A Preschool Obesity Treatment Clinical Trial: Reasons Primary Care Providers Declined Referrals

Provider Practice and Perceptions of Pediatric Obesity in Appalachian Kentucky

OBJECTIVES

This study assessed providers' present practices and perceived needs in Appalachian Kentucky to identify the standard of care and implementation of expert recommendations for managing pediatric obesity.

METHODS

Questionnaire data were gathered from 28 providers at a pediatric obesity continuing medical education workshop in eastern Kentucky. We assessed current practices, perceived barriers to treatment, and needed resources for managing pediatric obesity.

RESULTS

Respondents reported mixed adherence to expert recommendations, with providers less frequently addressing family-reported barriers to change and assessing a family's readiness to change behaviors related to pediatric obesity. Respondents also reported service barriers related to patient motivation, lack of time with patients, and a lack of referral options. Finally, providers reported needing multiple community resources to better address pediatric obesity, including improved physical education programs, access to community recreation centers, additional referral resources for multidisciplinary care, and additional training in motivational techniques.

CONCLUSIONS

There remains a significant need for education and guidance regarding the implementation of expert recommendations for addressing pediatric obesity in Appalachian Kentucky. Providers reported needing multiple community resources, including improved physical education programs, access to community recreation centers, additional referral resources for multidisciplinary care, and additional training in motivational techniques. We discuss the implications for disseminating and implementing expert recommendations in rural eastern Kentucky, with an emphasis on the roles of behavioral health experts.

Sleep duration and bedtime in preschool-age children with obesity: Relation to BMI and diet following a weight management intervention

BACKGROUND

Sleep duration is associated with obesity in preschoolers. Weight-management interventions may be an opportunity to incorporate sleep health recommendations.

OBJECTIVES

To examine changes in sleep in preschool-age children with obesity following a family-based weight-management intervention (Learning about Activity and Understanding Nutrition for Child Health [LAUNCH]) compared with motivational interviewing and standard care conditions. Additionally, we examined associations between sleep with body mass index (BMI) z score (BMIz) and diet.

METHODS

One hundred fifty-one children (4.6 ± 0.93 y) completed baseline (pretreatment) and posttreatment (week 24) assessments, including anthropometrics, 24-hour dietary recalls, and a 7-day sleep diary. Analysis of variance (ANOVA) and chi-squared tests compared sleep variables between groups; linear regression models examined effects of sleep on BMIz and dietary intake at posttreatment, controlling for baseline values.

RESULTS

Bedtime and sleep duration were not significantly different between treatment groups from baseline to posttreatment. After adjusting for baseline sleep, earlier bedtime was associated with lower BMIz (95% CI, 0.00-0.04; .03), intake of added sugars (95% CI, 0.70-4.32; .007), and sweet/dessert food servings (95% CI, 0.00-0.19; .04) at posttreatment. Longer night-time sleep duration was associated with fewer added sugars at posttreatment, adjusting for baseline sleep (95% CI, -3.79 to -0.35; .02).

CONCLUSIONS

More comprehensive sleep intervention incorporated into weight-management intervention may be necessary to promote positive changes for preschoolers with obesity. A focus on earlier bedtime and longer sleep duration appears to be important given associations between sleep duration and bedtime with BMIz and dietary intake.

Are Preschoolers Meeting the Mark? Comparing the Dietary, Activity, and Sleep Behaviors of Preschoolers With Obesity to National Recommendations

Objective

National health organizations and expert committees have issued recommendations for health behaviors related to obesity risk. Behavioral and family-based weight management interventions for preschoolers often target improving adherence to these recommendations, but it is unknown how the health behaviors of preschoolers with obesity enrolled in weight control treatments (WCTs) compare with these guidelines. In this study, the dietary intake, activity, and sleep behaviors of preschoolers with obesity enrolled in a family-based behavioral WCT are described and compared with national health behavior recommendations.

Methods

Health behaviors of 151 preschoolers with obesity (M age = 4.60, SD = 0.93) enrolled in a clinical trial of a weight management program were measured at baseline through caregiver-report questionnaires, three 24-hr dietary recalls, and accelerometers.

Results

In total, 70% of the sample exceeded daily caloric recommendations, only 10 and 5% met recommendations for fruit and vegetable intake, respectively, and only 30% met the recommendation of consuming no sugar-sweetened beverages. The majority of the sample met the daily recommendations for 60 min of moderate-to-vigorous activity (80%), < 2 hr of screen time (68%), and sleep duration (70%).

Conclusions

Behavioral weight management interventions for preschoolers with obesity should target the health behaviors where children are not meeting recommendations.

Weight up? Changes in children's anthropometry from time of referral to baseline assessment for paediatric weight management

Objectives

To examine children's wait time to access a multidisciplinary, tertiary-level weight management clinic and assess anthropometric changes from time of referral to baseline assessment.

Method

A retrospective medical record review was completed of children (5 to 17 years) enrolled in a multidisciplinary, tertiary-level paediatric weight management clinic from 2006 to 2015. Children's demographic and anthropometric data from their referral to and baseline assessment at the clinic were retrieved from medical records. Based on changes in body mass index (BMI) z-score from the time of referral to baseline assessment, children were categorized as decreasers (>0.05 unit decrease), increasers (>0.05 unit increase) or stabilizers (-0.05 to 0.05 unit change). The proportion of children with a ≥0.25 unit BMI z-score reduction was calculated. Analysis of variance and chi-squared tests were performed.

Results

Children (n=400) were 11.7 ± 2.9 years old at the time of referral, 52.8% (n=211) female, and had an average wait time of 4.5 ± 3.9 months. By 3 and 6 months postreferral, 44.0% (n=176) and 80.8% (n=323), respectively, had attended baseline assessments. Based on BMI z-score change, children were classified as decreasers (n=183; 45.8%), increasers (n=118; 29.5%) or stabilizers (n=99; 24.8%). One-fifth of children (n=86; 21.5%) experienced a BMI z-score reduction ≥0.25 units, a subgroup that was younger, had a higher BMI z-score at referral, and had a longer wait time between referral and baseline assessment (all P<0.05).

Conclusions

Most children who enrolled in paediatric weight management initiated treatment within six months and experienced a modest decrease or stabilization in BMI z-score during their wait time.

Parent Recommendations to Enhance Enrollment in Multidisciplinary Clinical Care for Pediatric Weight Management

OBJECTIVE

To explore parents' recommendations to enhance enrollment in multidisciplinary clinical care for managing pediatric obesity.

STUDY DESIGN

Data for this interpretative description study were collected through individual, semistructured interviews that were audiorecorded, transcribed verbatim, and analyzed thematically. Parents (n = 79) were recruited from 4 multidisciplinary weight management clinics in Canada located in Edmonton, Hamilton, Montreal, and Vancouver.

RESULTS

Most interviewed parents had children with obesity (body mass index ≥95th percentile; 84.2%), were female (87.3%), had postsecondary education (69.6%), and were white (75.9%). Parents' recommendations referred to enrollment opportunities, information about obesity services, motivation for treatment, and accessibility to obesity services. Specifically, parents recommended to increase referral options and follow-up contacts with families during the enrollment process, inform referring physicians and families about the availability and characteristics of obesity services, enhance families' motivation for treatment, prevent families from getting discouraged, make services more appealing to families, and address accessibility issues (eg, offering multiple options for appointment times, providing support for transportation).

CONCLUSIONS

Parents' recommendations support the need for family-centered approaches to enhance enrollment; however, their feasibility, acceptability, and effectiveness remain to be tested empirically.

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in children and adults with overweight or obesity

BACKGROUND

The prevalence of overweight and obesity is increasing globally, an increase which has major implications for both population health and costs to health services. This is an update of a Cochrane Review.

OBJECTIVES

To assess the effects of strategies to change the behaviour of health professionals or the organisation of care compared to standard care, to promote weight reduction in children and adults with overweight or obesity.

SEARCH METHODS

We searched the following databases for primary studies up to September 2016: CENTRAL, MEDLINE, Embase, CINAHL, DARE and PsycINFO. We searched the reference lists of included studies and two trial registries.

SELECTION CRITERIA

We considered randomised trials that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in children and adults with overweight or obesity.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane when conducting this review. We report the results for the professional interventions and the organisational interventions in seven 'Summary of findings' tables.

MAIN RESULTS

We identified 12 studies for inclusion in this review, seven of which evaluated interventions targeting healthcare professional and five targeting the organisation of care. Eight studies recruited adults with overweight or obesity and four recruited children with obesity. Eight studies had an overall high risk of bias, and four had a low risk of bias. In total, 139 practices provided care to 89,754 people, with a median follow-up of 12 months. Professional interventions Educational interventions aimed at general practitioners (GPs), may slightly reduce the weight of participants (mean difference (MD) -1.24 kg, 95% confidence interval (CI) -2.84 to 0.37; 3 studies, N = 1017 adults; low-certainty evidence).Tailoring interventions to improve GPs' compliance with obesity guidelines probably leads to little or no difference in weight loss (MD 0.05 (kg), 95% CI -0.32 to 0.41; 1 study, N = 49,807 adults; moderate-certainty evidence).It is uncertain if providing doctors with reminders results in a greater weight reduction than standard care (men: MD -11.20 kg, 95% CI -20.66 kg to -1.74 kg, and women: MD -1.30 kg, 95% CI [-7.34, 4.74] kg; 1 study, N = 90 adults; very low-certainty evidence).Providing clinicians with a clinical decision support (CDS) tool to assist with obesity management at the point of care leads to little or no difference in the body mass index (BMI) z-score of children (MD -0.08, 95% CI -0.15 to -0.01 in 378 children; moderate-certainty evidence), CDS tools may lead to little or no difference in weight loss in adults: MD -0.095 kg (-0.21 lbs), P = 0.47; 1 study, N = 35,665; low-certainty evidence. Organisational interventions Adults with overweight or obesity may lose more weight if the care was provided by a dietitian (by -5.60 kg, 95% CI -4.83 kg to -6.37 kg) or by a doctor-dietitian team (by -6.70 kg, 95% CI -7.52 kg to -5.88 kg; 1 study, N = 270 adults; low-certainty evidence). Shared care leads to little or no difference in the BMI z-score of children with obesity (adjusted MD -0.05, 95% CI -0.14 to 0.03; 1 study, N = 105 children; low-certainty evidence).Organisational restructuring of the delivery of primary care (i.e. introducing the chronic care model) may result in a slightly lower increase in the BMI of children who received care at intervention clinics (BMI change: adjusted MD -0.21, 95% CI -0.50 to 0.07; 1 study, unadjusted MD -0.18, 95% CI -0.20 to -0.16; N=473 participants; moderate-certainty evidence).Mail and phone interventions probably lead to little or no difference in weight loss in adults (mean weight change (kg) using mail: -0.36, 95% CI -1.18 to 0.46; phone: -0.44, 95% CI -1.26 to 0.38; 1 study, N = 1801 adults; moderate-certainty evidence). Care delivered by a nurse at a primary care clinic may lead to little or no difference in the BMI z-score in children (MD -0.02, 95% CI -0.16 to 0.12; 1 study, N = 52 children; very low-certainty evidence).Two studies reported data on cost effectiveness: one study favoured mail and standard care over telephone consultations, and the other study achieved weight loss at a modest cost in both intervention groups (doctor and doctor-dietitian). One study of shared care reported similar adverse effects in both groups.

AUTHORS' CONCLUSIONS

We found little convincing evidence for a clinically-important effect on participants' weight or BMI of any of the evaluated interventions. While pooled results from three studies indicate that educational interventions targeting healthcare professionals may lead to a slight weight reduction in adults, the certainty of these results is low. Two trials evaluating CDS tools (unpooled results) for improved weight management suggest little or no effect on weight or BMI change in adults or children with overweight or obesity. Evidence for all the other interventions evaluated came mostly from single studies. The certainty of the included evidence varied from moderate to very low for the main outcomes (weight and BMI). All of the evaluated interventions would need further investigation to ascertain their strengths and limitations as effective strategies to change the behaviour of healthcare professionals or the organisation of care. As only two studies reported on cost, we know little about cost effectiveness across the evaluated interventions.