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

Parental Factors Associated With Intentions to Initiate a Family-Based Pediatric Weight Management Program

Background: Childhood obesity can be addressed through family-based pediatric weight management; however, treatment enrollment in the United States is low. This study aimed to identify parental factors associated with intentions to initiate a family-based pediatric weight management program. Methods: Cross-sectional survey data were collected from an online panel of US parents with at least one 5- to 11-year-old child identified as likely to have overweight or obesity. Participants viewed a video about a hypothetical family-based pediatric weight management program, rated their 30-day initiation intentions for that program, and answered additional related questionnaires. Results: Participants (n = 158) identified as White/Caucasian (53%) or Black/African American (47%), were primarily female (61.4%) and married/cohabitating (81.6%) with children who were predominantly girls (53.2%) and, on average, 9-year-olds. Higher parents' perception of program effectiveness predicted initiation intentions (p < 0.001), while concern for their child's weight and parent depression and anxiety levels did not. Higher initiation intentions and perceived program effectiveness were reported by Black/African American participants (p < 0.01) and those with at least a bachelor's degree (p < 0.01) compared to White/Caucasian participants and those without a bachelor's degree, respectively. Initiation intentions were higher for those with greater financial security (p = 0.020) and fewer than three children in the home (p = 0.026). Participants endorsed initiation barriers of time constraints (25%), possible lack of enjoyment for the child (16.9%), and lack of family support (15%). Conclusions: Future program enrollment efforts may need to focus on strategies to increase perceived program effectiveness, although further research is needed that measures actual enrollment in real-world contexts.

Effectiveness of a Scalable mHealth Intervention for Children With Overweight and Obesity

Background: Multicomponent interventions are the first line of treatment for pediatric obesity, but are challenging to access. Mobile health (mHealth) interventions hold promise as they address commonly cited barriers for attending in person programs and have potential for wide scale dissemination. Methods: This retrospective cohort study examined data from youth who enrolled in the Kurbo program, which includes personal health coaching and a mobile app. Hierarchical linear regression was used to examine the impact of baseline percentage of the 95th% percentile for body mass index (%BMIp95), number of coaching sessions, and length of time enrolled in the program on change in %BMIp95, controlling for baseline age and sex. Results: A total of 3500 youth (mean age of 12.79 years, 71.3% female) were included. Youth experienced a 0.70 U decrease in BMI [standard deviation (SD) = 2.19] and a 4.45% decrease (SD = 8.5) in %BMIp95 over a mean of 31.5 weeks. The overall regression model was significant, R2 = 0.066, F(3,3494) = 77.18, and p < 0.001. Predictors of decrease in weight status included being female (b = -1.11, p < 0.001), higher baseline %BMIp95, (b = -0.58, p < 0.001), and greater number of coaching sessions (b = -0.12, p < 0.001), while greater time enrolled in the program (b = 0.02, p < 0.001) was associated with less change. Conclusion: Findings suggest a scalable coaching program with integrated digital tools for monitoring diet and activity can lead to significant reductions in weight status. Findings need to be replicated with more rigorous study designs, including a comparison condition and verified assessment of height and weight.

Clinician and healthcare managers' perspectives on the delivery of secondary and tertiary pediatric weight management services

Clinician and healthcare managers' (HCMs) views on weight management service delivery are imperative for informing the nature of future services to treat children with obesity. This qualitative study used semi-structured focus groups and one-on-one semi-structured interviews. Participants were 27 clinicians (medical, nursing, or allied health) and nine HCMs (senior executives in the hospital) who worked in six secondary or tertiary pediatric weight management clinics across five public hospitals in New South Wales, Australia. Clinicians reported that using a combination of group and individual sessions improved engagement with families and reduced attrition rates. Clinicians and HCMs recommended integrating clinics into community centers and providing specific programs for sub-groups, such as children from culturally and linguistically diverse communities or children with developmental delay. Many clinicians and HCMs stressed the importance of pediatric weight clinics using a holistic approach to treatment. To improve the likelihood of future funding for pediatric weight management clinics and to optimize models of care, centers must embed research into their practice. Addressing common barriers to current pediatric weight management services and designing future models of care based on key stakeholders' preferences is critical to achieving optimal care provision for this high-risk population.

Parent and carer experiences of health care professionals' communication about childhood obesity: a qualitative systematic review protocol

OBJECTIVE

The objective of the systematic review is to identify, critically appraise, and synthesize the best available qualitative evidence on parent and carer experiences of health care professionals' communication about childhood obesity.

INTRODUCTION

Parents and carers play a key role in a child's environment and healthy development, which is why they can find it confronting to discuss their child's weight. This review will provide an insight into the experiences of parents and carers with health care professionals' communication about their child's overweight or obesity.

INCLUSION CRITERIA

This qualitative review will consider participants who are parents and carers with a child with overweight or obesity (birth to 12 years). The phenomenon of interest is parents' and carers' lived experiences of childhood obesity communication from a health care professional, and the context is health care settings. Communication includes verbal or written communication about a child's obesity from health care professionals received by a parent or carer.

METHODS

The proposed review will systematically search the following databases: MEDLINE (EBSCO), CINAHL (EBSCO), PsycINFO (Ovid), Scopus, LILACS, and the Finnish health sciences database MEDIC. ProQuest Dissertations and Theses (ProQuest) will be searched for unpublished articles. A manual search will supplement the database searches. The quality of included studies will be assessed independently by 2 reviewers, and the qualitative data will be extracted from papers by 2 independent reviewers using the standardized JBI data extraction tool. The recommended JBI approach to critical appraisal, study selection, data extraction, and data synthesis meta-aggregation will be used.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022297709.

Waitlist management in a pediatric weight management clinic: implementing an orientation session

Background

This study evaluates implementation of an orientation session to address a waitlist of more than 2000 referrals to a pediatric weight management clinic in the Mid-South United States.

Methods

An hour-long group-based orientation to the pediatric weight management clinic was implemented to provide information about the structure and expectations of the clinic as well as education on healthy lifestyle recommendations. Families were contacted from the waitlist by telephone and invited to attend an orientation session prior to scheduling a clinic appointment.

Results

Of 2251 patients contacted from the waitlist, 768 scheduled an orientation session, of which 264 (34 %) attended. Of the 264 orientation participants, 246 (93 %) scheduled a clinic appointment. Of those, 193 (79 %) completed a clinic visit. Waitlist times decreased from 297.8 ± 219.4 days prior to implementation of orientation sessions to 104.1 ± 219.4 days after.

Conclusions

Orientation has been an effective and efficient way to triage patient referrals while maximizing attendance in limited clinic slots for patients and families demonstrating interest and motivation. Elements of this approach are likely generalizable to other pediatric clinical settings that must strategically manage a large volume of patient referrals.

Reactions to the U.S. Preventive Services Task Force guidelines for the management of adolescent obesity: A multi-informant qualitative approach

The U.S. Preventive Services Task Force (USPSTF) has set forth recommendations for clinicians to screen youth (6-18 years) for obesity. Those identified should be referred to comprehensive weight management programs consisting of at least 26 contact hours and focus on multiple targets of behaviour (ie, diet, physical activity, behaviour change). However, these recommendations are primarily based upon outcomes from randomized controlled trials and the feasibility of meeting these guidelines for adolescents in a clinical setting is unknown. The present study employed a multi-informant qualitative approach with adolescents, parents, and physicians, to identify and understand multiple perspectives on the feasibility and acceptability of implementing the USPSTF guidelines. In-depth interviews with seven adolescents, seven parents, and four physicians were analysed. Generally, participants viewed the guidelines positively but identified changes that may be necessary to increase the feasibility of adolescents engaging in programs that meet these guidelines. Participants also noted the importance of flexibility within programs, indicating that it would be difficult for many adolescents to participate in a program that was not tailored to their needs and resources. Future research should focus on adapting clinical weight management programs to meet both USPSTF guidelines and the needs of adolescents and their families.

Psychopathology and Adolescent Bariatric Surgery: A Topical Review to Support Psychologists in Assessment and Treatment Considerations

The rising rates of severe obesity among adolescents in the United States indicate a dire need for more intensive weight management strategies. While current evidence suggests that bariatric surgery is a safe and efficacious intervention for adolescents, the linkages with psychopathology before and after surgery are not well understood. Psychologists are an integral part of the interdisciplinary surgery team and play an important role in preparing youth for bariatric surgery as well as supporting adolescents post-surgery. The present manuscript reviews the literature on psychopathology in the context of adolescent bariatric surgery, discusses consideration of psychopathology as a contraindication for surgery, and provides recommendations on how psychologist members of the bariatric surgery team may balance attention to motivation and adherence to medical recommendations with assessment and treatment of psychopathology. Finally, the importance of continued research to confirm clinical consensus regarding decision-making and expansion of psychological resources within adolescent bariatric surgery programs are discussed.

Promoting Healthy Eating and Regular Physical Activity in Low-Income Families Through Family-Centered Programs: Implications for Practice

Research concerning children who are overweight has historically focused on providing services to the affected individuals, and limited attention has been paid to their families. Further, childhood obesity prevention and clinical programs continue to be impacted by contextual factors that increase the likelihood of attrition when targeting underserved populations. This paper provides data with relevance for interventions aimed at promoting healthy eating and regular physical activity with low-income families. Participants in a childhood obesity exploratory study provided recommendations to improve programs by reflecting on specific family and contextual issues related to children who are overweight and obese. Following a thematic analysis approach, we conducted semi-structured interviews with 16 low-income, single, female parents. All participants had, at the time of the interview, at least one overweight or obese child between the ages of 3 and 8. We report the critical role of context in the etiology and challenges of childhood obesity among disadvantaged populations. Findings also highlight the need for interventions to be culturally relevant and sensitive and to create opportunities to address and discuss participant experiences of discrimination, cultural factors, and family of origin influences. Interventions that do not address these contextual factors run the risk of being unsuccessful. Our findings are important for mental and public health professionals who are interested in the direct provision of services using a combination of social determinants of systemic perspectives.

Factors associated with dropout in a lifestyle modification program for weight management in children and adolescents

BACKGROUND

Significant dropout rates remain a serious concern in pediatric weight control program, but few studies have identified predictors of dropout.

AIMS

The objective of the study is to identify factors associated with dropout from a pediatric lifestyle modification weight control program at different phases.

METHODS

Data on overweight and obese participants (n = 242) aged 11-18 years in the Intervention for Childhood and Adolescent Obesity via Activity and Nutrition (ICAAN) study were collected at baseline, 6-months, and 24-months through self-report and a laboratory test. Logistic regression analysis was performed for those who dropped out during the first 6-months, and multivariate generalized estimating equation analysis identified longitudinal factors associated with those who dropped out after 24 months.

RESULTS

Lower family functioning (OR = 2.30, 95% CI [1.18-4.46]), exercise group (OR = 0.36, 95% CI [0.15-0.86]), lower initial attendance rate (OR = 6.09, 95% CI [2.94-12.6]), and non-self -referral pathways (OR = 2.35, 95% CI [1.05-5.27]) were significantly associated with 6-month dropouts. For late dropout, lower family functioning (OR = 1.71, 95% CI [1.06-2.77]) and lower initial attendance rates (OR = 2.06, 95% CI [1.12-3.81]) remained significant.

CONCLUSION

Family function and initial attendance rate were associated with lower dropout rates. Developing a supportive family environment and focusing on the early-stage factors at the intervention's outset may reduce overall dropout rates in obesity prevention intervention.

Obesity Applications in Smartphones: Development and Use of an Evaluation Tool

INTRODUCTION

Rates of obesity amongst children and teens in the United States have tripled since the 1970s, and 18.5% are now considered obese. With smartphone use among children and teens becoming the norm, smartphone applications may be a cost-effective solution to support patients and families motivated to change lifestyle behaviors and reduce obesity. The purpose of this quality-improvement project was (1) to develop an app evaluation tool and star rating system based on scientific evidence and current clinical practice guidelines in managing childhood obesity, and (2) to determine whether an in-service training can increase provider knowledge and efficacy in the use of smartphone apps in managing childhood obesity.

METHODS

An app evaluation tool (Ped-WHAT) was developed that includes evidence-based behavior modification strategies (BMS) and the American Academy of Pediatrics (AAP) guidelines for healthy weight management in pediatrics. Apps were given a rating based on the number of these criteria included in the app. An educational in-service training was developed to assist health care providers in using the app evaluation tool with patients. This training was tested with providers working in a pediatric weight management clinic. Pre- and post-training surveys were administered. Results were analyzed using t tests to assess differences.

RESULTS

Sixteen commercially available apps were evaluated using the Ped-WHAT tool. Those that included the greatest number of BMS and AAP criteria received the highest rating on a 0-5 scale. Statistically significant improvements in provider knowledge and confidence were found after the in-service training.

DISCUSSION

In this current digital environment, commercially available weight management apps should undergo evaluation by health care providers to ensure that they follow the standard of care and current practice guidelines/recommendations.

Public health nurse referrals for paediatric weight management: A nested mixed-methods study

AIMS AND OBJECTIVES

To (a) characterise and determine proportions of referred and enrolled children and (b) explore public health nurses' (PHNs) experiences, perspectives and recommendations regarding a new nurse-led referral pathway for paediatric weight management.

BACKGROUND

Children with obesity and their families in Canada access specialised services for obesity management through physician referral. Since this requirement can prevent timely access to health services, we established and tested a referral pathway whereby PHNs directly refer children to specialised care for obesity management.

DESIGN

Nested mixed-methods study reported using GRAMMS.

METHOD

Our research study included children (2-17 years of age; body mass index ≥85th percentile) referred by a PHN to the Pediatric Centre for Weight and Health (PCWH; Stollery Children's Hospital, Edmonton, Alberta, Canada) from April 2017-September 2018. We summarised referral and enrolment data using descriptive statistics and conducted one-on-one, semi-structured telephone interviews with PHNs; interviews were audio-recorded, transcribed verbatim, managed using NVivo 12 and analysed by two independent reviewers using content analysis.

RESULTS

Our sample included 79 referred children (4.4 ± 1.8 years old; 3.4 ± 1.3 BMI z-score; 52.7% male), of which 47 (59.5%) enrolled in care. PHNs' (n = 11) experiences, perspectives and recommendations regarding the new referral pathway were grouped into four categories: (a) practicality of the referral pathway (e.g., simple and straightforward), (b) utility of the referral pathway (e.g., economic and timesaving), (c) uptake of the referral pathway (e.g., physician's influence) and (d) recommendations to improve the referral pathway (e.g., having electronic access to the referral form).

CONCLUSIONS

A PHN-specific referral pathway led most children and families to enrol in paediatric weight management and overall was perceived as acceptable and appropriate among PHNs.

RELEVANCE TO CLINICAL PRACTICE

Our results highlight the valuable role that PHNs can play in directly referring children to specialised services for weight management. This pathway has the potential to reduce wait times and enhance treatment enrolment.

Responding positively to "children who like to eat": Parents' experiences of skills-based treatment for childhood obesity

This study aims to understand the challenges parents of preschoolers with obesity face. We assessed parents' experiences of a group treatment program focused on parenting skills; the treatment program was evaluated in a randomized controlled trial in Stockholm County. After completing the program's 10 weekly sessions, parents were invited to participate in a semi-structured interview. The interviews were audio recorded, transcribed and analyzed using thematic analysis. In total, 36 parents (67% mothers, mean age 39 years, 33% foreign background, 50% with university degree) were interviewed. Two main themes were developed: Emotional burden and Skills and strength from others. Emotional burden encompassed the parents' experiences of raising a child with obesity. Parents spoke about the difficulties of managing their child's appetite and of seeking help and treatment, as well as their feelings about the social stigma attached to obesity. Skills and strength from others encompassed the parents' experiences of participating in group treatment. Parents reported that they appreciated the practical behavior change techniques taught, especially those regarding food and how to make everyday life more predictable, and said the focus on parenting skills gave them the confidence to apply the techniques in everyday life. Parents also highlighted the strength of the group setting, saying it enabled them to discuss perceived challenges and learn from other parents. Our findings show that childhood obesity carries social and emotional implications for parents, and that an intervention that provides parents with skill-building and a discussion space can help in negotiating these implications. This suggests that childhood obesity intervention programs benefit from including a parent-based approach which offers training in parenting skills and support in managing socially and emotionally challenging situations.

Access to Multidisciplinary Care for Pediatric Weight Management: Exploring Perspectives of the Health Care Team within Canada and the United States

Background: In Canada and the United States, most families referred for pediatric weight management services do not start treatment. Of families who initiate care, many discontinue before the program ends. Parents and youth have reported difficulties in accessing services as an important barrier to starting or completing programming. The purpose of this study was to understand barriers and identify potential solutions related to access to care from the perspective of health care team members from Canada and the United States. Methods: Qualitative description method guided the study design. Participants were health care team members, purposefully recruited through Canadian and US-based pediatric weight management program registries. Telephone interviews were conducted with participants between February and May 2017. Interviews were transcribed verbatim and analyzed using content analysis. Results: Eighteen individuals from 16 sites participated (n = 8 Canada, n = 8 United States). Access barriers and potential solutions were related to: (1) referral and eligibility, (2) wait lists and program capacity, (3) logistics and costs, and (4) stigma and weight bias. Barriers were similar between Canadian and US sites, with the exception of cost-related barriers. Conclusions: Health care providers from Canada and the United States reported multiple societal, organizational, service, and family-level barriers to accessing multidisciplinary pediatric weight management care. Proposed solutions suggest that service providers can play a key role alongside families to improve access to appropriate care. Further research is needed to demonstrate the feasibility and effectiveness of proposed solutions.

Magnetic Resonance Imaging: A Personalized Approach to Understanding Fatty Liver Disease

OBJECTIVES

To assess information retention by parents/caretakers regarding nonalcoholic fatty liver disease (NAFLD) utilizing the actual image of their child's affected liver.

METHODS

In this pilot study, parents/caretakers of children with newly diagnosed NAFLD were presented with an magnetic resonance (MR) image of their child's fatty liver. An adjacent image of a normal-appearing liver was used to highlight the degree of fat accumulation present in their child's liver. The appearance of the fatty liver was used as an adjunct to patient education as provided by a nurse clinician. The efficacy of this approach was determined by a set of image- and disease-specific queries. Health literacy was assessed concurrently by the Newest Vital Sign (NVS) instrument. The image- and disease-specific queries were then repeated by telephone follow-up 2 to 4 weeks after initial clinic visit.

RESULTS

Parents/caretakers initially gave 100% correct responses regarding the variation of appearance of normal liver (pink) and their child's fatty liver (yellow). They also all correctly stated the fat content initially. At follow-up, their recall was 95% for the appearance of normal liver and 81% for fatty liver; recall was only 52% for fat content at follow-up. Nonvisualized elements of nonalcoholic steatohepatitis (NASH) and cirrhosis were not identified or recalled as well. Results may have been influenced by parent/caretaker health literacy competence.

CONCLUSIONS

Personalized images of fatty liver were effective visualization tools for parents/caretakers to comprehend NAFLD and comprehension was not compromised by health literacy. Clear visual instruments may improve parent/caretaker comprehension of these conditions and may help to address deficiencies in health literacy.

Development and use of an index for measuring implementation of a weight management program in children in primary care clinics in Texas

BACKGROUND

The Texas Childhood Obesity Research Demonstration study was an integrated, systems-oriented intervention that incorporated primary and secondary obesity prevention approaches targeting multiple sectors, including primary care clinics, to address childhood obesity. The primary care clinic component included the American Academy of Pediatrics' Next Steps weight management counseling materials that support brief healthy lifestyle-focused visits. The current study describes the methodology and assesses the implementation of the Next Steps program in the participating primary care clinics, as well as the association of implementation with enrollment of children with overweight and obesity in the secondary prevention intervention.

METHODS

The study used a serial cross-sectional study design to collect data from 11 primary care clinics in Houston (n = 5) and Austin (n = 6), Texas, in 2013-2014. Responses of primary care providers on 42 self-reported survey questions assessing acceptability, adoption, appropriateness, and feasibility of the program were utilized to create a mean standardized clinic implementation index score. Provider scores were aggregated to represent Next Steps implementation scores at the clinic level. A mixed effects logistic regression test was conducted to determine the association between program implementation and the enrollment of children in the secondary prevention.

RESULTS

Mean implementation index score was lower at Year 2 of implementation (2014) than Year 1 (2013) although the decrease was not significant [63.2% (12.2%) in 2013 vs. 55.3% (16.5%) in 2014]. There were no significant associations between levels of implementation of Next Steps and enrollment into TX CORD secondary prevention study.

CONCLUSIONS

The development of an index using process evaluation measures can be used to assess the implementation and evaluation of provider-based obesity prevention tools in primary care clinics.

Addressing Childhood Obesity for Type 2 Diabetes Prevention: Challenges and Opportunities

IN BRIEF Addressing the problem of childhood obesity is an important component of preventing type 2 diabetes. Although children and their families ultimately make decisions about diet, physical activity, and obesity management, many groups have a role in making these choices easier. They do this by providing families with tools and resources and by implementing policies and practices that support a healthy diet and physical activity in the places where children and their families spend their time. Diabetes educators are an important part of the solution.

Helping children and families to enrol in weight management: What can stakeholders do?

Many children and their families do not benefit from multidisciplinary clinical care (MCC) for paediatric weight management because they do not enrol in (initiate) treatment. The purpose of this report was to highlight practical recommendations to enhance the enrolment of Canadian children in MCC, which were drawn from multisite Canadian studies (quantitative and qualitative) that we completed recently. Recommendations to stakeholders, including primary care providers, MCC providers and decisions makers, were organized according to opportunities, motivation and barriers to enrol. Findings from our research suggested that enrolment in MCC can be improved by increasing opportunities and motivation to enrol as well as reducing the impact of enrolment barriers.