Obesity prevention and the primary care pediatrician's office

Promoting physical activity for children: an audit among Italian family pediatricians

BACKGROUND

This survey aimed to investigate the perception of Italian Pediatricians regarding the promotion of physical activity.

METHODS

From January to May 2015, a survey was conducted among family pediatricians working in Puglia, interviewed by a standardized questionnaire, that investigated demographic information, participation in sporting activity by the pediatrician, opinion on obesity and the promotion of physical activity, and attitude towards enquiring about the physical activity of patients with and without chronic diseases.

RESULTS

We collected 200 questionnaires (35.7% of target population): 51.5% of enrolled pediatricians stated that they were participating in sporting activities at the time of the survey. The average opinion regarding the relevance of the obesity was 9±1.4/10 and about the promotion of physical activity 9.6±0.8. All enrolled pediatricians asked for their patients' physical activity and encouraged inactive children to begin an appropriate activity. Pediatricians who took part in sport had a high probability of encouraging physical activity, among patients affected by chronic diseases.

CONCLUSIONS

Family pediatricians declared a good attitude regarding the promotion of physical activity for their patients according to national and international recommendations. The main concern emerging from our results is the risk of an "inappropriate interdiction" of physical activity in children affected by chronic diseases, in particular physicians that have never participated in a sport.

Medical treatment of weight loss in children and adolescents with obesity

Obesity remains one of the biggest health problems both in adults and children. Lifestyle modification, including diet and exercise, continues to be the mainstay of obesity prevention and treatment. Unfortunately, lifestyle modifications are often unsuccessful. Pharmacological treatment of obesity in pediatric patients can be applied in selected cases, and not before evidence of failure of the multidisciplinary lifestyle intervention. In this narrative review, we revised the most up-to-date evidence on medical treatment of weight loss in children and adolescents with obesity, including FDA- or EMA-approved and -experimented, not approved, drugs for pediatric population. Multidisciplinary treatment of childhood obesity, regulation of appetite control, energy balance and body weight were also discussed, in order to clarify the indications and mechanism action of drugs. Despite a substantial number of medications used for the treatment of obesity in adults, a limited number of drugs are approved by the drug regulatory agencies for pediatric population. Further research is needed to evaluate the efficacy and safety of novel pharmacological approaches for treatment of pediatric obesity in order to optimize weight management for children and adolescents and limit the development obesity-related comorbidities.

First, Do No Harm: Understanding Primary Care Providers' Perception of Risks Associated With Discussing Weight With Pediatric Patients

Many health care providers struggle with if- and how-to discuss weight with their pediatric patients. This study used one-on-one interviews with primary care providers (n = 20) to better understand their: (1) perception of risks associated with talking about weight with pediatric patients, (2) commitment to adhering to best practices of pediatric weight management, and (3) approaches to mitigate perceived risks. Providers felt concerned that discussing weight with children during clinic visits may have unintended negative impacts. Despite perceived risks, providers continued regular BMI screening and weight-focused conversations, but took care with regard to language and approach with the goal of mitigating perceived risks. Findings suggest that pediatric primary care providers perceive that engaging in weight-related discussions with their patients has the potential to lead to negative, unintended consequences. Future research is needed to understand if weight-focused conversations should be avoided altogether or if there are approaches that can effectively mitigate risks.

Completeness and representativeness of body mass index in children's electronic general practice records: Linked cross-sectional study in an ethnically-diverse urban population in the United Kingdom

OBJECTIVE

To assess completeness and accuracy of children's body mass index (BMI) recorded in general practice electronic health records (GP-EHRs).

METHODS

We linked National Child Measurement Programme (NCMP) records from 29 839 5-year-olds and 26 660 11-year-olds attending state schools in inner London to GP-EHRs (95% linked; 49.1% girls). We estimated adjusted odds (aOR) of at least one GP-BMI record by sex, ethnic background, area-level deprivation, weight-status and long-term conditions. We examined within-child BMI differences and compared obesity prevalence from these sources.

RESULTS

10.5% (2964/28330) and 26.0% (6598/25365) of 5- and 11-year-olds respectively had at least one GP-BMI record. Underweight (aOR;95% CI:1.71;1.34,2.19), obesity (1.45;1.27,1.65), South Asian background (1.55;1.38,1.74), presence of a long-term condition (8.15;7.31,9.10), and residence in deprived areas (Wald statistic 38.73; P-value<0.0001) were independently associated with at least one GP-BMI record. NCMP-BMI and GP-BMI differed by +0.45(95% Limits of Agreement -1.60,+2.51) and + 0.16(-2.86,+3.18) in 5- and 11-year-olds, respectively. The prevalence of obesity based on GP-BMI was 18.2%(16.1,20.5) and 35.9%(33.9,38.0) in 5- and 11-year-olds respectively, compared to 12.9%(12.5,13.3) and 26.9%(26.4,27.4) based on NCMP-BMI.

CONCLUSION

Child BMI is not comprehensively recorded in urban general practice. Linkage to school measurement records is feasible and enables assessment of health outcomes of obesity.

A Strategic Plan for Strengthening America's Families: A Brief from the Coalition of Behavioral Science Organizations

Despite significant progress in research on the treatment and prevention of psychological, behavioral, and health problems, the translation of this knowledge into population-wide benefit remains limited. This paper reviews the state of America’s children and families, highlighting the influence of stressful contextual and social conditions on child and family well-being and the concentration of disadvantage in numerous neighborhoods and communities throughout the nation. It then briefly reviews the progress that has been made in pinpointing policies that can reduce stressful contextual conditions such as poverty, discrimination, and the marketing of unhealthful foods and substances. It also describes numerous family and school interventions that have proven benefit in preventing psychological and behavioral problems as diverse as tobacco, alcohol, and other drug use; depression; antisocial behavior; academic failure; obesity prevention; and early childbearing. We argue that progress in translating existing knowledge into widespread benefit will require a nationwide effort to intervene comprehensively in neighborhoods and communities of concentrated disadvantage. We present a strategic plan for how such an effort could be organized. The first step in this organizing would be the creation of a broad and diverse coalition of organizations concerned with advancing public health and well-being. Such a coalition could increase public support both for the policies needed to focus on these disadvantaged areas and the research needed to incrementally improve our ability to help these areas.

The Correlation Between Parental Perceptions and Readiness to Change with Participation in a Pediatric Obesity Program Serving a Predominantly Black Urban Community: A Retrospective Cohort Study

BACKGROUND

This study assessed whether maternal BMI and perceptions about weight and reported level of readiness to change was correlated with compliance to a pediatric lifestyle modification program targeting a hard-to-reach urban population with a high prevalence of severe obesity.

METHODS

The Parental Readiness Questionnaire (PRQ) was administered to the child's mother at program entry. The PRQ consisted of forty-seven multiple-choice and 10-point Likert scale questions regarding family demographics, exercise and eating habits, attitudes about health, body image, and weight, and the desire to improve nutrition and physical activity. Analysis was performed on PRQs of participants to compare parental perceptions and readiness for change with compliance to program requirements. Analysis was conducted on 596 questionnaires and compliance was categorized into three groups based on attendance to follow-up visits.

RESULTS

Significant differences were found between short-term and long-term follow-up groups in regards to parental perception of one's health as well as the health, weight, and body image of their child. Differences were found in perceptions of one's own weight and body image as well as the health of one's self and child between the group with a maternal BMI < 35 and the group with a maternal BMI ≥ 35. A lower maternal BMI was associated with a better perception of one's own weight, body image, and health, as well as the health of the child.

CONCLUSION

Positive parental perceptions on weight were correlated with improved compliance to a pediatric lifestyle modification program.

Pediatric Obesity, Hypertension, Lipids

PURPOSE OF REVIEW

The rise of the pediatric obesity pandemic over the past 40 years has sharpened focus on the management of obesity, hypertension and lipid abnormalities in children. Multiple studies demonstrate that these risk factors track from childhood into adulthood predisposing individuals to premature atherosclerotic cardiovascular disease and putting them at risk for early morbidity and mortality.

RECENT FINDINGS

Importantly, obesity, hypertension and lipid problems are individual risk factors that can occur independently. Multiple studies have shown that each risk factor causes target organ damage in children. Intensive and focused lifestyle modifications can improve a child's subclinical disease and decrease the risk for future morbidity.

SUMMARY

Childhood offers a unique opportunity at primordial and primary prevention of atherosclerotic cardiovascular disease. Clinicians must focus on targeting these highly prevalent conditions and applying lifestyle modification and then pharmacologic or surgical therapies as needed.

Effect of Child Overweight/Obesity Didactic Session on Resident Confidence and Detection

Objective. To evaluate the impact of an obesity didactic session for pediatric physicians on confidence in counseling and identified overweight/obesity and follow-up recommendations. Methods. Pediatric residents underwent training and completed pre/post online surveys evaluating confidence in obesity prevention and identification. A booster training occurred 1 year later. Pre-/post-training scores were compared using χ² or Fisher's exact tests. Electronic medical records data for patients ≥3 years with BMI-for-age percentile ≥85 during 3 months prior/following the training/booster compared frequency of overweight/obesity identification and follow-up recommendations (≤3 months recommended vs longer) using logistic regression adjusting for age and overweight/obese status. Results. Post trainings, improvements in confidence to define/screen for obesity were observed, with a decline between trainings. Overweight/obese identification and follow-up time recommendations improved post-training (identification: 14.2% to 27.4%, adjusted odds ratio [aOR] = 3.16, 95% confidence interval [CI] = 1.54-6.51; follow-up: 48.9% to 58.9%, aOR = 1.63, 95% CI = 1.01-2.64), aOR = 1.77, 95% CI = 1.10-2.85, and identification remained stable/above pre-training rates both pre-/post-booster (25.8%, aOR = 3.14, 95% CI = 1.53-6.45; and 22.1%, aOR = 2.57, 95% CI = 1.25-5.30, respectively). Recommended follow-up time rates continued to rise when measured pre-booster (60.6%, aOR = 1.77, 95% CI = 1.10-2.85), then declined (46.0%, aOR = 0.95, 95% CI = 0.60-1.52). Conclusion. This didactic session improved resident confidence in defining/screening, identification of overweight/obesity and follow-up recommendations; however, rates of identification remained low. The successes of this intervention support similar didactic sessions in residency programs and identifies opportunities for improved resident/attending education.

An Interactive Web-Based Intervention to Achieve Healthy Weight in Young Children

This prospective, randomized, controlled trial for parents of overweight and obese 3- to 7-year-olds was performed to assess the feasibility of a program promoting healthy eating and lifestyle by targeting parents as agents of change. The intervention was composed of 6-in-person group sessions and a customized website over 12 months. The control group received customary care. The primary outcome was feasibility of the intervention to promote healthy behavior change measured by attendance. The secondary outcome was effectiveness assessed by attaining reduced body mass index (BMI) z scores, healthy behavior changes and increased parent self-efficacy. Seventy-three child-parent dyads were enrolled; 14 parents never attended any sessions. Participation in follow-up assessments did not meet the hypothesized level. Ultimate BMI z scores did not differ between control and intervention groups. Parenting skills did not improve in the intervention group. This intervention to achieve healthy lifestyle changes in children via their parents as "change agents" was unsuccessful.

Tailored communications for obesity prevention in pediatric primary care: a feasibility study

Recommendations for the prevention of childhood obesity encourage providers to counsel parents and their children on healthy diet and activity behaviors. This study evaluated the feasibility of a theory-based, tailored communication intervention for obesity prevention (Team Up for Health) delivered during a well-child visit. A two-armed randomized controlled trial was used. Parents of children aged 4-10 years were recruited from a list of patients due for a well-child visit at a pediatric primary care clinic. Parents were randomized to either the 'immediate' condition (parent and pediatrician received the tailored report at the well-child visit) or the 'delayed' condition (parent received the report at the end of the study). Self-report measures assessed physical activity, fruits, vegetables, television time, sugary drinks, and 100% fruit juice. Parents completed assessments at baseline, <48 h and 4-week follow-up. Providers were interviewed at the end of the study. Independent t-tests were used to examine between group differences. Seven areas of feasibility were evaluated: Recruitment, randomization, measurement, retention, acceptability, implementation and demand. Results showed high rates of measurement (85%) and acceptability (89%) and implementation (80%) of the intervention. In conclusion, Team Up for Health was feasible; however, a larger study is needed to evaluate its efficacy.

BMI is a poor predictor of adiposity in young overweight and obese children

BACKGROUND

The body mass index (BMI) is a simple and widely utilized screening tool for obesity in children and adults. The purpose of this investigation was to evaluate if BMI could predict total fat mass (TFM) and percent body fat (%FAT) in a sample of overweight and obese children.

METHODS

In this observational study, body composition was measured by dual energy x-ray absorptiometry (DXA) in 663 male and female overweight and obese children at baseline within a multidisciplinary, pediatric fitness clinic at an academic medical center. Univariate and multivariate regression analyses were conducted to evaluate whether BMI z-score (BMIz) predicts TFM or %FAT.

RESULTS

The BMIz, sex and age of subjects were identified as significant predictors for both TFM and %FAT. In subjects younger than 9 years, the BMIz was a weak to moderate predictor for both TFM (R² = 0.03 for males and 0.26 for females) and %FAT (R² = 0.22 for males and 0.38 for females). For subjects between 9 and 18 years, the BMIz was a strong predictor for TFM (R² between 0.57 and 0.73) while BMIz remained only moderately predictive for %FAT (R² between 0.22 and 0.42).

CONCLUSIONS

These findings advance the understanding of the utility and limitations of BMI in children and adolescents. In youth (9-18y), BMIz is a strong predictor for TFM, but a weaker predictor of relative body fat (%FAT). In children younger than 9y, BMIz is only a weak to moderate predictor for both TFM and %FAT. This study cautions the use of BMIz as a predictor of %FAT in children younger than 9 years.

Innovative Assessments Help Elucidate Sustained Improvements in Fitness and Metabolic Health in Obese Children

OBJECTIVE

Treatment of childhood obesity is a medical challenge and limited data are available describing successful long term interventions. This study presents a multi-disciplinary intervention that resulted in sustained physiological improvement over a one-year period.

METHODS

The criterion outcome variables include cardiovascular fitness (CVF) measured by a population-specific treadmill test to predict maximal oxygen uptake (predicted VO2 max) and the body composition (BC) variables of fat mass, non-bone lean mass and percent body fat from whole body dual energy x-ray absorptiometry (DXA) scans. Subjects were overweight and obese children (N=79) evaluated at baseline, 6 and 12 months at a University Hospital-based pediatric fitness clinic.

RESULTS

Statistically significant improvements in non-bone lean body mass (+4.24 kg ± 5.0, p<0.0001) and predicted VO2 max (+0.14L/min ± 0.10, p<0.0001) were seen at 6 months. These significant improvements were sustained over 12 months: body fat percentage (-2.28 ± 3.49, p<0.0001), lean mass (+6.0 kg ± 4.0, p<0.0001) and predicted VO2 max (+0.22 L/min ± 0.19, p<0.0001). These results were observed despite increases in weight and body mass index (BMI) at 6-months (weight: +6.6 kg ± 6.93, p<0.0001; BMI: +0.37 ± 1.21, p=0.47) and 12-months (weight: +6.3 kg ± 5.8, p<0.0001; BMI: +0.91 ± 2.06, p=0.0002).

CONCLUSION

These results reflect the sustained effect of a multidisciplinary approach, and the value of using valid and reliable assessment methods to measure sustained physiological changes in a sample of 79 overweight and obese children.

Outpatient evaluation, recognition, and initial management of pediatric overweight and obesity in U.S. military medical treatment facilities

BACKGROUND AND PURPOSE

As childhood obesity is a concern in many communities, this study investigated outpatient evaluation and initial management of overweight and obese pediatric patients in U.S. military medical treatment facilities (MTFs).

METHODS

Samples of 579 overweight and 341 obese patients (as determined by body mass index [BMI]) aged 3-17 years were drawn from MTFs. All available FY2011 outpatient records were searched for documentation of BMI assessment, overweight/obesity diagnosis, and counseling. Administrative data for these patients were merged to assess coded diagnostic and counseling rates and receipt of recommended laboratory screenings.

CONCLUSIONS

Generic BMI documentation was high, but BMI percentile assessments were found among fewer than half the patients. Diagnostic recording or recognition totaled 10.9% of overweight and 32.0% of obese. Counseling rates were higher, with 46.4% and 61.0% of overweight and obese patients, respectively, receiving weight related counseling. Among patients 10 years of age or older, rates of recommended lab screenings for diabetes, liver abnormality, and dyslipidemia were not greater than 33%. BMI percentile recording was strongly associated with diagnostic recording, and diagnostic recording was strongly associated with counseling.

IMPLICATIONS FOR PRACTICE

Improvements to electronic health records or implementation of local procedures to facilitate better diagnostic recording would likely improve adherence to clinical practice guidelines.

Reducing childhood obesity through coordinated care: Development of a park prescription program

Major hindrances to controlling the current childhood obesity epidemic include access to prevention and/or treatment programs that are affordable, provide minimal barriers for participation, and are available to the general public. Moreover, successful childhood obesity prevention efforts will require coordinated partnerships in multiple sectors such as government, health care, school/afterschool, and the community but very few documented sustainable programs currently exist. Effective, community-based health and wellness programs with a focus on maintaining healthy weight via physical activity and healthy eating have the potential to be a powerful referral resource for pediatricians and other healthcare professionals who have young patients who are overweight/obese. The Miami Dade County Department of Parks, Recreation and Open Spaces in partnership with the University of Miami UHealth Systems have created a "Park Prescription Program (Parks Rx 4Health(TM))" that formally coordinates pediatricians, families, parents, caregivers, and child/adolescents to provide daily obesity-prevention activities. This Parks Rx 4Health(TM) program that we describe here allows UHealth pediatricians to seamlessly refer their overweight and obese patients to Fit2Play(TM), an evidence-based, park-based afterschool health and wellness program. Measurable outcomes that include body mass index, blood pressure, fitness, and nutrition knowledge are being collected at baseline and at 3-and 6-mo after referral to document patient progress. Results are then shared with the referring physician so they can follow up with the patient if necessary. Identifying successful models that integrate primary care, public health, and community-based efforts is important to accelerating progress in preventing childhood obesity. Effective, community-based health and wellness programs with a focus on physical activity and nutrition education could be a powerful referral resource for pediatricians who have obese patients.

Rationale, design and methods for the RIGHT Track Health Study: pathways from childhood self-regulation to cardiovascular risk in adolescence

BACKGROUND

Cardiovascular risk factors during adolescence-including obesity, elevated lipids, altered glucose metabolism, hypertension, and elevated low-grade inflammation-is cause for serious concern and potentially impacts subsequent morbidity and mortality. Despite the importance of these cardiovascular risk factors, very little is known about their developmental origins in childhood. In addition, since adolescence is a time when individuals are navigating major life changes and gaining increasing autonomy from their parents or parental figures, it is a period when control over their own health behaviors (e.g. drug use, sleep, nutrition) also increases. The primary aim of this paper is to describe the rationale, design and methods for the RIGHT Track Health Study. This study examines self-regulation as a key factor in the development of cardiovascular risk, and further explores health behaviors as an explanatory mechanism of this association. We also examine potential moderators (e.g. psychosocial adversities such as harsh parenting) of this association.

METHOD/DESIGN

RIGHT Track is a longitudinal study that investigates social and emotional development. The RIGHT Track Health Study prospectively follows participants from age 2 through young adulthood in an effort to understand how self-regulatory behavior throughout childhood alters the trajectories of various cardiovascular risk factors during late adolescence via health behaviors. Individuals from RIGHT Track were re-contacted and invited to participate in adolescent data collection (~16.5, 17.5 and 18(+) years old). Individuals completed assessments of body composition, anthropometric indicators, fitness testing (via peak oxygen consumption), heart rate variability during orthostatic challenge, 7-day accelerometry for physical activity and sleep, 24-h dietary recalls, and blood analysis for biomarkers related to metabolic syndrome, inflammatory status and various hormones and cytokines. Individuals also completed extensive self-report measures on diet and eating regulation, physical activity and sedentary behaviors, sleep, substance use, medical history, medication use and a laboratory-day checklist, which chronicled previous day activities and menstrual information for female participants.

DISCUSSION

Insights emerging from this analysis can help researchers and public health policy administrators target intervention efforts in early childhood, when preventing chronic disease is most cost-effective and behavior is more malleable.

Use of a FITLINE to Support Families of Overweight and Obese Children in Pediatric Practices

BACKGROUND

The American Academy of Pediatrics (AAP) recommends a staged approach to pediatric weight management, starting with helping families to make targeted dietary and activity changes. This pilot study evaluated the preliminary efficacy of a pediatric practice-based referral program to support parents in helping their overweight/obese children improve their weight-related behaviors and BMI.

METHODS

A nonrandomized intervention study with contemporaneous control was used. Parents and their children ages 8-12 with BMI ≥85th percentile (N = 37) were recruited from a pediatric practice serving a low-income, multiethnic population. Providers delivered brief intervention and referred families to six weekly FITLINE telephone counseling sessions with a nutritionist who guided parents in helping their child make AAP-recommended changes. Child BMI and parent survey of child diet and physical activity were completed at baseline and 3 months. Medical record data from 44 children matched for age and BMI were collected.

RESULTS

Mean change in BMI from baseline to 3-month follow-up was -0.49 BMI units (standard deviation [SD], 0.95; p = 0.007) for the FITLINE group and 0.35 BMI units (SD, 0.96; p = 0.02) for the control group. Adjusting for baseline BMI, age, and sex, children in the FITLINE condition reduced BMI significantly more than children in the control condition (mean difference = -0.89; p = 0.0003). Significant improvements in many dietary and sedentary behaviors also were noted.

CONCLUSIONS

The FITLINE program reduced short-term BMI and improved dietary and sedentary behaviors. A randomized, controlled trial is warranted to assess the program's efficacy and potential to serve as a model for reducing obesity in pediatric practice.

'Croque&bouge': A feasible and acceptable programme for obesity prevention in preschoolers at risk and their parents

OBJECTIVES

To conceptualize and pilot test a programme of three workshops aiming to prevent the development of overweight in susceptible preschool children.

METHODS

Three workshops were conducted, targeting both parents and children. The curriculum for parents included discussions on feeding responsibilities, healthy eating, taste development, neophobia and physical activity recommendations. Children participated in various play activities with fruits and vegetables and read stories about hunger and satiety feelings. Recruitment was organized through paediatricians and child-care centres. Evaluation of the programme focused on feasibility, adequacy for children's age, parents' perception of impact and, for children, change of the ability to recognize and willingness to taste fruits and vegetables.

RESULTS

A total of 21 children and one of their parents participated in the programme. The programme was found to be feasible and adequate for the targeted community. Parents reported perceiving a positive impact of the intervention; however, this finding was not statistically significant. The major difficulty was identifying and recruiting families and engaging the parents in a discussion about weight.

CONCLUSIONS

This short programme aiming to improve parents' ability to offer healthy environment and promote healthy eating behaviour was feasible and acceptable for families with young children. When developing and implementing such programmes, close collaboration with paediatricians and other health providers should be sought in order to identify and reach children at risk of obesity and their family.

Obesity Prevention and Screening

Obesity is widespread, associated with several physical and psychosocial comorbidities, and is difficult to treat. Prevention of obesity across the lifespan is critical to improving the health of individuals and society. Screening and prevention efforts in primary care are an important step in addressing the obesity epidemic. Each period of human development is associated with unique risks, challenges, and opportunities for prevention and intervention. Screening tools for overweight/obesity, although imperfect, are quick and easy to administer. Screening should be conducted at every primary care visit and tracked longitudinally. Screening tools and cutoffs for overweight and obesity vary by age group.

Promoting conversations between physicians and families about childhood obesity: evaluation of physician communication training within a clinical practice improvement initiative

Childhood obesity rates have incrementally increased since the 1980s, sparking calls for initiatives focused on addressing this public health concern. In response, the family medicine residency clinic profiled in this research designed, executed, and evaluated a practice improvement initiative focused on physician communication behaviors and clinic processes that impact the management of unhealthy pediatric weight. The results of the evaluation effort demonstrated increased physician knowledge of communication principles, improvements in weight management counseling rates, and opportunities for health delivery system changes to promote the effective clinical management of unhealthy pediatric weight.

Pairing motivational interviewing with a nutrition and physical activity assessment and counseling tool in pediatric clinical practice: a pilot study

BACKGROUND

Recommendations to screen and counsel for lifestyle behaviors can be challenging to implement during well-child visits in the primary care setting. A practice intervention was piloted using the Family Nutrition and Physical Activity (FNPA) Screening Tool paired with a motivational interviewing (MI)-based counseling tool during well-child visits. Acceptability and feasibility of this intervention were assessed. Its impact on parent-reported obesigenic behavior change and provider efficacy in lifestyle counseling were also examined.

METHODS

This was an observational study in a pediatric primary care office. During well-child visits of 100 patients (ages 4-16 years), the FNPA tool was implemented and providers counseled patients in an MI-consistent manner based on its results. Duration of implementation, patient satisfaction of the intervention, and success of stated lifestyle goals were measured. Provider self-efficacy and acceptability were also surveyed.

RESULTS

The FNPA assessment was efficient to administer, requiring minutes to complete and score. Patient acceptability was high, ranging from 4.0 to 4.8 on a 5-point scale. Provider acceptability was good, with the exception of duration of counseling; self-efficacy in assessing patient "readiness for change" was improved. Parent-reported success of primary lifestyle goal was 68% at 1 month and 46% at 6 months.

CONCLUSIONS

The FNPA assessment with an MI-based counseling tool shows promise as an approach to identify and address obesigenic behaviors during pediatric well-child visits. It has the potential to improve provider efficacy in obesity prevention and also influence patient health behaviors, which can possibly impact childhood excessive weight gain. After refinement, this practice intervention will be used in a larger trial.

Rethinking obesity counseling: having the French Fry Discussion

Childhood obesity is a complex problem that warrants early intervention. General recommendations for obesity prevention and nutrition counseling exist. However, these are notably imprecise with regard to early and targeted interventions to prevent and treat obesity in pediatric populations. This study examines family medicine primary care providers' (PCPs) perceived barriers for preventing and treating pediatric obesity and their related practice behavior during well-child visits.

METHODS

A written survey addressing perceived barriers and current practices addressing obesity at well-child visits were administered to PCPs at eleven family medicine clinics in the Duke University Health System.

RESULTS

The most common perceived barriers identified by PCPs to prevention or treatment of obesity in children were families not getting enough exercise (93%) and families too often having fast food meals (86%). Most PCPs do not discuss fast foods at or prior to the twelve-month well-child visit. The two-year visit is the first well-child visit at which a majority of PCPs (68%) discuss fast food.

CONCLUSION

No clear consensus exists as to when PCPs should discuss fast food in early well-child checks. Previous research has shown a profound shift in children's dietary habits toward fast foods, such as French fries, that occurs between the one- and two-year well-child checks. Consideration should be given to having a "French Fry Discussion" at every twelve-month well-child care visit.

Fitwits: preparing residency-based physicians to discuss childhood obesity with preteens

OBJECTIVE

To evaluate the Fitwits MD office tool and games for obesity discussions with 9- to 12-year-olds.

METHODS

A nonrandomized intervention study using pre- and posttest assessments in 2 residency programs compared 31 control group and 55 intervention physicians (34 previously trained, 21 newly trained to use Fitwits). Surveys addressed comfort and competence regarding: obesity prevention and treatment, nutrition, exercise, portion size, body mass index (BMI), and the term "obesity." We surveyed all groups at baseline and 5 months (post 1) and new trainees 3 months later (post 2).

RESULTS

In post 1, prior trainees reported significantly increased comfort and competence for discussing obesity prevention, portion size, BMI, and "obesity." In post 2, new trainees reported significantly increased comfort and competence discussing obesity prevention and treatment, portion size, and BMI.

CONCLUSIONS

Experience using Fitwits improved residency-based physician comfort and competence in obesity prevention and treatment, portion size, BMI, and "obesity" discussions with preadolescents.

Motivational Interviewing in the Health Care Setting

Alcohol use disorders are related to many negative health, emotional, societal, and economic consequences. These disorders are often difficult to treat because individuals suffering from them tend to be ambivalent about and resistant to change. Motivational interviewing provides health care providers with the appropriate tools to treat individuals who are resistant to change and can help with long-term lifestyle and behavioral changes. Motivational interviewing has also been shown to be helpful when a lifestyle approach to treatment is used.

Expanding the role of primary care in the prevention and treatment of childhood obesity: a review of clinic- and community-based recommendations and interventions

Although pediatric providers have traditionally assessed and treated childhood obesity and associated health-related conditions in the clinic setting, there is a recognized need to expand the provider role. We reviewed the literature published from 2005 to 2012 to (1) provide examples of the spectrum of roles that primary care providers can play in the successful treatment and prevention of childhood obesity in both clinic and community settings and (2) synthesize the evidence of important characteristics, factors, or strategies in successful community-based models. The review identified 96 articles that provide evidence of how primary care providers can successfully prevent and treat childhood obesity by coordinating efforts within the primary care setting and through linkages to obesity prevention and treatment resources within the community. By aligning the most promising interventions with recommendations published over the past decade by the Institute of Medicine, the American Academy of Pediatrics, and other health organizations, we present nine areas in which providers can promote the prevention and treatment of childhood obesity through efforts in clinical and community settings: weight status assessment and monitoring, healthy lifestyle promotion, treatment, clinician skill development, clinic infrastructure development, community program referrals, community health education, multisector community initiatives, and policy advocacy.

Examining body mass index in an urban core population: from health screening to physician visit

BACKGROUND. Childhood obesity is commonly encountered in the primary care office and disproportionately affects those from low income or minority backgrounds.

OBJECTIVE

To determine how accurately primary care clinicians in an urban setting identified patients with body mass indices (BMIs) at or above the 95th percentile for age and to determine which obesity treatment strategies are used.

MATERIALS AND METHODS

The study population consisted of school-aged, inner-city children with a BMI at or above the 95th percentile for age whose charts were made available for data collection by retrospective chart review.

RESULTS

A total of 158 patient medical charts were reviewed. Of these, 90 (57%) patients failed to be identified by the provider as having an elevated BMI. Obesity treatment was initiated in only 68 (43%) of these patients.

CONCLUSIONS

Providers are not effectively recognizing childhood obesity and are not consistently implementing effective obesity treatment strategies.

Office-based randomized controlled trial to reduce screen time in preschool children

OBJECTIVE

To determine if an intervention for preschool-aged children in primary care is effective in reducing screen time, meals in front of the television, and BMI.

METHODS

A randomized controlled trial was conducted at a primary care pediatric group practice in Toronto, Canada. Three-year-old children and their parents were randomly assigned to receive a short behavioral counseling intervention on strategies to decrease screen time. The primary outcome 1 year later was parent reported screen time. Secondary outcomes included television in the child's bedroom, number of meals in front of the television, and BMI.

RESULTS

In the intention-to-treat analysis at 1 year, there were no significant differences in mean total weekday minutes of screen time (60, interquartile range [IQR]: 35-120 vs 65, IQR: 35-120; P = .68) or mean total weekend day minutes of screen time (80, IQR: 45-130 vs 90, IQR: 60-120; P = .33) between the intervention and control group. Adjusting for baseline BMI, there was a reduction in the number of weekday meals in front of the television (1.6 ± 1.0 vs 1.9 ± 1.2; P = .03) but no differences in BMI or number of televisions in the bedroom.

CONCLUSIONS

This pragmatic trial was not effective in reducing screen time or BMI but was effective in reducing meals in front of the screen. Short interventions focused solely on reducing screen time implemented in the primary care practice setting may not be effective in this age group.

Obesity prevention and intervention in dental practice

Dentists have an important role in preventing and detecting oral and systemic diseases because of their diagnostic and screening abilities and the frequency of patient visits. These skills and practice paradigms should be considered in solving the obesity epidemic. The well-described connection between periodontal disease and diabetes is a reason for dentists to intervene in the rise of obesity. Dentists are in a unique position to identify and aid in treatment of obstructive sleep apnea, a condition associated with obesity and diabetes. Dentists can play a role in raising awareness of overweight status and obesity risk behaviors in children.

Systematic review of effective strategies for reducing screen time among young children

Screen-media use among young children is highly prevalent, disproportionately high among children from lower-income families and racial/ethnic minorities, and may have adverse effects on obesity risk. Few systematic reviews have examined early intervention strategies to limit TV or total screen time; none have examined strategies to discourage parents from putting TVs in their children's bedrooms or remove TVs if they are already there. In order to identify strategies to reduce TV viewing or total screen time among children <12 years of age, we conducted a systematic review of seven electronic databases to June 2011, using the terms "intervention" and "television," "media," or "screen time." Peer-reviewed intervention studies that reported frequencies of TV viewing or screen-media use in children under age 12 were eligible for inclusion. We identified 144 studies; 47 met our inclusion criteria. Twenty-nine achieved significant reductions in TV viewing or screen-media use. Studies utilizing electronic TV monitoring devices, contingent feedback systems, and clinic-based counseling were most effective. While studies have reduced screen-media use in children, there are several research gaps, including a relative paucity of studies targeting young children (n = 13) or minorities (n = 14), limited long-term (>6 month) follow-up data (n = 5), and few (n = 4) targeting removing TVs from children's bedrooms. Attention to these issues may help increase the effectiveness of existing strategies for screen time reduction and extend them to different populations.

Provider perspectives on electronic decision supports for obesity prevention

Despite the availability of national evidenced-based guidelines related to pediatric obesity screening and prevention, multiple studies have shown that primary care physicians find it difficult to adhere to them or are unfamiliar with them altogether. This article presents physicians' perspectives on the use of electronic decision support tools, an alert and Smart Set, to accelerate the adoption of obesity-related recommendations into their practice. The authors interviewed providers using a test encounter walk-through technique that revealed a number of barriers to using electronic decision supports for obesity care in primary care settings. Providers' suggestions for improving their use of obesity-related decision supports are presented. Careful consideration must be given to both the development of electronic decision support tools and a multilayered educational outreach strategy if providers are going to be persuaded to use such supports to help them implement pediatric obesity prevention and management best practices.

"Childhood overweight and obesity: maternal perceptions of the time for engaging in child weight management"

BACKGROUND

There is an increasing awareness of the impact of parental risk perception on the weight course of the child and the parent's readiness to engage in preventive efforts, but only less is known about factors related to the parental perception of the right time for the implementation of preventive activities. The aim of this study was to examine parental perceptions of the appropriate time to engage in child weight management strategies, and the factors associated with different weight points at which mothers recognize the need for preventive actions.

METHODS

352 mothers with children aged 2-10 years took part in the study. We assessed mothers' perceptions of the actual and preferred weight status of their child, their ability to identify overweight and knowledge of its associated health risks, as well as perceptions of the right time for action to prevent overweight in their child. A regression analysis was conducted to examine whether demographic and weight related factors as well as the maternal general risk perception were associated with recognizing the need to implement prevention strategies.

RESULTS

Although most of the parents considered a BMI in the 75th to 90th percentile a valid reason to engage in the prevention of overweight, 19% of the mothers were not willing to engage in prevention until their child reached the 97th percentile. Whereas the child's sex and the identification of an elevated BMI were significant predictors for parents' recognition of the 75th percentile as right point to engage in prevention efforts, an inability to recognize physical health risks associated with overweight silhouettes emerged as a significant factor predicting which parents would delay prevention efforts until a child's BMI reached the 97th percentile.

CONCLUSION

Parental misperceptions of overweight and associated health risks constitute unfavorable conditions for preventive actions. Feedback on the health risks associated with overweight could help increase maternal readiness for change.

Paediatric obesity research in early childhood and the primary care setting: the TARGet Kids! research network

Primary paediatric health care is the foundation for preventative child health. In light of the recent obesity epidemic, paediatricians find themselves at the frontline of identification and management of childhood obesity. However, it is well recognized that evidence based approaches to obesity prevention and subsequent translation of this evidence into practice are critically needed. This paper explores the role of primary care in obesity prevention and introduces a novel application and development of a primary care research network in Canada—TARGet Kids!—to develop and translate an evidence-base on effective screening and prevention of childhood obesity.

Can a trial of motivational lifestyle counseling be effective for controlling childhood obesity and the associated cardiometabolic risk factors?

OBJECTIVES

This study was conducted to assess the effectiveness of a simple office-based program for encouraging healthy lifestyle on controlling childhood obesity and associated cardiometabolic risk factors.

METHODS

This non-randomized 24-week lifestyle modification trial was conducted among 457 obese children and adolescents, aged 2-18 years, who had at least one cardiometabolic risk factor in addition to obesity. This trial included three components of exercise, diet education and behavior modification, with all recommendations provided by a pediatrician, two general physicians and a nurse. Instead of strict inhibitory recommendations, healthier lifestyle was encouraged.

RESULTS

Overall 448 (98.04%) of enrolled children completed the trial with a mean age of 9.6 ± 2.9 years. After the trial, the mean of anthropometric measures and cardiometabolic risk factors decreased significantly, the mean high-density lipoprotein cholesterol (HDL-C) increased significantly, and the prevalence of the metabolic syndrome decreased from 20.8% to 1.8%. Triglycerides, LDL-C, diastolic blood pressure and WC had the highest decrease in all age groups, with the most prominent changes in the 14-18-year age group. By each -1SD decline in BMI and WC, risk factors had significant improvement.

CONCLUSION

Motivational office-based counseling can be effective in treatment of childhood obesity and its associated cardio-metabolic risk factors. Such approach can be implemented in the primary health care system; and can be of special concern in low- and middle-income countries with limited human and financial resources. We suggest that expanding the roles of non-physician clinicians such as nurse practitioners can help to increase the amount of time available for such services.

Counseling and behavior change in pediatric obesity

To effectively intervene with the overweight and obese youth, it is imperative that primary care providers and behavioral interventionists work in concert to help families implement healthy behaviors across socioenvironmental domains. In this article, the authors review current office-based counseling practices and provide evidence-based recommendations for addressing weight status and strategies for encouraging behavior change with children and families, primarily by increasing social support. By providing such collaborative targeted efforts, consistent health messages and support are delivered across children's everyday contexts, thereby helping the youth to achieve successful implementation of eating and activity behaviors and sustainable weight loss outcomes.

Treating childhood obesity in primary care

The objective of this prospective, cohort study was to assess an intervention for obese children (9-12 years of age) and their families delivered in primary care. A family-based, behavioral weight management program consisted of 11 sessions. The treatment consisted of a calorie goal, self-monitoring of daily food intake, physical activity and sedentary behavior, and other behavior change skills. A total of 78 children and families entered treatment; 23 children served as quasi-controls. The mean weight loss at 15 weeks among 55 children (71%) who completed the program was 2.4 lbs (SD = 5.24, range of -16.7 to +8.4 lbs) compared with a mean weight gain of 3.45 lbs (SD = 4.31, range of -5.0 to +12.0 lbs) among 23 control children. The mean change in body mass index z score from baseline to month 24 was -0.17 ± 0.32 (P < .001). Primary care is an appropriate place to identify and treat children with obesity.

Childhood obesity: a Wilsonian concept analysis

The rate of childhood obesity in the United States has tripled since 1980, with approximately 17% of U.S. children between the ages of 2 and 19 years currently identified as obese. Although a multitude of programs have been implemented to prevent and treat childhood obesity, no single strategy has been identified as the most effective method. Part of the problem in identifying successful interventions is clarifying what is meant by the term obesity as it applies to children. This article provides a concept analysis of the term obesity in relation to children using a Wilsonian approach.

Use of a tool to determine perceived barriers to children's healthy eating and physical activity and relationships to health behaviors

This pilot investigation assesses whether barriers to children's healthy eating and physical activity reported by parents on a newly developed brief pediatric obesity screening and counseling tool are related to healthy eating and physical activity behaviors. The sample included parents of 115 Medicaid-enrolled children in a general pediatric clinic. Of 10 barriers, 7 were statistically associated with parent-reported behaviors with odds ratios (ORs) ranging from 0.6 to 9.4. Relationships remained significant when child characteristics were controlled in the analysis. Although additional testing is needed, the tool provides clinicians with an approach to identify barriers and behaviors for targeted counseling.

Physician practices related to use of BMI-for-age and counseling for childhood obesity prevention: a cross-sectional study

BACKGROUND

Screening for obesity and providing appropriate obesity-related counseling in the clinical setting are important strategies to prevent and control childhood obesity. The purpose of this study is to document pediatricians (PEDs) and general practitioners (GPs) with pediatric patients use of BMI-for-age to screen for obesity, confidence in explaining BMI, access to referral clinics, and characteristics associated with screening and counseling to children and their caregivers.

METHODS

The authors used 2008 DocStyles survey data to examine these practices at every well child visit for children aged two years and older. Counseling topics included: physical activity, TV viewing time, energy dense foods, fruits and vegetables, and sugar-sweetened beverages. Chi-square tests were used to examine differences in proportions and logistic regression to identify characteristics associated with screening and counseling.

RESULTS

The final analytic sample included 250 PEDs and 621 GPs. Prevalence of using BMI-for-age to screen for obesity at every well child visit was higher for PEDs than GPs (50% vs. 22%, χ2 = 67.0, p ≤ 0.01); more PEDs reported being very/somewhat confident in explaining BMI (94% vs. GPs, 87%, p < 0.01); more PEDs reported access to a pediatric obesity specialty clinic for referral (PEDs = 65% vs. GPs = 42%, χ2 = 37.5, p ≤ 0.0001).In general, PEDs reported higher counseling prevalence than GPs. There were significant differences in the following topics: TV viewing (PEDs, 79% vs. GPs, 61%, χ2 = 19.1, p ≤ 0.0001); fruit and vegetable consumption (PEDs, 87% vs. GPs, 78%, χ2 = 6.4, p ≤ 0.01). The only characteristics associated with use of BMI for GPs were being female (OR = 2.3, 95% CI = 1.5-3.5) and serving mostly non-white patients (OR = 1.8, 95% CI = 1.1-2.9); there were no significant associations for PEDs.

CONCLUSIONS

The findings for use of BMI-for-age, counseling habits, and access to a pediatric obesity specialty clinic leave room for improvement. More research is needed to better understand why BMI-for-age is not being used to screen at every well child visit, which may increase the likelihood overweight and obese patients receive counseling and referrals for additional services. The authors also suggest more communication between PEDs and GPs through professional organizations to increase awareness of existing resources, and to enhance access and referral to pediatric obesity specialty clinics.

A systematic review of primary healthcare provider education and training using the Chronic Care Model for childhood obesity

The purpose of this systematic review was to examine 15 studies which evaluated interventions aimed at improving primary care providers' identification, assessment, prevention and/or management of obesity in children and adolescents. Interventions were evaluated in terms of length, components addressing nutrition, physical activity and behavioural counselling consistent with expert recommendations, and inclusion of components of the Chronic Care Model. Overall, training interventions were delivered face to face or in a combination of lecture, assigned readings, preceptorship with experienced providers, and critiqued evaluations of interactions of the provider with the patient and family. Many studies incorporated training of providers as an initial step prior to delivering an obesity intervention for children and adolescents measuring weight loss and behaviour change as outcomes. Each study was evaluated for components of the Chronic Care Model. The interventions most frequently utilized the elements of self-management support (69%), decision support (100%), delivery system support (77%) and clinical information systems (23%). Although science in this area is emerging, results suggest that intervention programmes that included more components of the Chronic Care Model were more effective.

Parental factors associated with screen time in pre-school children in primary-care practice: a TARGet Kids! study

OBJECTIVE

To identify child and parental factors associated with screen time in 3-year-old children.

DESIGN

Observational study.

SETTING

Participants were recruited from a large primary-care paediatric group practice in Toronto, Canada.

SUBJECTS

Healthy 3-year-old children were included. A questionnaire was completed by their parents on screen time. Descriptive statistics and linear regression models were used to assess associations between child screen time and selected factors. Multivariable models included factors from the univariate analysis with P < 0·1. Estimated effects and 95% CI are reported.

RESULTS

A total of 157 children were enrolled (91% recruitment). The mean screen time per weekday was 104 min (similar for weekend day). In all, 10% of children had a television (TV) in their bedroom; 59% consumed at least one meal while watching TV; and 81% of parents had household rules about screen time. Controlling for maternal education and age, eating lunch and dinner in front of the screen and mother being employed were associated with an increase in child weekday screen time of 96 (95% CI 30, 192), 42 (95% CI 12, 90) and 36 (95% CI 6, 72) min/d, respectively. Eating lunch in front of the screen and an increase of 1 h of parental screen time were associated with an increase of 78 (95% CI 36, 132) and 12 (95% CI 6, 18) min/d in child weekend screen time. Family rules decreased child weekend screen time by 30 (95% CI 6, 54) min/d.

CONCLUSIONS

Interventions that include these important parental factors should be evaluated for their effectiveness in reducing screen time.

Primary care practice addressing child overweight and obesity: a survey of primary care physicians at four clinics in southern Appalachia

OBJECTIVE

The prevalence of childhood overweight and obesity in southern Appalachia is among the highest in the United States (US). Primary care providers are in a unique position to address the problem; however, little is known about attitudes and practices in these settings.

METHODS

A 61-item healthcare provider questionnaire assessing current practices, attitudes, perceived barriers, and skill levels in managing childhood overweight and obesity was distributed to physicians in four primary care clinics. Questionnaires were obtained from 36 physicians.

RESULTS

Physicians' practices to address childhood overweight and obesity were limited, despite the fact that most physicians shared the attitude that childhood overweight and obesity need attention. While 71% of physicians reported talking about eating and physical activity habits with parents of overweight or obese children, only 19% reported giving these parents the tools they needed to make changes. Approximately 42% determined the parents' readiness to make small changes for their overweight or obese children. Physicians' self-perceived skill level in managing childhood overweight and obesity was found to be a key factor for childhood overweight- and obesity- related practices.

CONCLUSION

Primary care physicians in southern Appalachia currently play a limited role in the prevention or intervention of childhood overweight and obesity. Training physicians to improve their skills in managing childhood overweight and obesity may lead to an improvement in practice.

Adoption of body mass index guidelines for screening and counseling in pediatric practice

OBJECTIVE

The purpose of this study was to examine pediatrician implementation of BMI and provider interventions for childhood overweight prevention and treatment.

METHODS

Data were obtained from the American Academy of Pediatrics (AAP) Periodic Survey of Fellows No. 65, a nationally representative survey of AAP members. Surveys that addressed the provision of screening and management of childhood overweight and obesity in primary care settings were mailed to 1622 nonretired US AAP members in 2006.

RESULTS

One thousand five (62%) surveys were returned; 677 primary care clinicians in active practice were eligible for the survey. Nearly all respondents (99%) reported measuring height and weight at well visits, and 97% visually assess children for overweight at most or every well-child visit. Half of the respondents (52%) assess BMI percentile for children older than 2 years. Most pediatricians reported that they do not have time to counsel on overweight and obesity, that counseling has poor results, and that having simple diet and exercise recommendations would be helpful in their practice. Pediatricians in large practices and those who had attended continuing medical education on obesity were more familiar with national expert guidelines, were more likely to use BMI percentile, and had higher self-efficacy in practices related to childhood and adolescent overweight and obesity. Multivariate analysis revealed that pediatricians with better access to community and adjunct resources were more likely to use BMI percentile.

CONCLUSIONS

BMI-percentile screening in primary pediatric practice is underused. Most pediatricians believe that they can and should try to prevent overweight and obesity, yet few believe there are good treatments once a child is obese. Training, time, and resource limitations affect BMI-percentile use. Awareness of national guidelines may improve rates of BMI-percentile use and recognition of opportunities to prevent childhood and adolescent obesity.

Applying practice recommendations for the prevention and treatment of obesity in children and adolescents

To describe pediatric clinicians' adherence to practice recommendations for obesity prevention and treatment, we conducted a cross-sectional analysis of 227 medical records of 3- to 18-year-old patients (seen from September 2003 to April 2004) and a longitudinal analysis of data from 632 overweight and obese patients (followed through March 2006). The cross-sectional analysis showed that early practice adopters (n = 3) more frequently recorded BMI (91% of patients), a diagnosis (89%), and counseling (82%) compared with late adopters (n = 9; 34%, 51%, and 48% of patients, respectively; P < .001). The longitudinal analysis showed that among overweight and obese patients, documentation of BMI dropped from 96% at the first clinic visit to 27% by the fifth visit; documentation of individual risk behaviors fell from >or=72% at the first visit to <or=23% at the fifth visit. Despite initial adoption of screening and assessment practices, clinicians' attention to weight management diminished over time.

Use of a pediatrician toolkit to address parental perception of children's weight status, nutrition, and activity behaviors

BACKGROUND

Communication of children's weight status and targeted counseling by pediatricians may change parental perceptions or child dietary and physical activity behaviors. The aim of this study was to determine whether accuracy of parental perception of children's weight status and reports of related behaviors changed following a brief pediatrics resident intervention.

METHODS

Parents (N = 115) of children aged 4 to 12 years enrolled in Medicaid completed baseline questionnaires with providers about prior communication of weight status and/or body mass index (BMI), perceptions of their children's weight, and children's dietary and physical activity behaviors, and children were weighed and measured. Trained residents used a toolkit to communicate weight status to parents (via color-coded BMI charts) and counseled about mutually chosen healthy behaviors. Questionnaires were repeated at 1 and 3 months, and measurements were repeated for children with BMI > or =85%.

RESULTS

At baseline, 42% of parents of overweight children believed their children were at healthy weight. Most (n = 96; 83%) parents completed 1-month questionnaires, and 56% completed 3-month follow-up questionnaires. Improvements in fruit and vegetable consumption, sweet drinks, unhealthy snacks, frequency of restaurant food, lower-fat milk, and screen time occurred among both overweight and healthy weight children. There were also increases in discussions with providers about weight/BMI and parental accuracy of overweight assessment.

CONCLUSIONS

Parent accuracy of weight status and short-term childhood dietary and physical activity behavior changes improved following resident pediatrician use of a toolkit to support communication of weight status and counseling. Further research needs to determine whether accurate parental perception motivates improved behavior change or healthier BMI trajectories.

Feasibility and acceptability of a 1-page tool to help physicians assess and discuss obesity with parents of preschoolers

OBJECTIVE

To assess the feasibility and acceptability of a brief tool to help pediatricians communicate with parents of preschoolers about obesity risk, prevention, and treatment.

METHODS

The 2-sided Assessment and Targeted Messages (ATM) tool developed by the investigators included sections to assess nutrition and physical activity, self-efficacy and readiness-to-change, obesity-related family history, and treatment/prevention recommendations. Twenty-five pediatricians were recruited to use the ATM and then surveyed regarding their opinions of its feasibility and acceptability.

RESULTS

Response rate was 60%. Most ATM features were considered somewhat or very useful by the majority of respondents. The majority of physicians (62%) indicated that they were somewhat likely to use the ATM in the future, with only 23% indicating that they were very likely to use it. The greatest barrier to its use was time.

CONCLUSION

Pediatricians considered the ATM tool moderately feasible and acceptable. Time-efficient methods to help physicians address obesity should be explored.

Prevention of overweight and obesity in children under the age of 6 years

Although obesity was rarely observed among children 30 years ago, it is now evident among Canadian children of all ages. Currently, 15.2% of 2- to 5-year-old children are overweight, whereas 6.3% are obese. Limited data suggest that poor dietary and physical activity patterns are increasing obesity risk among these young children. Body weight and lifestyle behaviours are known to track from childhood to adulthood, thereby increasing the risk for obesity and other chronic diseases later in life. Intrauterine life, infancy, and the preschool years may all include critical periods that program the long-term regulation of energy balance, and therefore obesity-prevention strategies should be initiated in utero and continue throughout childhood and adolescence. Although single-strategy obesity-prevention initiatives have had limited success, programs that target multiple behaviours may help reduce body weight and body fat among young children. Parental involvement is key to the success of obesity-prevention programs at a young age, as parents have primary control over their children's food and activity environments. Accordingly, parental obesity is the best predictor of childhood obesity. Parents should be encouraged to teach and role model healthy lifestyle behaviours for their young children. Health professionals can also be involved in obesity prevention, as they are ideally placed to identify young children at risk for obesity. By calculating and plotting the body mass index for all children, and initiating obesity-prevention strategies in utero, health professionals can help curb the rise in overweight and obesity among young children.

Color-coding improves parental understanding of body mass index charting

OBJECTIVE

To assess parental understanding of body mass index (BMI) and BMI percentiles by using standard versus color-coded charts; to investigate how parental literacy and/or numeracy (quantitative skills) affects that understanding.

METHODS

A convenience sample of 163 parents of children aged 2 to 8 years at 2 academic pediatric centers completed a demographics questionnaire, the mathematics portion of the Wide Range Achievement Test (WRAT-3R), the Short Test of Functional Health Literacy in Adults (S-TOFHLA), and an "Understanding BMI" questionnaire, which included parallel BMI charting questions to compare understanding of standard versus color-coded BMI charting. Outcomes included parental-reported versus actual understanding of BMI, the odds (obtained by generalized estimating equations) of answering parallel questions correctly by using standard versus color-coded charting, and odds of answering questions correctly on the basis of numeracy and literacy.

RESULTS

Many parents (60%) reported knowing what BMI was, but only 30% could define it even roughly correctly. When parents used color-coded charts, they had greater odds of answering parallel BMI charting questions correctly than when they used standard charts (mean, 88% vs 65% correct; pooled adjusted odds ratio, 4.32; 95% confidence interval, 3.14-5.95; P < .01). Additionally, parents with lower numeracy (K-5 level) benefited more from color-coded charts (increased from 51% to 81% correct) than did higher numeracy parents (high school level or greater), who performed well with both charts (89% vs 99% correct).

CONCLUSIONS

Parents consistently performed better with color-coded than standard BMI charts. Color-coding was particularly helpful for lower numeracy parents. Future studies should investigate whether these results translate into the office setting and whether understanding motivates parents to implement important lifestyle changes.

Use of an electronic medical record system to support primary care recommendations to prevent, identify, and manage childhood obesity

Many primary care physicians are not providing care that is consistent with recommendations to prevent, to identify, and to manage childhood obesity. This report presents modifications made to the electronic medical record system of a large pediatric health care system, using a quality improvement approach, to support these recommendations and office system changes. Although it is possible to make practice changes secondary to electronic medical record system enhancements, challenges to development and implementation exist.

Bolstering confidence in obesity prevention and treatment counseling for resident and community pediatricians

OBJECTIVE

To assess whether equipping resident pediatricians and community pediatricians with both training and practical tools improves their perceived confidence, ease, and frequency of obesity-related counseling to patients.

METHODS

In 2005-2006, resident pediatricians (n = 49) and community pediatricians (n = 18) received training regarding three evidence-based obesity prevention/treatment tools and responded to pre- and post-intervention questionnaires. We analyzed changes in reported mean confidence, ease, and frequency of dietary, physical activity, and weight status counseling.

RESULTS

Baseline scores of confidence, ease, and frequency of counseling were higher in community pediatricians than residents. Mean scores increased significantly in the combined group, among residents only, and trended towards improvement in the community pediatricians following the intervention. Means for "control" questions were unchanged.

CONCLUSION

Training and tools for residents and community pediatricians improved their confidence, ease, and frequency of obesity-related counseling.

PRACTICE IMPLICATIONS

This study demonstrates that when feasible and appropriate tools and training were provided through a simple intervention, physicians gained confidence and ease and increased their counseling frequency. The results here suggest that widespread implementation of such educational interventions for community practitioners and practitioners in training could change the way physicians counsel patients to prevent the often frustrating problem of childhood obesity.