obesity, Australian general practice-specific, preventive care guidelines recommend General Practitioners (GPs) conduct growth monitoring and promote a number of healthy behaviours. However, challenges to providing preventive care in general practice may impact implementation. In October and November, 2022, a series of three workshops focusing on the prevention of childhood obesity were held with a group of Australian GPs and academics. The objective of the workshops was to determine practical ways that GPs can be supported to address barriers to the incorporation of obesity-related prevention activities into their clinical practice, for children with a healthy weight.

METHODS

This paper describes workshop proceedings, specifically the outcomes of co-ideation activities that included idea generation, expansion of the ideas to possible interventions, and the preliminary assessment of these concepts. The ecological levels of the individual, interpersonal, and organisation were considered.

RESULTS

Possible opportunities to support childhood obesity prevention were identified at multiple ecological levels within the clinic. The preliminary list of proposed interventions to facilitate action included GP education and training, clinical audit facilitation, readily accessible clinical guidelines with linked resources, a repository of resources, and provision of adequate growth monitoring tools in general practice.

CONCLUSIONS

Co-ideation with GPs resulted in a number of proposed interventions, informed by day-to-day practicalities, to support both guideline implementation and childhood obesity prevention in general practice.

Evaluating the Implementation of the Connect for Health Pediatric Weight Management Program

Importance

Adoption of primary care interventions to reduce childhood obesity is limited. Progress in reducing obesity prevalence and eliminating disparities can be achieved by implementing effective childhood obesity management interventions in primary care settings.

Objective

To examine the extent to which implementation strategies supported the uptake of research evidence and implementation of the Connect for Health pediatric weight management program.

Design, Setting, and Participants

This quality improvement study took place at 3 geographically and demographically diverse health care organizations with substantially high numbers of children living in low-income communities in Denver, Colorado; Boston, Massachusetts; and Greenville, South Carolina, from November 2019 to April 2022. Participants included pediatric primary care clinicians and staff and families with children aged 2 to 12 years with a body mass index (BMI) in the 85th percentile or higher.

Exposures

Pediatric weight management program with clinician-facing tools (ie, clinical decision support tools) and family-facing tools (ie, educational handouts, text messaging program, community resource guide) along with implementation strategies (ie, training and feedback, technical assistance, virtual learning community, aligning with hospital performance metrics) to support the uptake.

Main Outcomes and Measures

Primary outcomes were constructs from the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework examined through parent, clinician, and leadership surveys and electronic health record data to understand the number of children screened and identified, use of the clinical decision support tools, program acceptability, fidelity to the intervention and implementation strategies, and program sustainability.

Results

The program screened and identified 18 333 children across 3 organizations (Denver Health, 8480 children [46.3%]; mean [SD] age, 7.97 [3.31] years; 3863 [45.5%] female; Massachusetts General Hospital (MGH), 6190 children [33.8%]; mean [SD] age, 7.49 [3.19] years; 2920 [47.2%] female; Prisma Health, 3663 children [20.0%]; mean [SD] age, 7.33 [3.15] years; 1692 [46.2%] female) as having an elevated BMI. The actionable flagging system was used for 8718 children (48%). The reach was equitable, with 7843 children (92.4%) from Denver Health, 4071 children (65.8%) from MGH, and 1720 children (47%) from Prisma Health being from racially and ethnically minoritized groups. The sites had high fidelity to the program and 6 implementation strategies, with 4 strategies (67%) used consistently at Denver Health, 6 (100%) at MGH, and 5 (83%) at Prisma Health. A high program acceptability was found across the 3 health care organizations; for example, the mean (SD) Acceptability of Intervention Measure score was 3.72 (0.84) at Denver Health, 3.82 (0.86) at MGH, and 4.28 (0.68) at Prisma Health. The implementation strategies were associated with 7091 (39%) uses of the clinical decision support tool. The mean (SD) program sustainability scores were 4.46 (1.61) at Denver Health, 5.63 (1.28) at MGH, and 5.54 (0.92) at Prisma Health.

Conclusions and Relevance

These findings suggest that by understanding what strategies enable the adoption of scalable and implementation-ready programs by other health care organizations, it is feasible to improve the screening, identification, and management of children with overweight or obesity and mitigate existing disparities.

Assessment of the potential effects of l-carnitine and cinnamon supplementation on weight loss and body composition

OBJECTIVE

Aim: To assess efficacy of L-carnitine and cinnamon alone and in combination on body composition parameters in addition to compare between them.

PATIENTS AND METHODS

Materials and Methods: Sample of 28 obese and overweight adults in Babylon city, sample collection includes patients in places, or by internet, where interview take place according to specialize questionnaire height, weight, and body mass index were measured.

RESULTS

Results: A significant differences P<0.05 among gender distribution between male and female. A significant difference between (150-160 cm, 160-170 cm) as compared with (170-180 cm, 180-190 cm). A significant difference between 170-180 cm as compared with 180-190 cm but non-significant differences between 150-160 cm as compared with 160-170 cm. A significant difference between 26-35 as compared with 36-45, 46-55, but non-significant differences between 36-45 as compared with 46-55. A significant difference between body weight, body fat, water content, skeletal muscle, and body mass index after treatment, but non-significant differences between protein, and inorganic salt after treatment and at baseline. A significant difference between body weight, water content, skeletal muscle, and body mass index in group treated with cinnamon as compared with negative control group, but non-significant differences between body fat, protein, and inorganic salt as compared with negative control group.

CONCLUSION

Conclusions: The prevalence of overweight and obesity within accepted range of that reported in Iraq, important relationship was reported between several life style risk factor, as soon as diagnose increase in weight and education health program for behavior of life style were high recommended.

Should We "Wait and See"?: Change in Weight Status Among US Adolescents in the Population Assessment of Tobacco and Health Study

Background: Many parents and providers adopt a "wait and see" approach to obesity (OB) management. The goal of this study was to determine the likelihood that youth with overweight (OW) or OB would become normal weight over time. Methods: Data from the nationally representative Population Assessment of Tobacco and Health Study were used to examine the proportion of teens (aged 12-17 years) with OW/OB who tracked into a lower weight category over four waves of data collection (2013-2018). Analysis was restricted to those who completed all four waves of assessments (n = 10,086). Repeated-measures logistic regression models were used to describe the odds of having a BMI within the normal weight range at Waves 2-4, given an OW or obese weight status in the previous wave. Results: At Wave 1, 65% of the sample was normal weight, 18% had OW, and 17% had OB. By Wave 4, 24% had OW and 20% had OB. The adjusted odds of reporting a normal weight relative to OW/OB decreased by 13% each year. In Wave 4, only 2% [standard error (SE) 0.4%] of boys and 2% (SE 0.3%) of girls transitioned from OB to normal weight. For youth with OB in Wave 1, the probability of being in the normal weight category in Wave 2 was 0.04 (95% confidence interval 0.035-0.052), and decreased thereafter. Conclusion: Very few teens were able to return to normal weight once they developed OW/OB. Adopting a "wait and see" approach to OB management may be detrimental to a child's health.

Impact of ¡Míranos! on parent-reported home-based healthy energy balance-related behaviors in low-income Latino preschool children: a clustered randomized controlled trial

BACKGROUND

Widespread establishment of home-based healthy energy balance-related behaviors (EBRBs), like diet, physical activity, sedentary behavior, screen time, and sleep, among low-income preschool-aged children could curb the childhood obesity epidemic. We examined the effect of an 8-month multicomponent intervention on changes in EBRBs among preschool children enrolled in 12 Head Start centers.

METHODS

The Head Start (HS) centers were randomly assigned to one of three treatment arms: center-based intervention group (CBI), center-based plus home-based intervention group (CBI + HBI), or control. Before and following the intervention, parents of 3-year-olds enrolled in participating HS centers completed questionnaires about their child's at-home EBRBs. Adult-facilitated physical activity (PA) was measured by an index based on questions assessing the child's level of PA participation at home, with or facilitated by an adult. Fruit, vegetable, and added sugar intake were measured via a short food frequency questionnaire, and sleep time and screen time were measured using 7-day logs. A linear mixed effects model examined the intervention's effect on post-intervention changes in PA, intake of fruit, vegetable, and added sugar, sleep time, and screen time from baseline to post-intervention.

RESULTS

A total of 325 parents participated in the study (CBI n = 101; CBI + HBI n = 101; and control n = 123). Compared to control children, CBI and CBI + HBI parents reported decreases in children's intake of added sugar from sugar-sweetened beverages. Both CBI and CBI + HBI parents also reported smaller increases in children's average weekday screen time relative to controls. In addition, CBI + HBI parents reported CBI + HBI parents reported increases in children's adult-facilitated PA, fruit and vegetable intake, and daily sleep time during weekdays (excluding weekends) and the total week from baseline to post-intervention, while children in the CBI increased sleep time over the total week compared to the children in the control group.

CONCLUSIONS

Parent engagement strengthened the improvement in parent-reported EBRBs at home in young children participating in an evidence-based obesity prevention program in a childcare setting. Future studies should investigate equity-related contextual factors that influence the impact of obesity prevention in health-disparity populations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03590834. Registered July 18, 2018, https://clinicaltrials.gov/ct2/show/NCT03590834.

Effectiveness of a Smartphone App (MINISTOP 2.0) integrated in primary child health care to promote healthy diet and physical activity behaviors and prevent obesity in preschool-aged children: randomized controlled trial

BACKGROUND

Childhood overweight and obesity is a public health priority. We have previously reported the efficacy of a parent-oriented mobile health (mHealth) app-based intervention (MINISTOP 1.0) which showed improvements in healthy lifestyle behaviors. However, the effectiveness of the MINISTOP app in real-world conditions needs to be established.

OBJECTIVE

To evaluate the real-world effectiveness of a 6-month mHealth intervention (MINISTOP 2.0 app) on children's intake of fruits, vegetables, sweet and savory treats, sweet drinks, moderate-to-vigorous physical activity, and screen time (primary outcomes), and on parental self-efficacy (PSE) for promoting healthy lifestyle behaviors, and children's body mass index (BMI) (secondary outcomes).

METHODS

A hybrid type 1 effectiveness-implementation design was utilized. For the effectiveness outcomes, a two-arm, individually randomized controlled trial was conducted. Parents (n = 552) of 2.5-to-3-year-old children were recruited from 19 child health care centers across Sweden, and, randomized to either a control (standard care) or intervention group (MINISTOP 2.0 app). The 2.0 version was adapted and translated into English, Somali and Arabic to increase reach. All recruitment and data collection were conducted by the nurses. Outcomes were assessed at baseline and after six months, using standardized measures (BMI) and a questionnaire (health behaviors, PSE).

RESULTS

Among the participating parents (n = 552, age: 34.1 ± 5.0 years), 79% were mothers and 62% had a university degree. Twenty-four percent (n = 132) of children had two foreign-born parents. At follow-up, parents in the intervention group reported lower intakes of sweet and savory treats (-6.97 g/day; p = 0.001), sweet drinks (-31.52 g/day; p < 0.001), and screen time (-7.00 min/day; p = 0.012) in their children compared to the control group. The intervention group reported higher total PSE (0.91; p = 0.006), PSE for promoting healthy diet (0.34; p = 0.008) and PSE for promoting physical activity behaviors (0.31; p = 0.009) compared to controls. No statistically significant effect was observed for children's BMI z-score. Overall, parents reported high satisfaction with the app, and 54% reported using the app at least once a week.

CONCLUSION

Children in the intervention group had lower intakes of sweet and savory treats, sweet drinks, less screen time (primary outcomes) and their parents reported higher PSE for promoting healthy lifestyle behaviors. Our results from this real-world effectiveness trial support the implementation of the MINISTOP 2.0 app within Swedish child health care.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04147039; https://clinicaltrials.gov/ct2/show/NCT04147039.

Baseline Targeted Moderation in a Trial of the Family Check-Up 4 Health: Potential Explanations for Finding Few Practical Effects

Not all participants will benefit equally from even well-established, evidence-based prevention programs. For this reason, the field of prevention science is beginning to embrace individual tailoring of interventions. The Family Check-Up was among the first prevention programs to tailor at the family level as opposed to the more prevalent focus on adapting programs for different cultures, genders, and other immutable participant characteristics. Despite tailoring, families with lower levels of stress and parental mental health issues, children with lower baseline conduct problems, and families living in an extremely deprived neighborhood benefitted less from the Family Check-Up. This study examined baseline targeted moderation (BTM) within a trial of the Family Check-Up 4 Health (FCU4Health) program, an adaptation of the Family Check-Up for primary care delivery and explicit targeting of obesogenic behaviors. Ethnically diverse, low-income families (N = 240) with children ages 5.5 to 12 years identified in pediatric primary care with elevated body mass index (BMI) were enrolled and randomized to FCU4Health or usual care. Few BTM effects were found using single-variable-as-moderator and latent-class-as-moderator analytic approaches across the primary (child BMI, body composition) and secondary outcomes (family health routines; child eating behaviors, food choices, emotional problems, problem behaviors, quality of life; caregiver BMI and body composition), as well as hypothesized mediators (child self-regulation, parenting skills). The high-risk nature of the sample and the FCU4Health being individually tailored might have mitigated finding BTM effects. This trial was prospectively registered (NCT03013309 ClinicalTrials.gov).

Primary Care Clinicians' Perceived Role in Addressing Childhood Obesity in the Southern United States

OBJECTIVES

Primary care is an opportune setting to promote healthy behaviors for children and families. In 2007, an expert committee recommended that pediatric primary care clinicians assess nutrition and physical activity at wellness visits and offer recommendations; however, little is known about what pediatric primary care clinicians perceive their role as in childhood weight management. This qualitative study aimed to describe the perceived role of pediatric primary care clinicians in the prevention and treatment of childhood obesity in South Carolina, a state in the southern United States with high rates of childhood obesity.

METHODS

Pediatric primary care clinicians (n = 23) from South Carolina were recruited for two focus groups. Participants were asked semistructured, open-ended questions, and audio recordings were transcribed verbatim. Themes and subthemes were identified through an iterative coding and consensus-building process with two coders. Excerpts coded under the parent code of "clinician role" centered on three themes: conducting assessments, making referrals, and providing education.

RESULTS

Pediatric primary care clinicians in South Carolina coalesced around the important role of addressing childhood obesity within primary care. Notably, clinicians primarily discussed treatment rather than prevention strategies and described changes in the scope of their practice over time as a result of the increasing numbers of pediatric patients with obesity.

CONCLUSIONS

Addressing childhood obesity within primary care is a critical component of obesity prevention and treatment in the southern United States. Effective, sustainable prevention and treatment within primary care will depend on the involvement of pediatric clinicians, thus emphasizing the importance of understanding how they perceive their role within this setting.

Clinical practice guidelines for the prevention of childhood obesity: A systematic review of quality and content

Obesity in childhood is a significant global issue, and prevention is key to reducing prevalence. Healthcare providers can play an important role in the prevention of obesity. The aim of this systematic review was to identify and evaluate clinical practice guidelines (CPGs) for preventing childhood obesity with a focus on the role of medical doctors. Peer-reviewed literature and gray literature sources were searched for CPGs published from 2010 to 2021. Eleven CPGs were identified. Quality was evaluated using the Appraisal of Guidelines for Research and Evaluation Collaboration (AGREE II) instrument; seven CPGs were higher quality and four lower quality. Recommendations within the CPGs covered three main areas: growth monitoring, maintaining a healthy weight, and managing overweight. The importance of involving the whole family and healthy lifestyle behaviors was emphasized. The majority of the CPGs rated poorly in guideline applicability highlighting the need for practical implementation tools. Although our review identified a number of CPGs relevant to the prevention of obesity for doctors working with children and their families, more research is needed to produce high-quality meaningful and applicable CPGs to maximize uptake, implementation, and ultimately, benefit to children and their families.

A Longitudinal Effectiveness Study of a Child Obesity Electronic Health Record Tool

BACKGROUND

Primary-care providers, clinic staff, and nurses play an important role in reducing child obesity; yet time restraints and clinical demands compete with effective pediatric weight management and prevention.

METHODS

To investigate the potential impact of an electronic health record (EHR) enabled tool to assist primary care teams in addressing child obesity, we conducted a controlled effectiveness study of FitTastic compared with usual care on the BMI pattern of 291 children (2 to 17 years) up to 4 years later.

RESULTS

Per χ2 analysis, a greater proportion of children with baseline overweight/obesity in the EHR tool group than the control group had a favorable BMI pattern (32% vs 13%, P = .03). In logistic regression, FitTastic children were more likely than control children to have a favorable BMI pattern at follow-up (OR 3.8, 95% CI 1.1 to 13.2), adjusted for age, gender, race, and parental education.

CONCLUSION

Study findings suggest that EHR-enabled tools to assist primary care teams in managing child obesity may be useful for helping to address the weight in children with overweight/obesity, especially in younger children (2 to 5 years). Digital and EHR-enabled technologies may prove useful for partnering health care teams and families in the important tasks of setting positive, family-centered healthy lifestyle behavioral goals and managing child overweight and obesity.

Adapting pediatric obesity care to better suit adolescent patients: Design of a treatment platform and results compared with standard care in the national patient quality register

BACKGROUND

Obesity constitutes a critical risk for adolescent health. This study aimed at identifying youth-friendly components of obesity treatment.

METHODS

In this feasibility study, an adolescent obesity treatment platform was implemented at two Pediatric outpatient clinics in Sweden. Body mass index (BMI), BMI z-score, and the category of obesity (International Obesity Task Force) were compared before and after the intervention and with data on standard care from the Swedish Childhood Obesity Treatment Register.

RESULTS

The study included 99 participants (49 females) aged 13-18 years from 1 September 2014, to 31 December 2016. A pediatric nurse met the participants on average 6.5 times in the average inclusion period of 15 months. Physical activity sessions attracted 63 participants. Acceptance Commitment Therapy and In Real Life groups attracted 24 participants. At inclusion, 62 participants had obesity and 37 severe obesity, and 71/99 (72%) remained in the same category. The mean BMI increased from 32.0 to 33.4 kg/m2 (p < 0.01), but 56/94 (60%) participants lowered their BMI or increased less than 1 kg/m2 and 73% stayed to the end of the study. Participants who were new to treatment and participants coming for more than eight visits to the nurse did not increase in BMI. BMI did not change for the 221 out of 641 register patients who had two recordings of BMI in the study period.

CONCLUSIONS

The platform was successful in increasing retention, and 60% of participants lowered or maintained their BMI. Still, seven out of ten adolescents with obesity or severe obesity remained in the same weight category.

Implementation of a Scalable Family-Based Behavioral Treatment for Childhood Obesity Delivered through Primary Care Clinics: Description of the Missouri Childhood Obesity Research Demonstration Study Protocol

Background: Significant gaps exist in access to evidence-based pediatric weight management interventions, especially for low-income families who are disproportionately affected by obesity. As a part of the Centers for Disease Control and Prevention's Childhood Obesity Research Demonstration project (CORD 3.0), the Missouri team (MO-CORD) aims to increase access to and dissemination of an efficacious pediatric obesity treatment, specifically family-based behavioral treatment (FBT), for low-income families. Methods/Design: The implementation pilot study is a multisite matched-comparison group pilot of packaged FBT in pediatric clinics for low-income children with obesity, of ages 5 to 12 years old. The study is implemented in two Missouri pediatric primary care clinical sites, Freeman Health System Pediatric Clinics (rural Joplin) and Children's Mercy Hospital Pediatric Clinics (urban Kansas City). The design focuses on pragmatism through utilization of PRECIS (Pragmatic Explanatory Continuum Indicator Summary) domains, such as open eligibility criteria, limited follow-up intensity, reliance on medical records for creating a usual care comparison group data, and unobtrusive measurement of participant and provider adherence. The evaluation focuses on effectiveness as well as implementation outcomes and barriers to inform implementation scale up. Conclusions: Findings from this study will advance both science and practice by providing novel and immediately useful information to families, health care providers, health care organizations, payers, and other state Medicaid plans by developing and optimizing evidence-based pediatric weight management treatment for implementation and dissemination in health systems to address health disparities among low-income populations most affected by overweight and obesity.

Health behaviour outcomes of a family based intervention for paediatric obesity in primary care: A randomized type II hybrid effectiveness-implementation trial

BACKGROUND

Paediatric obesity is a multifaceted public health problem. Family based behavioural interventions are the recommended approach for the prevention of excess weight gain in children and adolescents, yet few have been tested under "real-world" conditions.

OBJECTIVES

To evaluate the effectiveness of a family based intervention, delivered in coordination with paediatric primary care, on child and family health outcomes.

METHODS

A sample of 240 families with racially and ethnically diverse (86% non-White) and predominantly low-income children (49% female) ages 6 to 12 years (M = 9.5 years) with body mass index (BMI) ≥85th percentile for age and gender were identified in paediatric primary care. Participants were randomized to either the Family Check-Up 4 Health (FCU4Health) program (N = 141) or usual care plus information (N = 99). FCU4Health, an assessment-driven individually tailored intervention designed to preempt excess weight gain by improving parenting skills was delivered for 6 months in clinic, at home and in the community. Child BMI and body fat were assessed using a bioelectrical impedance scale and caregiver-reported health behaviours (eg, diet, physical activity and family health routines) were obtained at baseline, 3, 6 and 12 months.

RESULTS

Change in child BMI and percent body fat did not differ by group assignment. Path analysis indicated significant group differences in child health behaviours at 12 months, mediated by improved family health routines at 6 months.

CONCLUSION

The FCU4Health, delivered in coordination with paediatric primary care, significantly impacted child and family health behaviours that are associated with the development and maintenance of paediatric obesity. BMI did not significantly differ.

Adapting a Parental Support App to Promote Healthy Diet and Physical Activity Behaviors (MINISTOP) for a Multi-Ethnic Setting: A Qualitative Study on the Needs and Preferences of Parents and Nurses within Swedish Child Health Care

Early efforts for prevention of childhood overweight and obesity are needed. In order to adapt an app promoting healthy diet and physical activity behaviors in children (MINISTOP 1.0) for multi-ethnic communities, we explored: (1) needs and concerns among Somali-, Arabic-, and Swedish-speaking parents in terms of supporting healthy diet and activity behaviors in their children; (2) nurses’ perceptions of parental needs and concerns in relation to diet and physical activity behaviors; and (3) how the features and content of the MINISTOP 1.0 app could be refined to better support health behaviors in children, among both parents and nurses. Focus groups with Somali-, Arabic-, and Swedish-speaking parents (n = 15), and individual interviews with nurses (n = 15) were conducted. Parents expressed several challenges in supporting children’s health behaviors, the need for a tailored app, and alternative ways of accessing the content (audio/video). Nurses emphasized the need of supporting parents early, and the value of a shared platform in different languages, to facilitate communication. This study contributes valuable insights about parental needs and relevant adaptations to a parental support app, such as addition of audio/video files for increased accessibility. This adapted app version—MINISTOP 2.0, can be useful for childhood obesity prevention in multi-ethnic communities.

Giving "prescriptions" for paediatric weight management follow-up in primary care

The American Academy of Paediatrics recommends that primary care paediatricians "prescribe" follow-up for weight management between well child checks. We sought to describe rates and predictors of prescribed and actual clinic attendance for weight management in primary care in a predominantly low-income population. A chart review was performed at a large, hospital-based, primary care clinic, where a treatment algorithm for obesity exists. Eligible children were 6 to 12 years of age with a body mass index (BMI) ≥85th percentile and seen for a well child check in 2014. Primary outcomes were the physician prescribing follow-up in primary care and the patient returning for weight management. Multivariable logistic regression was used to identify predictors of prescribing follow-up and predictors of return. Participants included 1339 patients: mean age 9 years (SD: 1.8 years); 53% female; 79% Black; 89% Medicaid-insured; 56% with an obese BMI (vs overweight). Twenty-seven percent of patients were prescribed follow-up in primary care, of which 13% returned (only 4% of the original sample). The odds of the physician prescribing follow-up were greater if the child had obesity (vs overweight), was older, female or non-Medicaid insured. Older and non-Black patients had greater odds of returning. Patients prescribed follow-up within 2 months or less (vs 3-6 months) were also more likely to return (aOR 2.66; CI: 1.34, 5.26). Rates of prescription for weight management in primary care are low and few patients return, even when follow-up is prescribed. Prescribing follow-up at shorter intervals from the index visit (≤ 2 months) may improve patient return.

Individual Physical Activity Behaviour and Group Composition as Determinants of the Effectiveness of a Childhood Obesity Intervention Program

INTRODUCTION

Up to now, there is limited clarity on factors that determine the effectiveness of childhood obesity interventions.

OBJECTIVE

This study intends to uncover individual- and program-level predictors of BMI-SDS and fitness to achieve significant, sustainable health improvements.

METHODS

Data of 249 children with obesity or overweight who participated in an outpatient multidisciplinary program were analysed and compared to 54 waitlist controls. Linear regression models were used to examine associations between individual- and group-level variables and BMI-SDS and fitness.

RESULTS

Among intervention children, BMI-SDS decreased by 0.19 units and physical fitness increased by 11.5%, versus a BMI-SDS decrease of 0.07 and a 1.8% decrease in fitness in the control group. Participants who reported being physically active before the program start achieved greater improvements in BMI-SDS (β = -0.177, p < 0.05) and physical fitness (β = 0.174, p < 0.05) than inactive peers. BMI-SDS decreased significantly more for members of gender-heterogeneous groups (β = 0.194, p < 0.05) with a narrow age range (β = 0.152, p < 0.05).

CONCLUSIONS

The program under review is effective in counteracting juvenile obesity. The results give reason to believe that forming mixed-gender groups with a small age range and providing increased support for reportedly inactive children may improve program effectiveness.

MINISTOP 2.0: a smartphone app integrated in primary child health care to promote healthy diet and physical activity behaviours and prevent obesity in preschool-aged children: protocol for a hybrid design effectiveness-implementation study

Background

Childhood obesity is still a major health problem in many countries, including Sweden. Childhood obesity and obesity-related behaviours in childhood, such as low physical activity and unhealthy eating habits, tend to track into adulthood, which highlights the need for early prevention. Our aims are to evaluate whether a parent-oriented mobile health app (the MINISTOP 2.0 app) integrated into primary child health care can improve diet and physical activity behaviours and reduce the prevalence of overweight and obesity in preschool-aged children as well as to evaluate the implementation among child health care nurses and parents.

Methods

This trial uses a hybrid type 1 effectiveness-implementation design. Families (n = 500) who attend a routine visit to one of 15–20 primary child health care centres throughout Sweden, when their child is 2.5 years, are offered participation in a randomised controlled trial (effectiveness evaluation). After acceptance, families will be randomised (1:1) to control or intervention groups. The intervention group receives a 6-month parent-oriented smartphone intervention aimed at improving the dietary and activity behaviours of their child (the MINISTOP 2.0 app) and the control group receives routine child health care. Dietary habits, physical activity and screen time (primary outcomes), body weight and height in children, and parental self-efficacy (secondary outcomes) are measured at baseline and at 6 months post randomisation. Implementation outcomes (i.e. perceived acceptability, appropriateness, and feasibility) of the intervention will be assessed among primary child health care nurses and parents in the trial through questionnaires and qualitative interviews.

Discussion

This trial will evaluate whether the MINISTOP 2.0 app can be used in primary child health care to improve diet and physical activity behaviours, and prevent overweight and obesity, in preschool-aged children. If effectiveness is proven, and the MINISTOP 2.0 app is considered acceptable, appropriate and feasible, it can be implemented nationally as part of the preventive strategies to combat childhood obesity provided by routine child health care.

Trial registration

The trial was registered at the Clinicaltrials.gov register platform (ID NCT04147039) on 31 October 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09808-w.

Higher Child Body Mass Index Is Associated with Greater School-Based Health Center Utilization

Background: Children with overweight status and obesity seek care for acute illnesses more often than normal weight peers. School-based health centers (SBHCs) have a role in acute and chronic disease management; however, little is known about SBHC use by children with overweight status and obesity. This study compared SBHC utilization by student body mass index (BMI) category and investigated whether SBHC visit diagnoses varied by BMI category. Methods: We performed a retrospective analysis of students (n = 1161) in grades K-8 enrolled in a large SBHC for 2 years. Negative binomial regression models were used to test the independent association between BMI category as defined by BMI percentile [normal/underweight (BMI percentile <85%) and overweight/obesity (BMI percentile ≥85%), either overweight (85% ≤BMI percentile <95%) or obesity (BMI percentile ≥95%)], and the number of SBHC visits (nurse, clinician, and total visits) for the 2-year interval. Top five diagnoses based on ICD-10 visit codes were compared. Results: Students in the overweight/obesity category (BMI percentile ≥85%) had higher visit rates than normal/underweight peers after adjusting for age and gender, but only total visits were statistically significant [nurse: incident rate ratio (IRR) 1.42 (95% CI 0.94-2.15); clinician: 1.27 (95% CI 0.93-1.75); total: 1.45 (95% CI 1.02-2.07)]. Visit diagnoses were similar by BMI category. Conclusions: Students with higher BMI percentiles, categorized as overweight/obesity, had higher SBHC utilization than normal/underweight peers, but visit diagnoses were similar. This higher utilization may provide an as-yet untapped opportunity to expand school-based obesity prevention and management.

Cultural adaptation of an existing children's weight management programme: the CHANGE intervention and feasibility RCT

BACKGROUND

Excess weight in children is a continuing health issue. Community-based children's weight management programmes have had some effect in promoting weight loss. Families from minority ethnic communities are less likely to complete these programmes but, to date, no programmes have been culturally adapted to address this.

OBJECTIVES

We aimed to (1) culturally adapt an existing weight management programme for children aged 4-11 years and their families to make it more suited to Pakistani and Bangladeshi communities but inclusive of all families and (2) evaluate the adapted programme to assess its feasibility and acceptability, as well as the feasibility of methods, for a future full-scale trial.

DESIGN

In phase I, a cultural adaptation of a programme that was informed by formative research and guided by two theoretical frameworks was undertaken and in phase II this adapted programme was delivered in a cluster-randomised feasibility study (for which the clusters were the standard and adapted children's weight management programmes).

SETTING

Birmingham: a large, ethnically diverse UK city.

PARTICIPANTS

In phase I, Pakistani and Bangladeshi parents of children with excess weight, and, in phase II, children aged 4-11 years who have excess weight and their families.

INTERVENTIONS

A culturally adapted children's weight management programme, comprising six sessions, which was delivered to children and parents, targeting diet and physical activity and incorporating behaviour change techniques, was developed in phase I and delivered in the intervention arm to 16 groups in phase II. The eight groups in the comparator arm received the standard (unadapted) children's weight management programme.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of Pakistani and Bangladeshi families completing (attending ≥ 60% of) the adapted programme. Secondary outcomes included the proportion of all families completing the adapted programme, the feasibility of delivery of the programme, the programme's acceptability to participants, the feasibility of trial processes and the feasibility of collection of outcome and cost data.

RESULTS

The proportion of Pakistani and Bangladeshi families and all families completing the adapted programme was 78.8% [95% confidence interval (CI) 64.8% to 88.2%] and 76.3% (95% CI 67.0% to 83.6%), respectively. The programme was feasible to deliver with some refinements and was well received. Ninety-two families participated in outcome data collection. Data collection was mostly feasible, but participant burden was high. Data collection on the cost of programme delivery was feasible, but costs to families were more challenging to capture. There was high attrition over the 6-month follow-up period (35%) and differential attrition in the two study arms (29% and 52% in the intervention and comparator arms, respectively).

LIMITATIONS

The study was not designed to address the issue of low participant uptake of children's weight management programmes. The design of a future trial may include individual randomisation and a 'minimal intervention' arm, the acceptability of which has not been evaluated in this study.

CONCLUSIONS

The theoretically informed, culturally adapted children's weight management programme was highly acceptable to children and families of all ethnicities. Consideration should be given to a future trial to evaluate clinical effectiveness and cost-effectiveness of the adapted programme, but the design of a future trial would need to address the logistics of data collection, participant burden and study attrition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81798055.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 33. See the NIHR Journals Library website for further project information. Kate Jolly is part-funded by the Collaboration for Leadership in Applied Health Research and Care West Midlands.

Childhood Obesity Evidence Base Project: A Systematic Review and Meta-Analysis of a New Taxonomy of Intervention Components to Improve Weight Status in Children 2-5 Years of Age, 2005-2019

Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

Reach of a low-intensity, multicomponent childhood overweight and obesity intervention delivered in an integrated primary care setting

Reach (i.e., proportion and representativeness of participants) of low-intensity, multicomponent childhood overweight/obesity interventions delivered in primary care settings with low-income and/or minority families is unknown. The purpose of this research is to describe the reach of a low-intensity, multicomponent childhood overweight/obesity intervention delivered in an integrated primary care setting in a federally qualified health center (FQHC). Eligibility criteria included children aged 4-10 years with a body mass index (BMI) ≥85th percentile, with a female caregiver. Using the electronic health record (EHR) and release forms, families were broadly categorized into groupings from recruitment flow, with differing proportions calculated from these groupings. Representativeness was determined using EHR data from families who were informed about the program (n = 963). Three calculated reach rates ranged from 54.9% to 3.9%. Lower reach rates were calculated using the number of families randomized (n = 73) as the numerator and the children from families who were informed about the program (n = 963) or all eligible children in the FQHC attending appointments (n = 1,864) as denominators. The first two steps in recruitment, informing families about the program and families initiating participation, were where the largest decreases in reach occurred. Children who were randomized were older, had a higher BMI, had a greater number of medical diagnoses indicating overweight or obesity, and were Hispanic. Reach of the intervention was low. Strategies that assist with reducing time for informing families of treatment and increasing families' awareness of their child's weight status should assist with enhancing reach.

Engaging stakeholders in the adaptation of the Connect for Health pediatric weight management program for national implementation

Background

Connect for Health is an evidence-based weight management program with clinical- and family-facing components for delivery in pediatric primary care for families of children ages 2 to 12 years. We used the Consolidated Framework for Implementation Research (CFIR) to guide formative work prior to national implementation. The purpose of this study was to describe the process and results of stakeholder engagement and program adaptation.

Methods

We used mixed qualitative and quantitative methods to iteratively adapt and optimize the program by assessing needs and perspectives of clinicians and parents, as well as contextual barriers, facilitators, and organizational readiness for the uptake of the proposed program tools and implementation strategies. We conducted interviews with primary care clinicians from four health care organizations in Boston, MA; Denver, CO; and Greenville, SC, and used principles of immersion-crystallization for qualitative analyses. We also conducted surveys of parents of children with a body mass index ≥ 85th percentile.

Results

We reached thematic saturation after 52 clinician interviews. Emergent themes representing the CFIR domains of intervention characteristics, outer and inner setting, and process included (1) importance of evidence-based clinical decision support tools that integrate into the workflow and do not extend visit time, (2) developing resources that respond to family’s needs, (3) using multimodal delivery options for family resources, (4) addressing childhood obesity while balancing competing demands, (5) emphasizing patient care rather than documentation and establishing sustainability plans, and (6) offering multiple training methods that incorporate performance feedback. Of the parents surveyed (n = 400), approximately 50% were Spanish-speaking and over 75% reported an annual income < $50,000. Parents affirmed the importance of addressing weight management during well-child visits, being provided with referrals and resources, and offering multiple methods for resource delivery. Decisions about program modifications were made at the program and healthcare-system level and based on stakeholder engagement findings. Modifications included cultural, geographic, and target audience adaptations, as well as varied resource delivery options.

Conclusions

To ensure the fit between the Connect for Health program and national implementation settings, adaptations were systematically made through engagement of clinician and parent stakeholders to support adoption, sustainability, and health outcomes.

Trial registration

NCT04042493

Treatment of Childhood Obesity Based on Brazilian Dietary Guidelines Plus Energy Restriction (PAPPAS HUPE Study): Protocol for a Randomized Clinical Trial

Background

The Food Guide for the Brazilian Population relies on natural or minimally processed foods mainly of plant origin such as beans and rice with low oil, salt, and sugar content and limited consumption of ultraprocessed foods. Reduction of ultraprocessed foods improves diet quality and energy consumption.

Objective

The goal of this study is to evaluate the effectiveness of an intervention for the treatment of obesity in children, with counseling based on the Brazilian Food Guide plus control of total energy intake.

Methods

A parallel, randomized clinical trial will include children aged 7 to 12 years. Randomization will be performed in blocks of 10 individuals using computer-generated random sequence numbers. Both the control and intervention groups will participate in 6 standardized educational activities based on the 10 steps of the Brazilian Food Guide. These activities will be conducted at the University Hospital Toy Library, located in the pediatric outpatient clinic. For the intervention group, in addition to the educational activities, an individualized food plan based on the nutritional recommendations of the Brazilian Society of Pediatrics will be prescribed and discussed with the mothers and fathers. The primary outcome of the study will be variations in body mass index, and secondary outcomes will include analysis of insulin resistance, blood pressure, body fat percentage, and waist and neck circumference.

Results

This project was funded by the National Council for Scientific and Technological Development in December 2017 (grant no 408333/2017-0). Recruitment began in August 2018 and by September 2019, we had enrolled the 101 participants. In addition to the patients referred by the national system of regulation, recruitment was made by medical outpatient referral and external indication. This is an ongoing study. We expect the results to be published in November 2020.

Conclusions

At the end of the project, in case of a positive result, a protocol for the treatment of obesity based on the Brazilian Food Guide will be proposed to the Unified Health System. A successful method to reduce childhood obesity is expected.

Trial Registration

Brazilian Registry of Clinical Trials RBR-3st5sn; http://www.ensaiosclinicos.gov.br/rg/RBR-3st5sn

International Registered Report Identifier (IRRID)

DERR1-10.2196/16170

A developmental cascade perspective of paediatric obesity: A systematic review of preventive interventions from infancy through late adolescence

The goals of this systematic review were to identify and describe paediatric obesity prevention interventions from infancy to late adolescence and to provide recommendations for future intervention research in light of a recently proposed developmental cascade (DC) model of paediatric obesity. We conducted an electronic search of randomized controlled trials with a minimum 6-month postintervention follow-up published between 1995 and 2019. We included 74 interventions: prenatal/infancy (n = 4), early childhood (n = 11), childhood (n = 38), early to mid-adolescence (n = 18), and late adolescence (n = 3). Infancy and early childhood trials targeted early feeding and positive parenting skills. Half of the childhood and adolescence trials were school based and used universal prevention strategies; those classified as selective or indicated prevention tended to involve the family for more intensive lifestyle modification. Less than 10% of studies followed participants over long periods of time (greater than or equal to 5 years), and only 16% and 31% of studies assessed intervention mediators and moderators, respectively. We recommend that future interventions focus on early prevention, assess long-term intervention effects, use a standardized taxonomy for defining intervention behavioural strategies, assess underlying mechanisms of action and intervention moderators, target parent and family management strategies across development, and increase scientific equity. We also provide specific recommendations regarding intervention targets for each developmental stage.

No additional long-term effect of group vs individual family intervention in the treatment of childhood obesity-A randomised trial

AIM

Long-term evaluations of childhood obesity treatments are needed. We examined changes in weight and cardiometabolic risk 1 year after children completed individual family or group-based weight management interventions.

METHODS

In 2009-2010, 6- to 12-year-old children with overweight or obesity from Finnmark and Troms (Norway) were recruited after media coverage and randomised to 24 months of individual family (n = 49) or group intervention (n = 48). Individual family intervention included counselling by a paediatric hospital team and a public health nurse in the local community. Group intervention included meetings with other families and a multidisciplinary hospital team, weekly physical activity sessions and a family camp. The primary outcome body mass index (BMI) and cardiometabolic risk factors were analysed 12 months after intervention.

RESULTS

From baseline to 36 months, children's BMI increased 3.0 kg/m² in individual family and 2.1 kg/m² in group intervention (between-group -0.9kg/m² , P = 0.096). Data were available from 62 children (64%). Between-group differences in C peptide (P = 0.01) were detected in favour of group intervention. Pooled data from both treatment groups showed continued decrease in BMI standard deviation score (P < 0.001).

CONCLUSION

No between-group difference in BMI was observed 12 months after intervention. Both groups combined showed sustained decrease in BMI standard deviation score.

Exploring how lifestyle weight management programmes for children are commissioned and evaluated in England: a mixed methodology study

OBJECTIVE

To assess how lifestyle weight management programmes for children aged 4-16 years in England are commissioned and evaluated at the local level.

DESIGN

This was a mixed-methods study comprising an online survey and semistructured telephone interviews.

SETTING

An online survey was sent to all local authorities (LAs) in England regarding lifestyle weight management services commissioned for children aged 4-16 years. Online survey data were collected between February and May 2016 and based on services commissioned between April 2014 and March 2015. Semistructured telephone interviews with LA staff across England were conducted between April and June 2016.

PARTICIPANTS

Commissioners or service providers working within the public health department of LAs.

MAIN OUTCOME MEASURES

The online survey collected information on the evidence base, costs, reach, service usage and evaluation of child lifestyle weight management services. The telephone interviews explored the nature of child weight management contracts commissioned by LAs, the type of outcome data collected and whether these data were shared with other LAs or organisations, the challenges faced by these services, and the perceived 'markers of success' for a programme.

RESULTS

The online survey showed that none of the participating LAs was aware of any peer-reviewed evidence supporting the effectiveness of their specific commissioned service. Despite this, the telephone interviews revealed that there was no national formal sharing of data to enable oversight of the effectiveness of commissioned services across LAs in England to help inform future commissioning decisions. Challenges with long-term data collection, service engagement, funding and the pressure to reduce the prevalence of obesity were frequently mentioned.

CONCLUSIONS

Robust, independent, cost-effectiveness analyses of obesity strategies are needed to determine the appropriate allocation of funding to lifestyle weight management treatment services, population-level preventative approaches or development of whole system approaches by an LA.

The effectiveness of health professional-delivered interventions during the first 1000 days to prevent overweight/obesity in children: A systematic review

Childhood obesity is a global public health challenge. Early prevention, particularly during the first 1000 days, is advocated. Health professionals have a role to play in obesity prevention efforts, in part due to the multiple routine contacts they have with parents. We synthesized the evidence for the effectiveness of obesity prevention interventions delivered by health professionals during this time period, as reviews to date have not examined effectiveness by intervention provider. We also explored what behaviour change theories and/or techniques were associated with more effective intervention outcomes. Eleven electronic databases and three trial registers were searched from inception to 04 April 2019. A total of 180 studies, describing 39 trials involving 46 intervention arms, were included. While the number of interventions has grown considerably, we found some evidence for the effectiveness of health professional-delivered interventions during the first 1000 days. Only four interventions were effective on a primary (adiposity/weight) and secondary (behavioural) outcome measure. Twenty-two were effective on a behavioural outcome only. Several methodological limitations were noted, impacting on efforts to establish the active ingredients of interventions. Future work should focus on the conduct and reporting of interventions.

The Healthy Homes/Healthy Kids 5-10 Obesity Prevention Trial: 12 and 24-month outcomes

BACKGROUND

Pediatric primary care is an important setting for addressing obesity prevention.

OBJECTIVE

The Healthy Homes/Healthy Kids 5-10 randomized controlled trial evaluated the efficacy of an obesity prevention intervention integrating pediatric primary care provider counseling and parent-targeted phone coaching.

METHODS

Children aged 5 to 10 years with a BMI between the 70th and 95th percentile and their parents were recruited from pediatric primary care clinics. Participants received well-child visit provider counseling about obesity and safety/injury prevention and were then randomized to a 14-session phone-based obesity prevention (OP; n = 212) or safety and injury prevention contact control (CC; n = 209) intervention. The primary outcome was 12 and 24-month child BMI percentile.

RESULTS

There was no overall significant treatment effect on child BMI percentile. Caloric intake was significantly lower among OP compared with CC participants at 12 months (P < .005). In planned subgroup analyses, OP condition girls had significantly lower BMI percentile (P < .05) and BMI z-score (P < .02) at 12 and 24 months relative to CC girls and were less likely to be overweight (38.0% vs 53.0%, P < .01) or (obese 3.4% vs 8.8%, P < .10) at follow-up.

CONCLUSIONS AND RELEVANCE

An obesity prevention intervention integrating brief provider counseling and parent-targeted phone counseling did not impact 12 and 24-month BMI status overall but did have a significant impact on BMI in girls.

Cultural adaptation of a children's weight management programme: Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study

BACKGROUND

Childhood obesity prevalence continues to be at high levels in the United Kingdom (UK). South Asian children (mainly Pakistani and Bangladeshi origin) with excess adiposity are at particular risk from the cardiovascular consequences of obesity. Many community-based children's weight management programmes have been delivered in the UK, but none have been adapted for diverse cultural communities. The aim of the Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study, was to culturally adapt an existing children's weight management programme for children aged 4-11 years so that the programme was more able to meet the needs of families from South Asian communities.

METHODS

The adaptation process was applied to First Steps, an evidence informed programme being delivered in Birmingham (a large, ethnically diverse city). A qualitative study was undertaken to obtain the views of South Asian parents of children with excess weight, who had fully or partially attended, or who had initially agreed but then declined to attend the First Steps programme. The resulting data were integrated with current research evidence and local programme information as part of a cultural adaptation process that was guided by two theoretical frameworks.

RESULTS

Interviews or focus groups with 31 parents in their preferred languages were undertaken. Themes arising from the data included the need for convenient timing of a programme in a close familiar location, support for those who do not speak English, the need to focus on health rather than weight, nutritional content that focuses on traditional and Western diets, more physical activity content, and support with parenting skills. The data were mapped to the Behaviour Change Wheel framework and Typology of Cultural Adaptation to develop an intervention programme outline. The research evidence and local programme information was then used in the detailed planning of the programme sessions.

CONCLUSIONS

The process of cultural adaptation of an existing children's weight management programme resulted in a theoretically underpinned programme that is culturally adapted at both the surface and deep structural levels.

TRIAL REGISTRATION

ISRCTN81798055 , registered: 13/05/2014.

Behavioral, contextual and biological factors associated with obesity during adolescence: A systematic review

INTRODUCTION/OBJECTIVE

Adolescence is a critical period for the development of obesity. Obesity arises from a complex interaction between several factors, which are not yet fully understood. Therefore, the purpose of this review was to identify and assess the peer-reviewed scientific literature on the behavioral, contextual and biological factors associated with obesity in adolescents.

METHODS

PubMed and Scopus were systematically searched to identify prospective cohort studies concerning the relation between behavioral, contextual and biological factors and obesity in adolescents aged 10 to 18 years.

RESULTS

40 studies published between the year 2000 and 2018 were included. A positive consistent association between genetic factors and obesity during adolescence was found. Also, there is evidence to support the association between socioeconomic status and obesity. There was conflicting evidence for the contribution of dietary intake, physical activity, sedentary behavior, sleep, food store environment, school food environment. For the remaining factors no associations were found, or no conclusions could be drawn due to the limited number of studies identified.

CONCLUSIONS

Further prospective studies that assess multiple obesity determinants simultaneously and use state-of-art measures are warranted to aid in the development of effective strategies and interventions to prevent obesity during adolescence.

Four-year outcome of randomly assigned lifestyle treatments in primary care of children with obesity

AIM

To assess the four-year outcome in children with obesity randomised to one of two 12-month lifestyle treatment programmes in primary care.

METHODS

At baseline, 64 children with obesity aged 8.0-13.0 years were randomised to a treatment programme managed either by a nurse, dietician and physiotherapist (n = 32) or by a nurse and dietician (n = 32).

RESULTS

From baseline to follow-up, the mean body mass standard deviation score (BMISDS) had decreased by -0.50 [standard deviation (SD) 0.73], p = 0.002, in the nurse, dietician and physiotherapist group (n = 27), by -0.26 (SD 0.73), p = 0.057 in the other group (n = 29); adjusted mean difference was -0.22, 95% confidence interval -0.59; 0.16, p = 0.25. Changes in weight categories did not differ between the groups: both had a change from obesity to normal weight in 1 and to overweight in 6; in the physiotherapist group 1 case of severe obesity changed to obesity. The combined treatment groups (n = 56) had a mean reduction in BMISDS of -0.37 (SD 0.73) and an improved distribution in weight categories, p = 0.015.

CONCLUSION

After four years, there was no difference in outcome between the treatment options. In the treatment groups combined the number of children with obesity and their adiposity measures were significantly lower.

Prevention of Childhood Obesity in Child Health Services: Follow-Up of the PRIMROSE Trial

BACKGROUND

Childhood obesity is an urgent public health concern, and there's a need for long-term, high-quality, primary prevention trials targeting parents of young children. The aim of the current study was to evaluate the long-term effect of a parental support program based on motivational interviewing (MI).

METHODS

A cluster randomized controlled trial was carried out in eight Swedish counties. Participating families (N = 1355) were enrolled when the child was 9 months old, and participated in nine sessions during ∼39 months. The aim was to pomote healthy food and physical activity (PA) habits using MI and principles from cognitive behavioral therapy. Nurses in Swedish child health services delivered the intervention, and the control group received usual healthcare. The current study was a 1-year follow-up of effects on children's weight-related measures. Regression analyses were conducted using generalized estimating equations, including analyses to investigate potential parental moderators of the effect.

RESULTS

There were no statistically significant intervention effects at follow-up [BMI difference = -0.13, p = 0.29, overweight relative risk (RR) = 0.96, p = 0.78, obesity RR = 0.57, p = 0.20]. Maternal waist circumference and unhealthy eating and paternal PA moderated the effect, but effects were small and failed to reach statistical significance after correction for multiple comparisons.

CONCLUSIONS

A parent-focused primary prevention intervention based on MI delivered within child health services did not result in effects at 1-year follow-up. The results were in line with those obtained at post-assessment and indicated no late onset of effect. Further studies exploring individual and contextual factors influencing the outcome are called for.

Identification of Overweight and Obesity in Low-Income Minority Children by Pediatric Providers and Child Characteristics Associated With Underrecognition

INTRODUCTION

Childhood overweight and obesity remains prevalent. We sought to identify characteristics associated with correct coding of obese and overweight children ages 2-9 years by pediatric primary care providers (PCPs) in an urban, minority clinic.

METHOD

Samples included electronic health records pre- (n = 262) and post- (n = 244) provider training to implement an intervention aiming to improve consistency in obesity prevention and management guidelines from 15 providers. Analysis included descriptive statistics and simple logistic regression.

RESULTS

Child characteristics consistently associated with correct coding in both pre- and post-intervention included children with obese body mass index percentiles (vs. overweight) and older-aged children (vs. toddlers). Provider characteristics were not associated.

DISCUSSION

Improvements in coding overweight and obese children occurred post-intervention, yet many were missed. Knowledge of characteristics associated with missed coding can inform targeted training for PCPs to implement evidence-based obesity guidelines with full fidelity for all families.

An exploratory look at comorbidities, utilization, and quality of care among obese and nonobese children in academic family medicine practice

Background

Obesity is one of the least addressed comorbidities among children who attend family medicine clinics. The aim of this study was to apply a population health framework to understand the differences between obese and nonobese pediatric patients in academic family medicine practice with regard to general demographics, comorbidities, and quality measures.

Methods

Exploratory retrospective chart reviews were conducted among obese children aged 2-17 years and a random sample of age-matched nonobese children in 2015. Data were gathered through the institute's electronic medical record system and included demographics, ICD-10 diagnosis codes, outpatient primary care and specialty care visits, in-network emergency department visits, and in-network hospital admissions.

Results

This exploratory study suggested that the obese pediatric population (n = 213) had a high prevalence of hypertension (P = .006) and sleep apnea (P = .05) and a larger number of diagnosed comorbidities (P = .008), whereas nonobese children had a high prevalence of environmental allergies (P = .001). There were no significant differences among quality measures between obese (n = 213) and age-matched nonobese pediatric patients (n = 219).

Conclusion

This study used readily available electronic health record data to highlight comorbidities that are more common among obese pediatric patients in academic family medicine practice, thus providing information that could potentially facilitate more timely screening and intervention.

A Systematic Review of Methods, Study Quality, and Results of Economic Evaluation for Childhood and Adolescent Obesity Intervention

Many suggested policy interventions for childhood and adolescent obesity have costs and effects that fall outside the health care sector. These cross-sectorial costs and consequences have implications for how economic evaluation is applied and although previous systematic reviews have provided a summary of cost-effectiveness, very few have conducted a review of methods applied. We undertook this comprehensive review of economic evaluations, appraising the methods used, assessing the quality of the economic evaluations, and summarising cost-effectiveness. Nine electronic databases were searched for full-economic evaluation studies published between January 2001 and April 2017 with no language or country restrictions. 39 economic evaluation studies were reviewed and quality assessed. Almost all the studies were from Western countries and methods were found to vary by country, setting and type of intervention. The majority, particularly "behavioural and policy" preventive interventions, were cost-effective, even cost-saving. Only four interventions were not cost effective. This systematic review suggests that economic evaluation of obesity interventions is an expanding area of research. However, methodological heterogeneity makes evidence synthesis challenging. Whilst upstream interventions show promise, an expanded and consistent approach to evaluate cost-effectiveness is needed to capture health and non-health costs and consequences.

Parental Perceptions of Child's Medical Care and Neighborhood and Child's Behavioral Risk Factors for Obesity in U.S. Children by Body Mass Index Classification

Environmental factors, preventive medical care, and behaviors play a role in childhood obesity. This study used the National Survey of Children's Health, 2011-2012, for 42,828 children, ages 10-17 years. Greater percent of children in the overweight/obese category performed no moderate-to-vigorous physical activity: 11.9 (10.6, 13.3) as compared to children in the underweight/normal weight category: 9.7 (8.9 10.6). No moderate-to-vigorous physical activity was associated with no preventive medical care, inadequate or no health care, parents reporting higher percent of no parks or playgrounds, and unsafe and unsupportive neighborhoods. Odds ratios of overweight/obesity were higher for males [OR = 2.06 (1.64, 2.60)], Hispanics [OR = 1.49 (1.17, 1.90)], non-Hispanic Black females [OR = 1.59 (1.20, 2.08)], younger females [OR_10-12 yrs. = 1.35 (1.03, 1.79) and OR_13-15 yrs. = 1.4. (1.06, 1.89) vs. OR = 1.00_16-17 yrs.], children with high television viewing [OR_{0-1 hr./day} = 0.72 (0.61, 0.86); OR_{>1 to <4 hrs./day} 0.84 (0.72, 0.99) = vs. OR = 1.00_{≥ 4 hrs./day},] and lower categories of physical activity [OR _{0 days/wk.} = 1.38 (1.13, 1.62); OR_{1-3 days/wk.} = 1.14 (1.22, 1.62) vs. OR_{7 days/wk}. = 1.00], higher poverty, smoke exposure, and parental perception of their neighborhood as unsupportive. Promoting preventive medical care and neighborhood cooperation may have potential to lower childhood obesity.

Evaluating a childhood obesity program with the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework

Primary care providers can use behavioral lifestyle interventions to effectively treat children with overweight and obesity, but implementing these interventions is challenging. Most childhood obesity intervention evaluation studies focus on effectiveness. Few studies describe implementation. Our goal was to evaluate critical components of a childhood obesity intervention in primary care. We conducted a pilot implementation study of an existing structured lifestyle intervention in the Canton of Bern, Switzerland from 2013 to 2015. The intervention consisted of 10 sessions, led by a primary care physician. It included children aged 6–8 years old, with BMI over the 90th age-adjusted percentile. We used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) evaluation framework to describe the pilot implementation study. We stratified description of RE-AIM components at the patient- and physician-level. For Reach: 864 children were screened; 65 were overweight; 394 physicians were invited to participate in the study. For Effectiveness: BMI z-score significantly decreased (−5.6%, p = 0.01). For Adoption: 14 participating physicians treated 26 patients. Implementation: the mean number of consultations was 8. For Maintenance: 9 (35%) children discontinued the intervention; 7 (50%) of physicians continued to apply at least one component of the intervention. The summarized components of the program within the RE-AIM framework suggest the program was successful. Stakeholders can use our results if they intend to disseminate and evaluate similar interventions in different settings.

•

We describe the implementation process of a childhood obesity intervention.

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This might help stakeholders implement similar interventions in their setting.

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Using RE-AIM makes it easier to compare implementation of similar programs.

"C.H.A.M.P. Families": Description and Theoretical Foundations of a Paediatric Overweight and Obesity Intervention Targeting Parents-A Single-Centre Non-Randomised Feasibility Study

Childhood obesity represents a significant global health challenge, and treatment interventions are needed. The purpose of this paper is to describe the components and theoretical model that was used in the development and implementation of a unique parent-focussed paediatric overweight/obesity intervention. C.H.A.M.P. Families was a single-centre, prospective intervention offered to parents of children aged between 6–14 years with a body mass index (BMI) ≥85th percentile for age and sex. The intervention included: (1) eight group-based (parent-only) education sessions over 13-weeks; (2) eight home-based activities; and (3) two group-based (family) follow-up support sessions. The first section of the manuscript contains a detailed description of each intervention component, as well as an overview of ongoing feasibility analyses. The theoretical portion details the use of evidence-based group dynamics principles and motivational interviewing techniques within the context of a broader social cognitive theory foundation. This paper provides researchers with practical examples of how theoretical constructs and evidence-based strategies can be applied in the development and implementation of parent-focussed paediatric obesity interventions. Given the need for transparent reporting of intervention designs and theoretical foundations, this paper also adds to the areas of implementation science and knowledge translation research.

School-based secondary prevention of overweight and obesity among 8- to 12-year old children: Design and sample characteristics of the SNAPSHOT trial

Rising levels of severe obesity among children, worsening disparities by race and ethnicity and reluctance of primary care clinicians' to provide obesity management to children are compelling reasons to consider alternatives to primary care management of childhood obesity. The Students Nurses and Parents Seeking Healthy Options Together (SNAPSHOT) trial will test the efficacy of an elementary school-based, school nurse-led, healthy weight management program to reduce excess weight gain among children, 8- to 12-years old with a body mass index (BMI) ≥75th percentile, by increasing healthy dietary practices and physical activity and decreasing sedentary behaviors. SNAPSHOT has enrolled and randomized 132 child/parent dyads to either the: (1) 9-month SNAPSHOT intervention that includes four home visits, 14 kid groups held during out-of-school time and five parent groups or (2) a newsletter program consisting of monthly mailings and family-focused healthy lifestyle information. Outcomes are assessed at baseline, 12-months (post intervention) and 24-months (follow-up) post randomization. The primary outcome is child age- and gender-adjusted BMI z-score. Secondary outcomes include child dietary intake assessed with 24-h dietary recall interviews and accelerometer-measured activity levels. The SNAPSHOT intervention is a model of secondary obesity prevention for children that addresses the urgent need for theory-informed, evidence-based and safe weight management programs, delivered by skilled health professionals in accessible settings. This report describes development of the SNAPSHOT trial, including recruitment and randomization procedures, assessments, intervention and implementation plans, and baseline characteristics of the study sample.

A qualitative insight into informal childcare and childhood obesity in children aged 0-5 years in the UK

BACKGROUND

Previous studies in various countries have found that informal childcare (provided by relatives, friends etc.) was associated with an increased risk of obesity in children aged 0-5 years. However, no qualitative research has been done to explore possible reasons for such a relationship and potential interventions to tackle it. We conducted a qualitative study with both parents and informal carers to explore their 1) experiences in receiving or giving informal childcare for British children aged 0-5 years; 2) perceived explanations of the relationship between informal childcare and childhood obesity and 3) preferred intervention ideas and delivery strategies for preventing obesity among those children under informal care.

METHODS

Four in-depth focus groups with a total of 14 participants (7 parents, 7 informal caregivers) were conducted in Birmingham and Edinburgh (1 parent group and 1 informal caregiver group in each city). Data were audio recorded, transcribed verbatim and analysed using a thematic approach.

RESULTS

The significance of informal care to parents, carers, and society was recognised (theme one). Informal carers were identified to have practical and emotional support roles for the parents (theme two). Informal care was perceived to contribute to childhood obesity in four ways (theme three): cross-generation conflict preventing adoption of healthy practices; the trade-off for parents between receiving childcare and maintaining control; reduced energy capacity of carers; and increased snacking. Potential intervention ideas and delivery strategies (theme four) were identified. Examples of identified ideas included providing carers with up-to-date weaning advice, and suggestions of healthy snacks and ways to increase physical activity level in informal care. The suggestion of utilising existing primary care platforms (e.g. health visitor check-ups) to reach and deliver low-cost information based interventions, to all children aged 0-5 years who receive informal care, was highlighted.

CONCLUSIONS

This exploratory qualitative study provided novel insights into potential explanations for the evidenced link between informal care and childhood obesity in children aged 0-5 years, despite a small size and limited participants in each focus group. Our findings support the idea of and inform the development towards an information based and low-cost intervention delivered through existing primary care platforms.

A randomized controlled trial to prevent obesity among Latino paediatric patients

BACKGROUND

Obesity disproportionately affects Latino youth. Community clinics are an important resource, yet there is little evidence for the efficacy of clinic-based approaches in this population.

OBJECTIVE

The purpose of this study was to test the efficacy of a clinic-based intervention to lower body mass index (BMI) and improve body composition among overweight Latino children.

METHODS

A randomized trial (2 group × 3 repeated measures) was conducted among 297 randomly sampled, overweight paediatric patients (5-10 years old) and their parents. The 12-month family-based culturally tailored behavioural intervention (Luces de Cambio) was based on the 'traffic light' concepts to address behaviour change and was delivered by clinic health educators and mid-level providers. The primary study outcome was child BMI (kg m^-2 ) assessed at baseline, 6-month (n = 191) and 12-month (n = 201) post-baseline. A subsample of the children was examined for overall and site-specific adiposity using dual-energy X-ray absorptiometry (n = 79).

RESULTS

There were no significant intervention effects on child BMI (p > 0.05); however, intervention children showed significantly (p < 0.05) lower total and trunk per cent fat compared with the usual care condition.

CONCLUSIONS

The Luces intervention did not reduce child BMI, yet small but significant reductions were observed for child per cent body fat. Further research is needed to identify and reduce barriers to recruitment and participation among Latino families.

Health Care Provider's Role in Obesity Prevention and Healthy Development of Young American Indian Children

INTRODUCTION

Health care providers (HCPs) serving American Indian (AI) populations are critical stakeholders in promoting healthy weight-related behaviors of young AI children. The purpose of this study is to develop an understanding of how HCP perceive their role in the healthy development of young AI children, and how they envision working with early care and education teachers and parents to enhance children's health.

METHOD

Twenty HCP that serve young AI children in Oklahoma participated in individual interviews. Thematic analysis was conducted on coded transcripts and three main themes, each with two to four subthemes were identified.

RESULTS

HCP had limited contact with teachers, felt family health was equal or more important than child health, and parental empowerment and gradual change was essential for success.

CONCLUSION

Creating ways to involve HCP, early care and education teachers, and parents together in multilevel and multisector interventions has the potential to improve the health of young AI children.

Diagnosis, treatment and prevention of pediatric obesity: consensus position statement of the Italian Society for Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics

The Italian Consensus Position Statement on Diagnosis, Treatment and Prevention of Obesity in Children and Adolescents integrates and updates the previous guidelines to deliver an evidence based approach to the disease. The following areas were reviewed: (1) obesity definition and causes of secondary obesity; (2) physical and psychosocial comorbidities; (3) treatment and care settings; (4) prevention.The main novelties deriving from the Italian experience lie in the definition, screening of the cardiometabolic and hepatic risk factors and the endorsement of a staged approach to treatment. The evidence based efficacy of behavioral intervention versus pharmacological or surgical treatments is reported. Lastly, the prevention by promoting healthful diet, physical activity, sleep pattern, and environment is strongly recommended since the intrauterine phase.

Effective strategies for prevention, control, and treatment of obesity in primary health care setting for adolescents, adults, and elderly people: A protocol for systematic review and meta-analysis

BACKGROUND

It is unquestionable that obesity is a global epidemic and one of the main public health problems in the world. The management of obesity in Primary Health Care has an important role if being considered the magnitude and serious consequence of this problem. Despite this, there is no effective standard protocol for the treatment of this disease. Studies that synthesize and assess the effectiveness of strategies for prevention, control, and treatment of obesity in Primary Health Care setting are still scarce. The objective of this study is review and synthesize study evidence for obesity management strategies among adolescents, adults and elderly developed at the Primary Health Care worldwide.

METHODS

Seven electronic databases (Medline, Lilacs, Embase, Psycinfo, Cochrane, WHOLIS and Open Gray) will be searched with no date limit for identification of clinical trials examining the effectiveness of prevention, control and treatment of obesity in Primary Health Care. As primary outcome will be changes in body weight. As secondary outcomes will be body mass index, body adiposity, waist circumference, and waist-hip ratio. Two independent authors will perform the selection of studies, data extraction, and the assessment of risk of bias.

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

This systematic review will be first to synthesize scientific evidence for obesity management strategies at Primary Health Care among adolescents, adults, and elderly. The review will benefit healthcare professionals and policymakers.

ETHICS AND DISSEMINATIONS

Ethical approval is not required in this study because the data used include peer-reviewed publications, which do not comprise any information that could identify subjects.

TRIAL REGISTRATION NUMBER

PROSPERO (CRD42018092416).

Protocol for a systematic review of methods and cost-effectiveness findings of economic evaluations of obesity prevention and/or treatment interventions in children and adolescents

BACKGROUND

Childhood obesity is a major global public health problem, with governments increasingly having to undertake various strategies to reduce excess weight in their populations. Considering the increasing number of well-conducted intervention studies in the field of childhood obesity prevention, there are relatively few published economic evaluations. The proposed systematic review will explore the methods of these economic evaluations, examine the limitations and establish the evidence base for cost-effectiveness analyses.

METHODS/DESIGN

Systematic review methodology will be applied to identify, select and extract data from published economic evaluation studies (trial-based, non-trial based, simulation-based, decision model and trial based model economic evaluations) of obesity prevention and/or treatment interventions in children and adolescents. A systematic literature search will be conducted using bibliographic databases (MEDLINE, EMBASE, CINAHL, Web of Science, EconLit, PsycINFO, Cochrane Library, Centre for Reviews and Dissemination (CRD) and Cost-Effectiveness Analysis (CEA) Registry). The review will only include full economic evaluations. There will be no restrictions based on language, perspective, follow-up duration, sample size, country or setting. To minimise selection bias, translation of non-English language articles will be undertaken. The quality of included studies will be assessed. Following data extraction, a narrative synthesis of the results from the included studies will be undertaken. Subgroup analysis will be considered where deemed appropriate.

DISCUSSION

The findings from this review, which will include primary studies, will provide evidence to assist health policy decision makers interpret economic evaluations in this field. In addition, we will identify gaps in the current literature to inform future-related research.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42017062236.

Lifestyle weight management programmes for children: A systematic review using Qualitative Comparative Analysis to identify critical pathways to effectiveness

This study aimed to identify critical features of successful lifestyle weight management interventions for overweight children (0-11years). Eleven qualitative UK-based studies examining children's, parents' and providers' perspectives and experiences of programmes were synthesised to identify components felt to be critical. Studies for this views synthesis were identified from existing reviews and an update of one review's search, which was run in December 2015. The identified components were then explored in a synthesis of intervention evaluations (five 'most effective' and 15 'least effective') conducted in western Europe, North America, Australia or New Zealand. The intervention evaluations were identified from existing reviews and an update of one review's search, which was run in March 2016. This evaluation synthesis was carried out using Qualitative Comparative Analysis. Three important mechanisms were present in all the most effective interventions but absent in all the least effective: 1/ showing families how to change: a) providing child physical activity sessions, b) delivering practical behaviour change strategy sessions, c) providing calorie intake advice; 2/ ensuring all the family are on board: a) delivering discussion/education sessions for both children and parents, b) delivering child-friendly sessions, c) aiming to change behaviours across the whole family; 3/ enabling social support for both parents and children by delivering both child group sessions and parent group sessions. To conclude, programmes should ensure the whole family is on board the programme, that parents and children can receive social support and are not just told what to change, but shown how.