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

What are health professionals' perceptions of conducting routine growth assessments and lifestyle interventions? A qualitative study involving allied health professionals, nurses and doctors in rural and regional New South Wales

BACKGROUND

Allied health professionals, nurses and doctors within the New South Wales (NSW) public health system provide trusted health information to a large proportion of families across the state. This means they are well positioned to opportunistically assess and discuss child weight status with families. Prior to 2016, weight status was not routinely addressed in most NSW public health settings, however recent policy changes promote quarterly growth assessments for all children aged under 16years who attend these facilities. The Ministry of Health recommend health professionals use the 5 As framework, a consultation approach to encourage behaviour change, to identify and manage children with overweight or obesity. This study aimed to explore allied health professionals', nurses' and doctors' perceptions of conducting routine growth assessments and providing lifestyle support to families in a local health district in rural and regional NSW, Australia.

METHODS

This descriptive, qualitative study involved online focus groups and semi-structured interviews with health professionals. Audio recordings were transcribed and coded for thematic analysis, with rounds of data consolidation between research team members.

RESULTS

Allied health professionals, nurses and doctors who work in a variety of settings within a local health district of NSW participated in one of four focus groups (n =18 participants) or semi-structured interviews (n =4). The predominant themes related to: (1) health professionals' professional identity and their perceived scope of practice; (2) interpersonal qualities of health professionals; (3) the service delivery ecosystem in which health professionals worked. Diversity in attitudes and beliefs about routine growth assessments were not necessarily specific to discipline or setting.

CONCLUSIONS

Allied health professionals, nurses and doctors recognise the complexities involved in conducting routine growth assessments and providing lifestyle support to families. The 5 As framework used in NSW public health facilities to encourage behaviour change may not allow clinicians to address these complexities in a patient centred way. The findings of this research will be used to inform future strategies aimed at embedding preventive health discussions into routine clinical practice, and to support health professionals to identify and manage children with overweight or obesity.

Childhood Obesity, Diabetes. and Cardiovascular Disease Risk

This mini-review aims to briefly summarize the pathophysiology of childhood obesity, type 2 diabetes mellitus (T2DM), and cardiovascular disease (CVD) risk in children and adolescents. Recent data on efficacy of lifestyle interventions, medications, and metabolic surgery for obesity, T2DM, and CVD risk factors are also reviewed. We conducted a PubMed search of English-language original and review articles relevant to childhood obesity, T2DM, and CVD risk factors, and biomarkers in children with an emphasis on recent publications. Childhood obesity arises from an intricate interaction between genetic, physiologic, environmental, and socioeconomic factors. The rise in the prevalence of childhood obesity is associated with the development of comorbidities including T2DM and CVD at an early age. A multipronged approach is central to the detection, monitoring, and management of childhood obesity and associated adverse metabolic consequences.

Referral to Adolescent Weight Management Interventions: Qualitative Perspectives From Providers

OBJECTIVE

Current guidelines for treatment of obesity in adolescence include screening and referring youth with obesity to appropriate weight management (WM) care. However, prior work has not explored the referral process to adolescent WM programs, especially for youth from lower-income backgrounds, who are at increased risk of obesity and related negative health outcomes. This qualitative study sought to understand pediatricians' current practices regarding referrals to adolescent WM interventions with a focus on adolescents from lower-income backgrounds.

METHODS

Individual interviews were conducted with 11 medical providers that had referred at least 5 adolescents from low-income backgrounds to WM interventions. Applied thematic analysis was used for data analysis.

RESULTS

Identified themes included weight-related discussions with adolescents as potentially fraught, as providers want to address weight-related health concerns while being thoughtful about potential harm. Providers also noted varied factors affecting their decision to refer to WM programs, including health implications, perceived motivation of the patient and family, and availability of programs. Providers identified that many families experience shame or guilt around referral to WM. Few themes were identified regarding impact of income on weight-related conversations with adolescents.

CONCLUSION

Findings were novel in regard to discussions of weight in adolescents with obesity leading to WM referral. Despite being a primary focus of the present study, few themes were identified regarding specific considerations for adolescents from low-income backgrounds. Future clinical research should focus on provider-focused interventions to increase sensitivity regarding weight-related discussions and attention to diversity, equity, and inclusion.

The Effects of a Multisector, Multilevel Intervention on Child Dietary Intake: California Childhood Obesity Research Demonstration Study

Consuming too few fruits and vegetables and excess fat can increase the risk of childhood obesity. Interventions which target mediators such as caregivers' dietary intake, parenting strategies, and the family meal context can improve children's diets. A quasi-experimental, pre-post intervention with four conditions (healthcare (HC-only), public health (PH-only), HC + PH, and control) was implemented to assess the effects of the interventions and the effects of the mediators. HC (implemented with the Obesity Care Model) and PH interventions entailed capacity building; policy, system, and environment changes; and a small-scale media campaign to promote healthy eating. Linear mixed models were used to assess intervention effects and the mediation analysis was performed. Predominantly Hispanic/Latino children and caregivers from rural communities in Imperial County, California, were measured at baseline (N = 1186 children/848 caregivers) and 12 months post-baseline (N = 985/706, respectively). Children who were overweight/obese in the HC-only condition (M = 1.32) consumed more cups of fruits at the 12-month follow-up than those in the control condition (M = 1.09; p = 0.04). No significant mediation was observed. Children in the PH-only condition consumed a significantly higher percentage of energy from fat (M = 36.01) at the follow-up than those in the control condition (M = 34.94, p < 0.01). An obesity intervention delivered through healthcare settings slightly improved fruit intake among at-risk children, but the mechanisms of effect remain unclear.

Barriers and facilitators of integrating physiotherapy into primary health care settings: A systematic scoping review of qualitative research

Purpose

This scoping review investigated the barriers and facilitators to integrating physiotherapy into primary health care (PHC).

Materials and methods

PubMed, Scopus, Web of Science, Embase, ProQuest, and REHABDATA were searched. Two independent reviewers were involved in screening, selecting, and extracting data. Data were synthesized using thematic analysis.

Results

Of the 483 screened documents, 44 qualitative studies, primarily from high-income countries, were included. All of the studies had good methodological quality. Barriers and facilitators of integrating physiotherapy into PHC were extracted within the WHO six building blocks framework. In total, 41 items were identified as barriers to the integration process. The studies included 49 recommendations to facilitate integrating physiotherapy services into PHC.

Conclusion

Integrating physiotherapy services into PHC faces many barriers. The most commonly suggested potential barriers are poor knowledge of physicians about physiotherapy, ineffective teamwork, physiotherapists' time constraints/workload, a lack of clarity over the role and knowledge of physiotherapists, unawareness of physiotherapy users about these services, and lack of intra- and inter-professional collaborations. The most commonly suggested recommendations to facilitate the integration process include: Clarifying the role of involved professionals, strengthening teamwork, improving intra- and inter-professional collaborations, and providing comprehensive training programs for physiotherapists.

Guided Self-Help for Pediatric Obesity in Primary Care: A Randomized Clinical Trial

OBJECTIVES

Our aim was to compare the effect of 2 treatment models on attendance and child weight status: a less intense guided self-help (GSH) program delivered in the primary care setting versus traditional family-based behavioral treatment (FBT) delivered in an academic center.

METHODS

We conducted a randomized clinical trial among 164 children between 5 and 13 years old with a BMI ≥85th percentile and their parents. The intervention group (GSH) received 14 individual sessions over 6 months, with 5.3 hours of treatment. The control group (FBT) received 20 group-based sessions over 6 months, with 20 hours of treatment. Main outcomes included proportion of sessions families attended and change in child BMI z-score (BMIz), percentage from the 95th BMI percentile, difference from the 95th BMI percentile at the end of treatment, and 6-month follow-up.

RESULTS

Mean age of children was 9.6 years, BMI z-score 2.1, 49% female, and >90% Latino. The odds of attending GSH compared to FBT was 2.2 (P < 0.01). Those assigned to GSH had a 67% reduced risk of attrition (hazard ratio = 0.33, 95% confidence interval 0.22-0.50, P < .001). Intent-to-treat analysis showed no between-group differences in change in BMIz and percentage from the 95th BMI percentile over time. Combined, there was a significant reduction in BMIz from baseline to posttreatment (β = -0.07 (0.01), P < .01, d: 0.60) and a slight increase from posttreatment to follow-up (β = 0.007 (0.13), P = .56).

CONCLUSIONS

This study provides support for a novel, less intense GSH model of obesity treatment, which can be implemented in the primary care setting. Future studies should examine effective approaches to dissemination and implementation of GSH in different settings to increase access to treatment.

Weight Communication: How Do Health Professionals Communicate about Weight with Their Patients in Primary Care Settings?

This study aimed to investigate how health professionals (HPs) communicate about weight with their patients. Semi-structured interviews were conducted with 33 health professionals (7 family physicians, 13 nurse practitioners, and 13 dietitians) working in multidisciplinary healthcare settings in Canada. Thematic analysis revealed four main approaches used by HPs to communicate about weight: 1) Analyzing patient perspectives, 2) focusing on overall health rather than weight, 3) directly addressing the topic, and 4) avoiding the topic. The approach chosen was influenced by HPs' outlook on obesity; for example, those who believed obesity to be a chronic disease did not hesitate to communicate about weight. However, some HPs who reported having obesity mentioned avoiding the topic of weight with their patients and emphasized the importance of establishing a trusting relationship with patients before addressing the topic. The approach chosen by HPs also seemed to be influenced by patient receptiveness, level of readiness, and motivation. Weight communication can be sensitive and the approach used to begin the topic of weight may differ based on patient- and HP factors. Future clinical practice guidelines may benefit from shifting toward communicating about modifiable risk factors rather than weight.

Undergraduate medical education interventions aimed at managing patients with obesity: A systematic review of educational effectiveness

The growing obesity epidemic requires an evidence-based approach to management of patients with obesity. Two systematic reviews on obesity-management interventions in undergraduate medical education, both published in 2012, reported discrepant findings. This study aimed to build on previous research by identifying, systematically reviewing, and synthesizing current literature on the effectiveness of educational interventions aimed at teaching management of patients with obesity to medical students. A comprehensive search of seven databases was performed with no date or language restrictions. Database search identified 6462 studies; 5373 were screened against title and abstract, 156 full-text articles were retrieved, 31 met eligibility criteria, and 17 were included after critical appraisal of study methodology. Nine cohort-studies, three qualitative, two case-controls, two mixed-methods, and one randomized controlled trial were included. Findings supported the educational effectiveness of brief (<3 h) educational interventions, the value of video-clips to deliver content, and the importance of in-person teaching. Findings also demonstrated an increase in the number of studies describing educational interventions aimed at teaching management of patients with obesity to medical students. These results can be used by medical educators to inform the design of educationally effective curricula focused on the management of patients with obesity in undergraduate medical education.

Physician-related predictors of referral for multidisciplinary paediatric obesity management: a population-based study

BACKGROUND

It is recommended that primary care-based physicians refer children with overweight and obesity to multidisciplinary paediatric obesity management, which can help to improve weight and health.

OBJECTIVE

To determine predictors of referral to multidisciplinary paediatric obesity management.

METHODS

This retrospective, population-level study included physicians who could refer 2-17 years old with a body mass index ≥85th percentile to one of three multidisciplinary paediatric obesity management clinics in Alberta, Canada. Physician demographic and procedural data were obtained from Practitioner Claims and Provider Registry maintained by Alberta Health from January 2014 to December 2017. Physician characteristics were compared based on whether they did or did not refer children for obesity management. Univariable and multivariable logistic regression models analysed associations between physician characteristics and referral making.

RESULTS

Of the 3863 physicians (3468 family physicians, 395 paediatricians; 56% male; 49.3 ± 12.2 years old; 22.3 ± 12.6 years since graduation) practicing during the study period, 1358 (35.2%) referred at least one child for multidisciplinary paediatric obesity management. Multivariable regression revealed that female physicians (versus males) [odds ratio (OR): 1.68, 95% confidence interval (CI): 1.46-1.93; P < 0.0001], paediatricians (versus family physicians) (OR: 4.89, 95% CI: 3.85-6.21; P < 0.0001) and urban-based physicians (versus non-urban-based physicians) (OR: 2.17, 95% CI: 1.79-2.65; P < 0.0001) were more likely to refer children for multidisciplinary paediatric obesity management.

CONCLUSIONS

Approximately one-third of family physicians and paediatricians referred children for multidisciplinary paediatric obesity management. Strategies are needed to improve referral practices for managing paediatric obesity, especially among male physicians, family physicians and non-urban-based physicians as they were less likely to refer children.

Interventions improving health professionals' practice for addressing patients' weight management behaviours: systematic review of reviews

Health professionals require education and training to implement obesity management guidelines and ultimately impact on the health outcomes experienced by their patients. Therefore, a systematic review of systematic reviews that evaluated interventions designed to change the practice of health professionals when addressing diet and physical activity with their patients was conducted. MEDLINE Complete; Cochrane database of systematic reviews; PsycINFO; CINAHL Complete; Global Health; Embase; INFORMIT: Health Subset; Health System Evidence and RX for change were searched in March 2019, with no date or language limits. Identified references underwent screening, full-text analyses and data extraction in duplicate. The search identified 15 230 references. Five systematic reviews that provided a narrative syntheses of a combined 38 studies were included. Health professional participants generally reported being satisfied with the training interventions. Heterogeneity between and within included reviews, non-controlled designs of individual studies and low quality of evidence at an individual study level and review level made it difficult to draw firm conclusions regarding what interventions are most effective in changing health professionals' knowledge, skills, self-efficacy, attitudes and practice. However, similar gaps in the literature were identified across included reviews. Key areas that could be addressed in future interventions including organization and system-level barriers to providing advice, health professionals' attitudes and motivation and weight stigma have been highlighted. Health professionals and patients could be more involved in the planning and development of interventions that work towards improving diet and physical activity advice and support provided in healthcare.

Design of the GOT Doc study: A randomized controlled trial comparing a Guided Self-Help obesity treatment program for childhood obesity in the primary care setting to traditional family-based behavioral weight loss

Currently one-third of children in the United States have overweight or obesity (OW/OB). The goal of Healthy People 2020 is to reduce the proportion of children with OW/OB and increase the proportion of primary care visits that include nutrition and weight-related counseling. Unfortunately, many health care providers find it difficult to offer effective weight-related counseling and treatment in the primary care setting. Therefore, new models of care are needed that allow a greater proportion of children with OW/OB and their parents to access care and receive quality weight management treatment. The current paper describes the GOT Doc study which is designed to test the effectiveness of a Guided Self-Help (GSH) model of obesity treatment that can be delivered in the primary care setting compared to a traditional Family-Based Behavioral weight loss treatment (FBT) delivered at an academic center. We will assess the impact of this program on attendance (access to care) and changes in child BMI percentile/z-score. We will also examine the impact of this treatment model on change in child lifestyle behaviors, parent support behaviors, and parent self-efficacy and empowerment to make behavior change. Finally, we will assess the cost-effectiveness of this model on changes in child BMI percentile/z-score. We believe the GSH intervention will be a cost-effective model of obesity management that can be implemented in community practices around the country, thereby increasing access to treatment for a broader proportion of our population and decreasing rates of childhood obesity.

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Effective childhood obesity treatment is not widely available or easily accessible.

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Guided Self-Help (GSH) model of treatment has been developed for pediatric obesity.

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GSH is easier to implement and can be delivered in the primary care setting.

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GSH can increase access to much needed treatment.

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Evaluation of its effectiveness in the primary care setting is needed.

Potential solutions for pediatric weight loss programs in the treatment of obesity in rural communities

Pediatric obesity remains disproportionately more prevalent in rural communities; however, multidisciplinary, pediatric weight loss programs, which are often located in tertiary-care centers, may not be accessible to rural families. Limited models to specifically address pediatric obesity in rural communities exist. Therefore, innovative solutions are required for expanded treatment of pediatric obesity in rural communities. This article discusses potential solutions for multidisciplinary, tertiary-care pediatric weight loss programs to improve access and treatment of pediatric obesity in rural communities. A selected review of the literature suggests that strategies to overcome barriers to treatment in rural communities include telephone calls and telemedicine conferencing by obesity specialists from academic centers (obesity medicine specialists, endocrinologists, dietitians, and psychotherapists) as well as training local primary care providers in rural communities to screen, diagnose, and treat patients with obesity. Multidisciplinary, tertiary-care pediatric weight loss programs have a profound opportunity to impact the treatment of pediatric obesity in rural communities by training practicing rural primary care providers as well as strengthening their commitment to educate future generations of clinicians on the treatment of pediatric obesity through medical training including physician assistant, nurse practitioner, and pediatric and family medicine resident education and skill building. This article identifies potential mechanisms for expansive treatment of pediatric obesity in rural communities by multidisciplinary, tertiary-care weight loss programs and highlights areas of specific focus needed for future investigation.

Using logic models to enhance the methodological quality of primary health-care interventions: guidance from an intervention to promote nutrition care by general practitioners and practice nurses

The methodological designs underpinning many primary health-care interventions are not rigorous. Logic models can be used to support intervention planning, implementation and evaluation in the primary health-care setting. Logic models provide a systematic and visual way of facilitating shared understanding of the rationale for the intervention, the planned activities, expected outcomes, evaluation strategy and required resources. This article provides guidance for primary health-care practitioners and researchers on the use of logic models for enhancing methodological rigour of interventions. The article outlines the recommended steps in developing a logic model using the 'NutriCare' intervention as an example. The 'NutriCare' intervention is based in the Australian primary health-care setting and promotes nutrition care by general practitioners and practice nurses. The recommended approach involves canvassing the views of all stakeholders who have valuable and informed opinions about the planned project. The following four targeted, iterative steps are recommended: (1) confirm situation, intervention aim and target population; (2) document expected outcomes and outputs of the intervention; (3) identify and describe assumptions, external factors and inputs; and (4) confirm intervention components. Over a period of 2 months, three primary health-care researchers and one health-services consultant led the collaborative development of the 'NutriCare' logic model. Primary health-care practitioners and researchers are encouraged to develop a logic model when planning interventions to maximise the methodological rigour of studies, confirm that data required to answer the question are captured and ensure that the intervention meets the project goals.

Community Healthcare and Technology to Enhance Communication in Pediatric Obesity Care

Childhood obesity continues to be a critical healthcare issue and a paradigm of a pervasive chronic disease affecting even our youngest children. When considered within the context of the socioecological model, the factors that influence weight status, including the social determinants of health, limit the impact of multidisciplinary care that occurs solely within the medical setting. Coordinated care that incorporates communication between the healthcare and community sectors is necessary to more effectively prevent and treat obesity. In this article, the Expert Exchange authors, with input from providers convened at an international pediatric meeting, provide recommendations to address this critical issue. These recommendations draw upon examples from the management of other chronic conditions that might be applied to the treatment of obesity, such as the use of care plans and health assessment forms to allow weight management specialists and community personnel (e.g., school counselors) to communicate about treatment recommendations and responses. To facilitate communication across the healthcare and community sectors, practical considerations regarding the development and/or evaluation of communication tools are presented. In addition, the use of technology to enhance healthcare-community communication is explored as a means to decrease the barriers to collaboration and to create a web of connection between the community and healthcare providers that promote wellness and a healthy weight status.

How Views of the Organization of Primary Care Among Patients with Hypertension Vary by Race or Ethnicity

INTRODUCTION

We assessed potential racial or ethnic differences in the degree to which veterans with pharmaceutically treated hypertension report experiences with their primary care system that are consistent with optimal chronic illness care as suggested by Wagner's Chronic Care Model (CCM).

MATERIALS AND METHODS

A cross-sectional analysis of the results of the Patient Assessment of Chronic Illness Care (PACIC), which measured components of the care system suggested by the CCM and was completed at baseline by participants in a hypertension disease management clinical trial. Participants had a recent history of uncontrolled systolic blood pressure.

RESULTS

Among 377 patients, non-Hispanic African American veterans had almost twice the odds of indicating that their primary care experience is consistent with CCM features when compared with non-Hispanic White patients (odds ratio (OR) = 1.86; 95% confidence interval (CI) = 1.16-2.98). Similar statistically significant associations were observed for follow-up care (OR = 2.59; 95% CI = 1.49-4.50), patient activation (OR = 1.80; 95% CI = 1.13-2.87), goal setting (OR = 1.65; 95% CI = 1.03-2.64), and help with problem solving (OR = 1.62; 95% CI = 1.00-2.60).

CONCLUSIONS

Non-Hispanic African Americans with pharmaceutically treated hypertension report that the primary care system more closely approximates the Wagner CCM than non-Hispanic White patients.

The Chronic Care Model to Improve Management of Childhood Obesity

One-third of children in the United States are overweight or obese. Comorbidities continue into adulthood if a healthy weight is not established. While expert guidelines for management of this condition are recognized, provider adherence to guidelines is lacking. The purpose of this quality improvement project was to evaluate the effectiveness of the chronic care model (CCM) on improving primary care provider identification, prevention, and management of childhood overweight and obesity. A pre- and postintervention chart audit was completed to evaluate documentation of 20 assessment measures included in expert guidelines. A chi-square analysis was conducted to assess differences. Statistically significant improvements were found in documentation of parental obesity, family medical history, sleep assessment, endocrine assessment, and weight classification as a diagnosis. Use of the CCM had a positive impact on provider adherence to expert guidelines. Furthermore, not all aspects of the CCM must be used to see statistically significant improvements.

Screening and treatment of obesity in school health care - the gap between clinical guidelines and reality

AIMS

School health care offers a natural setting for childhood obesity interventions. Earlier studies reveal inadequate screening and treatment in primary care. However, longitudinal studies in unselected populations are lacking. We aimed to examine how school nurses and physicians identified obesity, diagnosed it and offered interventions over primary school. We compared the results with Finnish recommendations.

METHODS

From our cohort of 2000 primary school sixth graders (aged 12-14), 172 were obese at least once during primary school. We manually collected retrospective electronic health record (EHR) data of these 'ever-obese' children.

RESULTS

Of the ever-obese children, 96% attended annual nurse assessments more than twice. School physicians met 53% of the ever-obese children at health checks at first grade and 93% at fifth grade. Of overweight-related extra visits to school nurses, 94% took place without parents. Parents were present in 48% of extra school physician visits. Only 29% of the 157 who became obese during the first five school grades received an obesity diagnosis. However, school physicians mentioned weight problems in EHR for 90% of the children and, similarly, school nurses for 99%. The majority received a treatment plan at least once. For 78%, at least one plan was made with the parents. Still, 28% missed nutrition plans, 31% exercise plans and 90% lacked recorded weight development targets.

CONCLUSIONS

The gap between clinical guidelines and reality in school health care could be narrowed by improving diagnosing and parent collaboration. Obstacles in parent involvement and work methods in school health care need further study.

Evaluation of Nurse Practitioner Strategies to Promote Adherence to Childhood Obesity Clinical Guidelines

The significant trend of the obesity epidemic leading to treatment of expensive, lifelong illnesses, especially among Hispanic children, confirms the need for efforts to increase provider adherence to clinical guidelines. This Quality Improvement Project was designed to examine how a practice intervention influenced provider adherence to childhood obesity guidelines among Hispanic children. The practice intervention, based on a unique practice model, consisted of provider awareness, provider involvement, and collaborative support by the researcher. Statistically significant results were obtained regarding guideline adherence. The practice model developed for implementing guidelines in this study will be of benefit to other clinicians. The main project outcome was that the model resulted in significant changes in practice patterns and increased provider adherence to aspects of childhood obesity clinical guidelines. The Practice Improvement Model should be replicated in other settings to evaluate its contribution to improved adherence to any clinical practice guideline.

Referrals and Management Strategies for Pediatric Obesity-DocStyles Survey 2017

Background: Childhood obesity care management options can be delivered in community-, clinic-, and hospital-settings. The referral practices of clinicians to these various settings have not previously been characterized beyond the local level. This study describes the management strategies and referral practices of clinicians caring for pediatric patients with obesity and associated clinician characteristics in a geographically diverse sample. Methods: This cross-sectional study used data from the DocStyles 2017 panel-based survey of 891 clinicians who see pediatric patients. We used multivariable logistic regression to estimate associations between the demographic and practice characteristics of clinicians and types of referrals for the purposes of pediatric weight management. Results: About half of surveyed clinicians (54%) referred <25% of their pediatric patients with obesity for the purposes of weight management. Only 15% referred most (≥75%) of their pediatric patients with obesity for weight management. Referral types included clinical referrals, behavioral referrals, and weight management program (WMP) referrals. Within these categories, the percentage referrals ranged from 19% for behavioral/mental health professionals to 72% for registered dieticians. Among the significant associations, female clinicians had higher odds of referral to community and clinical WMP; practices in the Northeast had higher odds of referral to subspecialists, dieticians, mental health professionals, and clinical WMP; and clinics having ≥15 well child visits per week were associated with higher odds of referral to subspecialists, mental health professionals, and health educators. Not having an affiliation with teaching hospitals and serving low-income patients were associated with lower odds of referral to mental health professionals, and community and clinical WMP. Compared to pediatricians, family practitioners, internists, and nurse practitioners had higher odds of providing referrals to mental health professionals and to health educators. Conclusion: This study helps characterize the current landscape of referral practices and management strategies of clinicians who care for pediatric patients with obesity. Our data provide insight into the clinician, clinical practice, and reported patient characteristics associated with childhood obesity referral types. Understanding referral patterns and management strategies may help improve care for children with obesity and their families.

Preventive healthcare for young children: A systematic review of interventions in primary care

High rates of preventable health problems amongst children in economically developed countries have prompted governments to seek pathways for early intervention. We systematically reviewed the literature to discover what primary care-targeted interventions increased preventive healthcare (e.g. review child development, growth, vision screening, social-emotional health) for preschool children, excluding vaccinations. MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched for published intervention studies, between years 2000 and 2014, which reflected preventive health activities for preschool children, delivered by health practitioners. Analysis included an assessment of study quality and the primary outcome measures employed. Of the 743 titles retrieved, 29 individual studies were selected, all originating from the United States. Twenty-four studies employed complex, multifaceted interventions and only two were rated high quality. Twelve studies addressed childhood overweight and 11 targeted general health and development. Most interventions reported outcomes that increased rates of screening, recording and recognition of health risks. Only six studies followed up children post-intervention, noting low referral rates by health practitioners and poor follow-through by parents and no study demonstrated clear health benefits for children. Preliminary evidence suggests that multi-component interventions, that combine training of health practitioners and office staff with modification of the physical environment and/or practice support, may be more effective than single component interventions. Quality Improvement interventions have been extensively replicated but their success may have relied on factors beyond the confines of individual or practice-led behaviour. This research reinforces the need for high quality studies of pediatric health assessments with the inclusion of clinical end-points.

Behavior change interventions and policies influencing primary healthcare professionals' practice-an overview of reviews

BACKGROUND

There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers.

METHODS

Study design: overview of reviews.

DATA SOURCE

MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015).

STUDY SELECTION

two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language.

DATA EXTRACTION AND SYNTHESIS

two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.).

RESULTS

Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change.

CONCLUSIONS

Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.

Short-Term Efficacy and Correlates of Change in Health Weight Management Program for Chinese American Children

A pretest and posttest study design was used to test a healthy weight management intervention with overweight and/or obese Chinese American children. Children attended 8-weekly small group sessions while parents attended a single 2-hour parent workshop. Children had their weight, height, blood pressure, waist and hip circumference, and fast lipids data assessed and completed several questions questionnaires regarding food choices, self-efficacy, and knowledge at baseline, 2 months, and 6 months. Parents completed questionnaires regarding demographic, acculturation level and family environment. We found significant reduction of body mass index, waist/hip ratio, systolic blood pressure and improvement of child's eating style, physical activity knowledge, self-efficacy, and children's quality of life at 6-month follow-up. In addition, significant improvement of high-density lipoprotein cholesterol and decrease in triglyceride were found at 6-month follow-up. Improvement of nutrition self-efficacy and decreased stimulus environment were associated with decreased body mass index in overweight and obese Chinese American children.

The Feasibility and Efficacy of Healthy Weight Management Program for Low Income Chinese American Overweight and Obese Children in a Primary Care Clinic

INTRODUCTION

Childhood obesity is one of the most prevalent public health concerns.

METHOD

A pre and post study design was used to explore the efficacy of an obesity prevention program. Children had weight, height, blood pressure, and waist circumference measured, and completed self-reported questionnaires on food intake, knowledge, self-efficacy, and health-related quality of life. Parents completed demographic and acculturation surveys.

RESULTS

Seventy children participated in the study. Results demonstrated significant reduction of BMI, systolic blood pressure, and fast food consumption and improvement of self-efficacy, knowledge, and quality of life.

DISCUSSION

Childhood obesity intervention is feasible and has short-term efficacy.

Perceptions of Adolescents with Overweight and Obesity for the Development of User-Centered Design Self-Management Tools within the Context of the Chronic Care Model: A Qualitative Study

BACKGROUND

The Chronic Care Model (CCM) is helpful to illustrate multiple levels of influence in the management of chronic disease, such as overweight and obesity in adolescents. Unfortunately, various constraints create gaps in the management process activities performed within the CCM. Consumer health technologies (CHT) may serve as a linkage between adolescents with overweight or obesity, their parents, and their pediatricians.

OBJECTIVE

To conduct formative research to qualitatively identify views of adolescents with overweight and obesity on use of consumer health technologies to manage weight loss across chronic care management settings.

DESIGN

As part of a multi-perspective qualitative study, 10 focus groups were conducted with adolescents with overweight and obesity.

PARTICIPANTS/SETTING

Forty-eight adolescents (15 male, 33 female) aged 12 to 17 years who were current participants of an intensive lifestyle change camp in the summer of 2012 participated in focus groups. All adolescents were classified as overweight (21%) or obese (79%) according to body mass index (BMI) for age charts published by the Centers for Disease Control and Prevention.

ANALYSIS

All focus groups were recorded, transcribed verbatim, and checked for accuracy. Predefined and open coding were used to analyze transcripts for emerging themes.

RESULTS

Adolescents perceive CHT, with its functional requirements of assistance with restaurant food selection, teaching cooking skills, and providing encouragement and motivation, to be helpful with overweight and obesity self-management. Desired features to carry out these functional requirements included avatars, self-monitoring capabilities, social networking, and rewards.

CONCLUSION

Our findings largely agree with previously reported parental perceptions of the benefit of CHT for adolescent overweight and obesity self-management and strengthen support for the design and implementation of CHT within the CCM.

A Virtual Childhood Obesity Collaborative: Satisfaction With Online Continuing Education

INTRODUCTION

This descriptive study evaluated school-based health center (SBHC) providers' satisfaction with Web-based continuing education as part of a virtual childhood obesity intervention.

METHOD

Thirty-six participants from 24 SBHCs in six states participated in the training modules. Modules were divided into four learning sessions, with a total of 17 training modules. Participants completed satisfaction surveys after each module, as well as an overall survey at the end of the training. Questions were rated on a 4-point Likert scale (4 = strongly agree, 3 = agree, 2 = disagree, 1 = strongly disagree).

RESULTS

Participation in the first two learning sessions was higher than the last two. Provider satisfaction of training modules by question type and content area was quite high (μ = 3.66-3.33). Overall satisfaction means ranged from 3.76 to 3.24. Many providers also reported plans to make changes in their practice after completing the training.

DISCUSSION

This study demonstrated that a virtual childhood obesity collaborative is an acceptable delivery method for continuing education.

The challenges of trying to increase preventive healthcare for children in general practice: results of a feasibility study

BACKGROUND

In Australia, general practice, the linchpin for delivery of preventive health care to large segments of the population, provides child-immunisation and preventive health alongside government services. Despite this, less than half of eligible children complete a Healthy Kids Check (HKC), a preschool preventative health assessment available since 2008. Using a rigorous theoretical process, the barriers that affected delivery and reduced general practitioner and practice nurse motivation to provide HKCs, were addressed. The resulting multifaceted intervention, aimed at increasing the proportion of children receiving evidence informed HKCs from general practice, was piloted to inform a future randomised controlled trial.

METHODS

The intervention was piloted in a before and after study at three sites located southeast of Melbourne, between February and October 2014. The HKC-intervention involved: 1) Delivery of training modules that motivated reception and clinical staff by delivering key messages about local prevalence rates and the "Core Story of Child Development" 2) Practical advice to prepare clinics for specific HKC-examinations 3) Workflow advice regarding systems that included all staff in the HKC process, and 4) Provision of a "Community Resources Folder" that enabled decision making and referrals. A major component of the intervention incorporated the promotion of structured developmental screening by the practice team using Parents' Evaluation of Developmental Status.

RESULTS

Twenty of 22 practitioners and practice managers agreed to join the study. Post-training questionnaires showed participants had developed their skills working with young children as a result of the training and all respondents believed they had successfully implemented standardised HKC services. Post intervention proportions of children completing HKCs significantly increased in two of the practices and quality improvements in HKC-processes were recorded across all three sites.

CONCLUSION

This pilot study confirmed the feasibility of delivering a multi-faceted intervention to increase HKCs from general practice and demonstrated that significant quality improvements could be made. Future studies need to extend the intervention to other states and research the health outcomes of HKCs.

'I just don't want to get bullied anymore, then I can lead a normal life'; Insights into life as an obese adolescent and their views on obesity treatment

BACKGROUND

Adolescent obesity is a complex condition involving social, emotional, behavioural and cultural issues.

DESIGN

One-to-one interviews and small focus groups with overweight and obese young people were conducted. Qualitative research is an appropriate method to explore the complexity of this issue.

SETTING AND PARTICIPANTS

Overweight and obese adolescent's attending a community weight management intervention in South Yorkshire.

MAIN VARIABLES STUDIED

Interviews aimed to explore the experiences of obese adolescents and their perspectives towards obesity treatment.

RESULTS

Adolescent's provided detailed accounts of their perspectives on weight gain, alluding to disordered patterns of eating and overeating, reported as being triggered by social and emotional factors, and in particular, bullying. Avoidance of bullying and a desire to integrate socially with peers were key drivers to seek treatment. Young people reported what they should do to lose weight, yet responsibility for successful weight loss and lifestyle change was repeatedly attributed to the treatment received, as opposed to viewing this as a combination of self-motivation coupled with support provided by friends and family.

CONCLUSION

Weight loss programmes need to consider the complex experience of obese young people in their design, focusing on how to implement long-term lifestyle changes.

Our Choice/Nuestra Opción: the Imperial County, California, Childhood Obesity Research Demonstration study (CA-CORD)

BACKGROUND

Despite recent declines among young children, obesity remains a public health burden in the United States, including among Latino/Hispanic children. The determining factors are many and are too complex to fully address with interventions that focus on single factors, such as parenting behaviors or school policies. In this article, we describe a multisector, multilevel intervention to prevent and control childhood obesity in predominantly Mexican-origin communities in Southern California, one of three sites of the CDC-funded Childhood Obesity Research Demonstration (CA-CORD) study.

METHODS

CA-CORD is a partnership between a university-affiliated research institute, a federally qualified health center, and a county public health department. We used formative research, advisory committee members' recommendations, and previous research to inform the development of the CA-CORD project. Our theory-informed multisector, multilevel intervention targets improvements in four health behaviors: fruit, vegetable, and water consumption; physical activity; and quality sleep. Intervention partners include 1200 families, a federally qualified health center (including three clinics), 26 early care and education centers, two elementary school districts (and 20 elementary schools), three community recreation centers, and three restaurants. Intervention components in these sectors target changes in behaviors, policies, systems, and the social and physical environment. Evaluation activities include assessment of the primary outcome, BMI z-score, at baseline, 12-, and 18-months post-baseline, and sector evaluations at baseline, 12, and 24 months.

CONCLUSIONS

Identifying feasible and effective strategies to prevent and control childhood obesity has the potential to effect real changes in children's current and future health status.

Six to success: improving primary care management of pediatric overweight and obesity

INTRODUCTION

Despite the existence of established guidelines addressing pediatric obesity, many primary care providers fail to successfully implement recommendations. This study measured the impact of Six to Success, a weight management program based on the Chronic Care Model, on primary care provider adherence to pediatric weight management guidelines.

METHOD

We used comprehensive pre- and postimplementation chart audits (N = 396) to conduct a quality improvement study at a hospital-based pediatric outpatient clinic. Charts of patients with a body mass index percentile at or above the 85th percentile (preimplementation, n = 90; postimplementation, n = 97) were audited for 23 identification, assessment, and prevention measures recommended in the care of the pediatric overweight/obese patient.

RESULTS

Statistically significant improvements to clinical guideline adherence were found in the following areas: correct diagnosis, physical examination, lifestyle assessment, use of motivational interviewing, and prevention strategies.

DISCUSSION

These findings suggest that Six to Success can be an effective method of improving primary care provider adherence to established pediatric weight management guidelines.

Efficacy of technology-based interventions for obesity prevention in adolescents: a systematic review

About one third of adolescents in the USA are overweight and/or obese. Obesity during the adolescent years is associated with many adverse health consequences, including type 2 diabetes, hypertension, hyperlipidemia, and psychosocial problems. Because of substantial advances in technologies and wide acceptance by adolescents, it is now possible to use technology for healthy weight management and prevention of obesity. This systematic review used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and aimed to evaluate the existing literature reported on the effectiveness of technology-based intervention (web-based, e-learning, and active video games) in preventing obesity in adolescents. The primary aim of this review was to explore if components of specific interventions were associated with a reduction in body mass index. Research articles obtained from CINAHL, Embase, PubMed, PsycInfo, and the Cochrane database from1990 to 2014 were reviewed. A total of 131 published articles were identified, and 14 met the inclusion criteria of a randomized or nonrandomized clinical study with body mass index as primary outcome and/or secondary outcomes of diet/physical activity and/or psychosocial function, tested lifestyle interventions to prevent obesity, used technology, and studied adolescents (aged 12-18 years). The results indicated that six of 14 studies found body mass index and/or body fat decreased at short-term (less than 12 months) follow-up. Six of eleven studies that examined physical activity or physical activity-related outcomes found an improved physical activity outcome (time playing active video games and increase in physical activity time), while five of seven studies which assessed dietary outcomes indicated improvement in dietary behaviors. Five of seven studies suggested an improvement in psychosocial function (reduced depression, improved self-esteem and efficacy, improvement on Behavior Assessment Scale) in adolescents involved in the technology-based intervention. All effective interventions utilized dietary and physical activity strategies as part of intervention components. Because of the variation in duration of intervention (range 10 weeks to 2 years), it is not clear what length of intervention is most effective. Future research should assess the long-term impact of technology-based interventions and evaluate mediators and moderators for weight change in adolescents.

Improving diet and physical activity to reduce population prevalence of overweight and obesity: an overview of current evidence

OBJECTIVE

The aim of this study is to provide an overview of interventions to reduce or prevent overweight or obesity and improve diet or physical activity.

METHODS

A review of meta-analyses and/or systematic reviews of these interventions in any setting or age group were conducted. Narrative systematic reviews were included for intervention categories with limited meta-analyses available. Summary measures including weighted mean difference, standardised mean difference, and I-squared, were examined.

RESULTS

A total of 60 meta-analyses and 23 systematic reviews met the inclusion criteria. Dietary interventions and multi-component interventions targeting overweight and obesity appeared to have the greatest effects, particularly in comparison with workplace or technology or internet-based interventions. Pharmaceutical and surgical interventions produced favourable results for specific population sub-groups (i.e. morbidly obese). Population-wide strategies such as policy interventions have not been widely analysed. The effectiveness of the interventions to assist in maintaining behaviour or weight change remains unclear.

CONCLUSIONS

Various individually targeted interventions were shown to reduce body weight, although effect sizes were typically modest, and the durability of effects has been questioned. New approaches to evaluating population-based interventions, such as taxes and regulation, are recommended. Future research modelling the long-term effects of interventions across the lifespan would also be beneficial.

Pediatrician-led motivational interviewing to treat overweight children: an RCT

OBJECTIVE

The aim of this study was to evaluate the effect of family pediatrician-led motivational interviews (MIs) on BMI of overweight (85th ≥ BMI percentile ≥ 95 th) children aged 4 to 7 years.

METHODS

All the family pediatricians working in Reggio Emilia Province (Italy) were invited to participate in the study; 95% accepted. Specific training was provided. Parents were asked to participate in the trial if they recognized their child as overweight. Children were individually randomly assigned to MIs or usual care. All children were invited for a baseline and a 12-month visit to assess BMI and lifestyle behaviors. The usual care group received an information leaflet, and the intervention group received 5 MI family meetings. The primary outcome was the individual variation of BMI, assessed by pediatricians unblinded to treatment groups.

RESULTS

Of 419 eligible families, 372 (89%) participated; 187 children were randomized to MIs and 185 to the usual care group. Ninety-five percent of the children attended the 12-month visit. The average BMI increased by 0.49 and 0.79 during the intervention in the MI and control groups, respectively (difference: -0.30; P = .007). MI had no effect in boys or in children whose mothers had a low educational level. Positive changes in parent-reported lifestyle behaviors occurred more frequently in the MI group than in the control group.

CONCLUSIONS

The pediatrician-led MI was overall effective in controlling BMI in these overweight children aged 4 to 7 years, even though no effect was observed in male children or when the mother's education level was low.

Development and validity of a questionnaire to test the knowledge of primary care personnel regarding nutrition in obese adolescents

Background

In light of its epidemic proportions in developed and developing countries, obesity is considered a serious public health issue. In order to increase knowledge concerning the ability of health care professionals in caring for obese adolescents and adopt more efficient preventive and control measures, a questionnaire was developed and validated to assess non-dietitian health professionals regarding their Knowledge of Nutrition in Obese Adolescents (KNOA).

Methods

The development and evaluation of a questionnaire to assess the knowledge of primary care practitioners with respect to nutrition in obese adolescents was carried out in five phases, as follows: 1) definition of study dimensions 2) development of 42 questions and preliminary evaluation of the questionnaire by a panel of experts; 3) characterization and selection of primary care practitioners (35 dietitians and 265 non-dietitians) and measurement of questionnaire criteria by contrasting the responses of dietitians and non-dietitians; 4) reliability assessment by question exclusion based on item difficulty (too easy and too difficult for non-dietitian practitioners), item discrimination, internal consistency and reproducibility index determination; and 5) scoring the completed questionnaires.

Results

Dietitians obtained higher scores than non-dietitians (Mann–Whitney U test, P < 0.05), confirming the validity of the questionnaire criteria. Items were discriminated by correlating the score for each item with the total score, using a minimum of 0.2 as a correlation coefficient cutoff value. Item difficulty was controlled by excluding questions answered correctly by more than 90% of the non-dietitian subjects (too easy) or by less than 10% of them (too difficult). The final questionnaire contained 26 of the original 42 questions, increasing Cronbach’s α value from 0.788 to 0.807. Test-retest agreement between respondents was classified as good to very good (Kappa test, >0.60).

Conclusion

The KNOA questionnaire developed for primary care practitioners is a valid, consistent and suitable instrument that can be applied over time, making it a promising tool for developing and guiding public health policies.

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.

Population-level intervention strategies and examples for obesity prevention in children

With obesity affecting approximately 12.5 million American youth, population-level interventions are indicated to help support healthy behaviors. The purpose of this review is to provide a summary of population-level intervention strategies and specific intervention examples that illustrate ways to help prevent and control obesity in children through improving nutrition and physical activity behaviors. Information is summarized within the settings where children live, learn, and play (early care and education, school, community, health care, home). Intervention strategies are activities or changes intended to promote healthful behaviors in children. They were identified from (a) systematic reviews; (b) evidence- and expert consensus-based recommendations, guidelines, or standards from nongovernmental or federal agencies; and finally (c) peer-reviewed synthesis reviews. Intervention examples illustrate how at least one of the strategies was used in a particular setting. To identify interventions examples, we considered (a) peer-reviewed literature as well as (b) additional sources with research-tested and practice-based initiatives. Researchers and practitioners may use this review as they set priorities and promote integration across settings and to find research- and practice-tested intervention examples that can be replicated in their communities for childhood obesity prevention.

Validation of a hip-worn accelerometer in measuring sleep time in children

This study compared measures of sleep from an accelerometer worn on the hip to measures obtained from an accelerometer worn on the wrist, the gold standard measure of sleep behavior in community research. The accelerometer worn on the hip provides a measure of total sleep time in 10- to 11-year-old children comparable to the wrist-worn unit. We provide an alternate method to ascertain bedtime and final wake time when diary data are missing. A hip-worn accelerometer may provide a cost-effective means of gathering physical activity and sleep data simultaneously in large samples of children with or without an accompanying sleep diary.

Psychosocial correlates of healthy beliefs, choices, and behaviors in overweight and obese school-age children: a primary care healthy choices intervention pilot study

The relationships among weight, mental health, social competence, healthy lifestyle beliefs, choices, and behaviors in overweight and obese school-age children (9 to 12 years) who were participating in a pilot Healthy Choices Intervention Program were examined using a descriptive correlational design. Results indicated that the children's weight negatively correlated with the children's self-concept, social skills, and, most importantly, healthy lifestyle choices. Their healthy lifestyle beliefs demonstrated positive correlations with their intentions to choose a healthy lifestyle. The children's healthy lifestyle beliefs and choices also were associated with increased cooperation and empathy behaviors. A positive self-concept was associated with decreased anxiety and depressive symptomology. These data support the need for health care providers to understand the psychological and social issues that overweight and obese school-age children experience. Cognitive behavior skills building techniques, such as those in the Healthy Choices Intervention Program, may promote healthy lifestyle choices and behaviors.

Building capacity for childhood obesity prevention and treatment in the medical community: call to action

Large gaps exist in the capacity of the US medical system to participate meaningfully in childhood obesity-prevention efforts and to meet the treatment needs of obese children. Current primary care practice for the prevention and treatment of childhood obesity often varies from evidence-based recommendations. Childhood obesity specialists have partnered successfully with schools of medicine, professional societies, and other organizations to collaboratively engage with primary care providers in quality improvement for obesity prevention and treatment. This review and commentary targets 2 audiences. For childhood obesity experts and their organizational partners, methods to support change in primary practice and the evidence supporting their use are outlined. For primary care providers and non-obesity specialists, effective strategies for changing practice and the potential benefits of addressing childhood obesity systematically are discussed.