Intervention in Primary Care for Obese Children
Slide Presentation from the AHRQ 2010 Annual Conference
On September 28, 2010, Ellen Wald made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (835 KB). (Plugin Software Help).
Intervention in Primary Care for Obese Children
Ellen R. Wald, MD
Conflict of Interest: I have no relationships to declare. I do not intend to reference unlabeled/unapproved uses of drugs or products.
- Obesity in children, adolescents and adults has increased dramatically during the last two decades.
- Obesity in children is a key predictor of obesity in adolescents and adults.
- Psychosocial problems.
- Medical co-morbidities.
- Primary care is an appropriate setting to impact overweight children/families.
- Children seen frequently for preventive and acute care.
- Parents available for counseling.
- Data to show periodic counseling can effect weight loss efforts.
- Our previous study demonstrated beneficial outcome for program delivered by "in office" staff.
Addressing Child Nutrition and Physical Activity in Pediatric Primary Care
Specific Aim: Assess the outcome of providing an intervention for overweight children and their families in the primary care setting by professionals trained in behavioral management following a standardized program.
- Between 9 and 12 years of age.
- BMI ≥ the 95th percentile for age and gender.
- Had a parent or caregiver who was willing to participate with the child.
- Severe medical condition such as pseudotumor cerebri, sleep apnea, etc.
- Cognitive impairments-prohibiting participation.
Entry to Program:
- Directly referred from primary care provider (PCP).
- Review of electronic medical record—informational letter from PCP inviting them to call the study coordinator.
- It was anticipated that eligible children would be recruited in summer and randomized 1:2 (treatment now vs treatment later).
- Accrual slow—recruitment continued.
- Most children able to begin intervention.
- Those required to wait became controls.
- Not randomized.
- No systematic bias.
- Children initially in control group who eventually joined intervention are not included in the analysis of the intervention group that is shown here.
- Family-based (one parent or guardian required to attend all sessions with child) behavioral weight management.
- 8 weekly sessions:
- Separate parent and child group meetings.
- Brief individual family coaching weekly.
- 3 additional sessions at 2-3 week intervals.
- Delivered by two master's prepared graduate students, supervised by senior psychologist.
- Booster sessions every 3 months until 2 years were completed.
- Newsletter every month:
- Focused on nutrition and activity.
- Healthy recipes.
- Suggested meal plans.
- Recreational activities.
Content of Group Sessions
- Importance of self-monitoring.
- Eating plan/food reference guide/portions.
- Importance of limit setting, positive reinforcement and parenting skills.
- Decrease sedentary and increase physical activity.
- Creating a successful eating and physical activity environment = stimulus control.
- Planning for special events.
Green: Go ahead
Nutrient dense, lower calorie
Yellow: Proceed with caution
Nutrient adequate, more calories
Red: Stop! Think before you eat
High in fat, sugar, and "empty" calories
*From Epstein & Squires, 1988
Overall Behavioral Targets
- Decrease intake of high fat, low nutrient value foods.
- Increase intake of low fat, high nutrient value foods.
- Decrease sedentary behaviors.
- Increase activity and exercise.
Procedures and Outcome Measures
- Weight, height, BMI at entry.
- Weight, height, BMI at baseline.
- Weight, height, BMI and BMI z-score at 15 weeks and 12 and 24 months.
- Completers: children who attended 6 of 8 weekly sessions and at least 1 of 3 follow-up sessions within original 11 session program.
- Intervention vs control at 15 weeks.
- Intervention pre- and post-baseline, 15 weeks, 12 months, and 24 months:
- Intention to treat.
- Per protocol.
Image: Flow diagram shows the following steps for children screened:
- Children screened (n=159):
- Eligible (n=145):
- Treatment now (n=78).
- Control (n=23):
- Treatment later (n-13).
- Never treated lost to follow-up after 15 weeks (n=11).
- Signed consent, never started treatment (n=44).
- Ineligible (n=14).
Image: Flow diagram shows the following process for children screened (continued from Slide 17):
- Treatment now (n=78):
- Eligible with week 1 weights (n=55):
- Short-term outcome (n=53):
- 12-Month outcome (n=37):
- 24-Month outcome (n=38).
- No final outcome (n=6).
- Missed 12-month weigh-in (n=7).
- Dropped out (n=11).
- Non-completers (n=23):
- Remain in program (n=3).
- Lost to follow-up (n=20).
|% Any college
Outcome at 15 Weeks (P=0.18): Intention to Treat Analysis for BMI-z Score
Outcome at 15 Weeks (P=0.006): Intention to Treat Analysis for BMI-z Score
Weight Change from Baseline to 15 Weeks
||Weight Change (lbs)
||-0.4 + 5.64
||-2.4 + 5.24
||+3.5 + 4.31
Weight Change in Controls
Image: Bar graph shows weight change in pounds for the control subjects (n=23). Two subjects lost half a pound; 14 gained up to 5 pounds; 6 gained between 5 and 10 pounds, and 1 gained more than 10 pounds.
Weight Change in Completers
Image: Bar graph shows weight change in pounds for subjects who completed the interventions (n= 53). Approximately two-thirds lost weight, from small amounts up to 17 pounds; the remainder gained weight, from small amounts up to 8 pounds.
Image: Two line graphs compare the intervention and control groups according to intent-to-treat analysis and per-protocol analysis for 24 months.
What We Learned
- Children in the intervention group who were completers achieved a significant reduction in BMI-z score compared to children in the control group at 15 weeks.
- 48% of those who began the program maintained a significant reduction in BMI-z score for 24 months after entry.
What We Learned
- These results were comparable to those observed when a similar study was performed with nurses rather than psychologists as counselors.
- Diaries considered laborious.
- Stoplight diet too restrictive.
What We Recommend
- Start earlier than 8 or 9 years.
- Liberalize "diet" and stress portion size.
- Maintenance phase must be more frequent than every 3 months.
Addressing Child Nutrition and Physical Activity in the Primary Care Setting 2
||Ellen R. Wald, M.D.
||Linda J. Ewing, Ph.D., RN
||Stacey Moyer, RN
||Heidi Sigmund, PhD
Jennifer Lindwall, MS
Seoka Salstrom, PhD
Michelle Jennings-Johnson, M.S.
Laura Fillingame Knudtson PhD
Support: Agency for Healthcare Research and Quality
Current as of April 2012
Intervention in Primary Care for Obese Children. Slide Presentation from the AHRQ 2010 Annual Conference (Text Version). April 2012.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf10/grossman/wald.htm