Treating childhood obesity in primary care

Family-based pediatric weight management interventions in US primary care settings targeting children ages 6-12 years old: A systematic review guided by the RE-AIM framework

Obesity is a pandemic that disproportionately affects children from vulnerable populations in the USA. Current treatment approaches in primary care settings in the USA have been reported to be insufficient at managing pediatric obesity, primarily due to implementation challenges for healthcare systems and barriers for families. While the literature has examined the efficacy of pediatric obesity interventions focused on internal validity, it lacks sufficient reporting and analysis of external validity necessary for successful translation to primary care settings. We conducted a systematic review of the primary-care-setting literature from January 2007 to March 2020 on family-based pediatric weight management interventions in both English and/or Spanish for children ages 6-12 years in the USA using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. A literature search, using PRISMA guidelines, was conducted in January 2022 using the following electronic databases: Medline Ovid, Embase, and Cochrane Library. 22 270 records were screened, and 376 articles were reviewed in full. 184 studies were included. The most commonly reported dimensions of the RE-AIM framework were Reach (65%), Efficacy/Effectiveness (64%), and Adoption (64%), while Implementation (47%) and Maintenance (42%) were less often reported. The prevalence of reporting RE-AIM construct indicators ranged greatly, from 1% to 100%. This systematic review underscores the need for more focus on external validity to guide the development, implementation, and dissemination of future pediatric obesity interventions based in primary care settings. It also suggests conducting additional research on sustainable financing for pediatric obesity interventions.

Targeted dietary approaches for the management of obesity and severe obesity in children and adolescents: A systematic review and meta-analysis

There is a need for a detailed understanding of effective dietary interventions for children with obesity. This systematic review examined the effectiveness of diets of varying energy content as a component of weight treatment in children and adolescents with obesity, severe obesity and obesity-related comorbidity. A systematic search of six databases, from 2000 to 2021, for intervention studies of targeted dietary treatment for obesity in children aged 2-18 years identified 125 studies. Dietary interventions were grouped according to diet type and energy target. Risk of bias was assessed using the Effective Public Healthcare Panacea Project assessment tool. Meta-analysis examined change in body mass index (BMI) at intervention end. A broad array of diet types were effective at reducing BMI in children with obesity. When dietary types were considered by energy target, a gradient effect was observed. Very-low energy diets were most effective with a - 4.40 kg/m² (n = 3; 95% CI -7.01 to -1.79). While dietary interventions with no specified energy target were ineffective, resulting in a BMI gain of +0.17 kg/m² (n = 22; 95% CI 0.05 to 0.40). Practical definitions of dietary energy target in the management of obesity and severe obesity are urgently required to ensure treatment seeking children have timely access to efficacious interventions.

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions

The objective of this technical report is to provide clinicians with evidence-based, actionable information upon which to make assessment and treatment decisions for children and adolescents with obesity. In addition, this report will provide an evidence base to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are clinically based, effective treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori key questions.

Feedback Following a Family-Focused Pediatric Weight Management Intervention: Experiences From the New Impact Program

Weight management interventions have the potential to reduce body mass index and help families adopt healthier behaviors. This study examined feedback from families to identify central aspects of various intervention strategies based on self-determination theory constructs that have the strongest influence on patient success, with the aim of understanding how best to approach weight management in a clinical pediatric setting. Telephone interviews were conducted with 22 individuals (20 parents/guardians and 2 teenagers) who participated in a multidisciplinary weight management program and data was analyzed using inductive and deductive thematic analysis processes. Participants identified motivational interviewing strategies that were most influential to their success. Parents and patient's identified barriers and facilitators to success included patient readiness to change, personal logistics, family engagement, and establishing long- and short-term goals. Successful pediatric obesity management requires consideration to both the patient and family's readiness, structured implementation adaptations to address barriers, intentional efforts to move from external reward to internal motivation, and strategies to ensure families develop self-efficacy toward achievable healthy behaviors.

Disparities in Nutrition Counseling at Pediatric Wellness Visits in South Carolina

Background: In 2007, an Expert Committee recommended that dietary patterns be assessed at each wellness visit and that counseling on diet and nutrition be provided to all children. Few studies have examined the "uptake" of obesity prevention practices into pediatric primary care. This study aimed to describe patterns of nutrition counseling among children at wellness visits in South Carolina between 2008 and 2017 and determine whether sociodemographic disparities existed. Methods: The sample included 123,864 children 2-18 years of age who had a wellness visit at one of South Carolina's four major health care systems between January 1, 2008, and December 31, 2017. Documentation of nutrition counseling was defined by the International Classification of Diseases (ICD)-9/10 codes. A matched sample design and conditional logistic regression were used to examine sociodemographic disparities in children who did and did not receive nutrition counseling. Results: Nutrition counseling was documented at 3.55% of wellness visits. Significant sociodemographic disparities were found, including that African American and Hispanic children were less likely to receive counseling than white or non-Hispanic children. Differences were also found by urban/rural residence, health insurance, and BMI. Despite guidelines, ICD 9/10 code indicating diagnosis of overweight or obesity was documented for only 12.2% of children. Conclusions: Nutrition counseling was rarely documented in a large sample of electronic medical record (EMR) data from pediatric wellness visits in South Carolina-a state heavily burdened by childhood obesity. Children's BMIs were infrequently recorded, which may be a barrier to tracking BMI over time. Sociodemographic and geographic differences in nutrition counseling may exacerbate disparities in childhood obesity.

Brief Primary Care Obesity Interventions: A Meta-analysis

CONTEXT

Although practice guidelines suggest that primary care providers working with children and adolescents incorporate BMI surveillance and counseling into routine practice, the evidence base for this practice is unclear.

OBJECTIVE

To determine the effect of brief, primary care interventions for pediatric weight management on BMI.

DATA SOURCES

Medline, CENTRAL, Embase, PsycInfo, and CINAHL were searched for relevant publications from January 1976 to March 2016 and cross-referenced with published studies.

STUDY SELECTION

Eligible studies were randomized controlled trials and quasi-experimental studies that compared the effect of office-based primary care weight management interventions to any control intervention on percent BMI or BMI z scores in children aged 2 to 18 years.

DATA EXTRACTION

Two reviewers independently screened sources, extracted data on participant, intervention, and study characteristics, z-BMI/percent BMI, harms, and study quality using the Cochrane and Newcastle-Ottawa risk of bias tools.

RESULTS

A random effects model was used to pool the effect size across eligible 10 randomized controlled trials and 2 quasi-experimental studies. Compared with usual care or control treatment, brief interventions feasible for primary care were associated with a significant but small reduction in BMI z score (-0.04, [95% confidence interval, -0.08 to -0.01]; P = .02) and a nonsignificant effect on body satisfaction (standardized mean difference 0.00, [95% confidence interval, -0.21 to 0.22]; P = .98).

LIMITATIONS

Studies had methodological limitations, follow-up was brief, and adverse effects were not commonly measured.

CONCLUSIONS

BMI surveillance and counseling has a marginal effect on BMI, highlighting the need for revised practice guidelines and the development of novel approaches for providers to address this problem.

Association of Maternal and Child Health Center (Posyandu) Availability with Child Weight Status in Indonesia: A National Study

Little is known about the childhood obesity prevention and treatment practices of Maternal and Child Health services (Posyandu) in Indonesia or in other countries. The present study aims to assess the association of the availability of Posyandu with overweight and obesity in children of different household wealth levels. This was a secondary analysis of data collected in the 2013 Riskesdas (or Basic Health Research) survey, a cross-sectional study, representative population-based data. Height and weight, the availability of Posyandu, and basic characteristics of the study population were collected from parents with children aged 0 to 5 years (n = 63,237). Non-availability of Posyandu significantly raised the odds of being obese (OR = 1.13, 95% CI: 1.06–1.21) and did not show a significant relationship in the odds for overweight (OR = 0.99, 95% CI: 0.93–1.07). This relationship persisted after a full adjustment (OR = 1.16, 95% CI: 1.07–1.25 and OR = 1.04, 95% CI: 0.96–1.13, respectively). There was effect modification by household wealth, which was stronger for obese children. The availability of Posyandu has a protective association with childhood obesity in Indonesia. Posyandu services are well placed to play an important role in obesity prevention and treatment in early life.

Taking Steps Together

Objectives. Successful childhood obesity intervention models that build sustainable behavioral change are needed, particularly in low-income, ethnic minority communities disparately affected by this problem. Method. Families were referred to Taking Steps Together (TST) by their primary care provider if at least one child had a body mass index ≥85%. The TST intervention comprised 16 weekly 2-hour classes including educational activities, group cooking/eating, and physical activities for parents and children. TST’s approach emphasized building self-efficacy, targeting both children and parents for healthy change, and fostering intrinsic motivation for healthier living. Pre–post intervention data were collected on health-related behaviors using a survey, and trained staff measured weight and height. Results. Adults ( n = 33) and children ( n = 62) were largely Hispanic/Latino and low-income. Adults and children significantly increased their fruit and vegetable consumption and weekly physical activity, and adults significantly decreased sugared beverage consumption and screen time. No change in body mass index was observed for adults or children. Conclusions. This family-focused childhood obesity intervention integrated evidence-based principles with a nonprescriptive approach and produced significant improvements in key healthy behaviors for both adults and children.

Stage 1 treatment of pediatric overweight and obesity: a pilot and feasibility randomized controlled trial

BACKGROUND

Staged clinical treatment of pediatric obesity is recommended, but untested. Understanding the lowest intensity stage's effectiveness is necessary for future research.

METHODS

This was a randomized controlled trial of children ages 4 to <9 years. Participants were recruited after routine evaluations at a primary care pediatric clinic revealed a BMI ≥85th percentile. The intervention was patterned after the "Prevention plus, Stage 1" treatment recommended by an expert committee. Groups were compared for changes, over a 3-month time period, in BMI z-score and parental reports of behavioral issues related to childhood obesity using intent-to-treat (ITT) analysis.

RESULTS

Seventy-two (30% of eligible) children were enrolled and 64 were remeasured at 3-month follow-up. ITT analysis revealed that both groups improved mean BMI z-score [adjusted change -0.07, control, and -0.04, intervention; 95% confidence interval (CI) of difference=-0.14-0.20]. Over half of the children in each group improved their BMI z-score (adjusted proportion decreasing=55% in control vs. 72% in intervention; 95% CI of difference=-0.07-0.42). The intervention group improved comparatively to the control group on numerous behavioral indicators.

CONCLUSIONS

Implementation of the lowest intensity stage of current recommendations is feasible and possibly of benefit toward lifestyle changes. Results of this study can be used by future clinical researchers designing protocols to test the full multi-staged approach for the treatment of pediatric overweight and obesity in primary care clinical settings.

Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity

It is the position of the Academy of Nutrition and Dietetics that prevention and treatment of pediatric overweight and obesity require systems-level approaches that include the skills of registered dietitians, as well as consistent and integrated messages and environmental support across all sectors of society to achieve sustained dietary and physical-activity behavior change. This position paper provides guidance and recommendations for levels of intervention targeting overweight and obesity prevention and treatment from preschool age through adolescence. Methods included a review of the literature from 2009 to April 2012, including the Academy's 2009 evidence analysis school-based reviews. Multicomponent interventions show the greatest impact for primary prevention; thus, early childhood and school-based interventions should integrate behavioral and environmental approaches that focus on dietary intake and physical activity using a systems-level approach targeting the multilevel structure of the socioecological model as well as interactions and relationships between levels. Secondary prevention and tertiary prevention/treatment should emphasize sustained family-based, developmentally appropriate approaches that include nutrition education, dietary counseling, parenting skills, behavioral strategies, and physical-activity promotion. For obese youth with concomitant serious comorbidities, structured dietary approaches and pharmacologic agents should be considered, and weight-loss surgery can be considered for severely obese adolescents. Policy and environmental interventions are recommended as feasible and sustainable ways to support healthful lifestyles for children and families. The Academy supports commitment of resources for interventions, policies, and research that promote healthful eating and physical-activity behaviors to ensure that all youth have the opportunity to achieve and maintain a weight that is optimal for health.