 |
|
 |
|
 |
 |
|
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SUPPLEMENT ARTICLE |
a Child Health Evaluation and Research Unit, Division of General Pediatrics, Division of General Internal Medicine, and Gerald R. Ford School of Public Policy
b College of Nursing and Healthcare Innovation, Arizona State University, Phoenix, Arizona
c Weight Management Program, Alfred I. duPont Hospital, Wilmington, Delaware
d Nutrition and Food Sciences, College of Agriculture and Life Sciences, University of Vermont, Burlington, Vermont
e Department of Epidemiology, Biostatistics, and Public Health, McGill University, Montreal, Quebec, Canada;
f Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan
 |
ABSTRACT |
|---|
 TOP ABSTRACT EVIDENCEAPPROACHES TO OBESITY PREVENTIONOPPORTUNITIES FOR OBESITY...RECOMMENDATIONS FOR PREVENTION...APPENDIX: 15-MINUTE OBESITY...REFERENCES |
|---|
Key Words: obesity • prevention
Abbreviations: ADA—American Dietetic Association • PE—physical education • YRBS—Youth Risk Behavior Survey • MI—motivational interviewing • OR—odds ratio • CI—confidence interval
Obesity threatens the health of today's children to such an extent that they may, for the first time in US history, have a shorter lifespan than their parents.1 The considerable challenges of addressing and treating obesity throughout the life cycle have led to increasing interest in preventing obesity altogether.
Recent summaries of evidence on the prevention of obesity2,3 reviewed comprehensively the body of research in this field. Following those efforts, we have focused this report on what health care providers can do to prevent childhood obesity in their clinical practices and in their communities, on the basis of evidence from the literature. Current evidence is clearly stronger in some areas than in others, and we have endeavored to inform providers about the relative strength of evidence by classifying available evidence at distinct levels (in descending order of strength). In addition, the prevention writing group has recommended specific clinical strategies, on the basis of analysis of available data from obesity interventions and other medical and behavioral interventions, as well as from clinical experience.
The goal of this set of recommendations is to enable children's health care providers (physicians, nurse practitioners, dieticians, counselors, and others) to find in one document the latest summary of evidence for prevention opportunities in health care settings and local communities. The main areas of evidence reviewed for this report include (1) food and nutrients, (2) eating behaviors, (3) family interactions around food and meals, (4) physical activity and sedentary behaviors, and (5) working with parents to address children's eating and activity behaviors. In each of these domains, we review the evidence; at the end of the report, we present our recommendations to providers for prevention of childhood obesity.
We complement our evidence review with a separate section regarding approaches to obesity prevention, which details how clinicians can adopt and implement specific counseling approaches and practice-based interventions regarding childhood obesity prevention. Our goal is to provide practitioners with practical strategies they can readily apply in their clinical work to address childhood obesity. Finally, we assess opportunities to interact with and to advocate for local and state policy initiatives, as a means for clinicians to address childhood obesity in their communities through coordination with, and advocacy for, community prevention efforts.
|
EVIDENCE |
|---|
|
TOPABSTRACTEVIDENCEAPPROACHES TO OBESITY PREVENTIONOPPORTUNITIES FOR OBESITY...RECOMMENDATIONS FOR PREVENTION...APPENDIX: 15-MINUTE OBESITY...REFERENCES |
|---|
An analysis of data from the 1994 to 1996 and 1998 US Department of Agriculture Continuing Surveys of Food Intakes by Individuals determined that 55% of children 3 to 19 years of age reported implausible energy intakes. Reported energy intake was not associated with BMI percentile in the total sample. In the sample of children who reported plausible energy intakes, however, reported energy intake was associated positively with BMI percentile for boys 6 to 11 years of age and adolescents 12 to 19 years of age. No relationship was found for children 3 to 5 years of age or girls 6 to 11 years of age. Therefore, it is important for future studies to exclude implausible dietary reports to discern dietary associations with BMI.8
Dietary Fat
Evidence supports an unclear association between dietary fat and obesity in children.4 The American Dietetic Association (ADA) conducted an evidence analysis and identified 15 longitudinal studies from 12 different cohorts of children, 3 months to 18 years of age, published between 1992 and 2003.9–23 Four studies found positive associations between dietary fat intake and adiposity.13,17,19,23 Four studies had mixed results and found both positive associations and nonsignificant associations between dietary fat intake and adiposity.9–12 The other 7 studies found no significant associations between dietary fat intake and adiposity.
In a longitudinal study of 70 white children 2 to 8 years of age, mean dietary fat intakes recorded between the ages of 2 and 8 years were positive predictors of BMI at 8 years.24 In a tracking study conducted in China, 6- to 13-year-old obese children were monitored for a 2-year period. Those who remained obese after 2 years had higher fat intakes (as a percentage of energy), in comparison with children who shifted from obese to not obese.25 There is no evidence in the literature to support the suggestion that low dietary fat intake is associated with childhood obesity.4
Calcium and Dairy Products
Recent research from some observational studies suggests that lower intakes of dairy products and/or calcium are associated with obesity in children.4 Of 7 observational studies published between 1995 and 2004, 4 found no associations26–29 and 3 found negative associations between calcium intakes and various measures of adiposity.13,30,31
In a longitudinal study of 52 white children monitored from 2 months to 8 years of age, dietary calcium intake from milk, cheese, and yogurt was associated with lower percentage of body fat at 8 years of age.30 Other researchers found that children who consumed cereal with milk were at lower risk of being obese than were children who ate less cereal.32 Girls 9 to 14 years of age who consumed diets rich in calcium weighed less and had less abdominal fat than did girls who consumed less calcium.33
Numerous intervention trials involving calcium and/or dairy supplementation and a measure of adiposity were identified in an ADA evidence analysis,4 with the majority showing no difference between intervention and control groups. Therefore, it is possible that calcium and dairy products are serving as markers for a better diet and/or healthier lifestyle in the observational studies and are not themselves the cause of lower body fatness in children.
Fruits and Vegetables
An ADA evidence analysis concluded that the evidence supports a modest effect of fruit and vegetable intake in protecting against increased adiposity in children.4 Fruits and vegetables have been promoted for the prevention of childhood obesity because of their low energy density, high fiber content, and satiety value.4 Fruits and vegetables are most likely, compared with other food groups, to be consumed in inadequate amounts by children.34 Several studies found no association between fruit and vegetable intake and childhood adiposity28,29,31,35–44; nevertheless, in none of the 17 studies reviewed in the ADA evidence analysis was increased fruit and vegetable intake related to increased adiposity. The studies that found a significant inverse relationship between fruit or fruit and vegetable intake and adiposity tended to have larger sample sizes, compared with those that found no relationship. The evidence was stronger for fruits alone or for fruits and vegetables combined than for vegetables alone. Part of this disparity may be attributable to the fact that different fruits and vegetables may have different effects on childhood obesity and overweight. For instance, more than one third of the total daily amount of vegetables in the US food supply consisted of iceberg lettuce, frozen potatoes (mostly french fries), and potato chips.4
Fruit Juice
Intake of 100% fruit juice is not related to adiposity in children unless it is consumed in unusually large quantities.4 The ADA reviewed 15 studies on the impact of fruit juice consumption on childhood obesity. Four of 6 longitudinal studies found no association between fruit juice intake and obesity,16,38,45,46 whereas 2 other longitudinal studies found either no association or an inverse association.36,47 Neither of 2 nationally representative, cross-sectional studies found a relationship between fruit juice consumption and reported BMI.48,49 One case-control study and 3 other cross-sectional studies found a positive association between fruit juice intake and a measure of adiposity.29,39,50,51 In 2 studies of related cohorts, only large amounts of juice (
12 fl oz/day) were associated with increased obesity.50,51 The remaining 3 cross-sectional studies found no relationship between 100% fruit juice intake and obesity.44,52,53
Largely on the basis of this evidence, the American Academy of Pediatrics recommends that intake of fruit juice should be limited to 4 to 6 oz (1 serving) per day for children 1 to 6 years of age. For children 7 to 18 years of age, juice intake should be limited to 8 to 12 oz (2 servings) per day.54
Sugar-Sweetened Beverages, Including Soft Drinks
Evidence strongly supports a positive association between the intake of calorically sweetened beverages and adiposity in children.4 A total of 19 observational studies published between 1999 and 2004 that assessed intake of sweetened beverages and the association with some measure of adiposity in children were reviewed, including 6 longitudinal studies, 3 nationally representative, cross-sectional studies, and 10 case-control or other cross-sectional studies.*The ADA concluded that the larger, more strongly designed, and higher-quality studies substantiated that sweetened beverage intake is related to obesity among children.
Since completion of the ADA evidence analysis, additional studies support a positive association between sugar-sweetened beverages and childhood overweight and obesity. Nationwide food consumption survey data collected in the 1999 to 2000 National Health and Nutrition Examination Survey demonstrate that soft drinks and sugar-sweetened fruit drinks are the principal source of energy in the diets of US male and female adolescents.64
In a separate sample of 10904 low-income children 2 to 3 years of age, consumption of sweetened drinks increased the odds of becoming obese among those who were at risk for obesity at baseline and of remaining obese among those who were already obese by 60%. The authors concluded that reducing sweetened drink consumption is one strategy to manage the weight of preschool children.65
Several nutrition policy documents make recommendations regarding sugar-sweetened beverages. The American Academy of Pediatrics policy statement on soft drinks in schools recommends that pediatricians should work to eliminate sweetened drinks in schools.66 The 2005 Dietary Guidelines Advisory Committee stated that "available prospective studies suggest a positive association between the consumption of sweetened beverages and weight gain. A reduced intake of added sugars (especially sugar-sweetened beverages) may be helpful in weight control and in achieving recommended intakes of nutrients."67 The 2005 Institute of Medicine report Preventing Childhood Obesity stated that "much remains to be learned about whether a unique association exists between intake of sweetened beverages and changes in BMI. Because of concerns about excessive consumption of sweetened beverages and the displacement of more nutrient-rich or lower calorie alternatives, children should be encouraged to avoid high-calorie, nutrient-poor beverages."2
Childhood Eating Behaviors and Obesity
Breakfast Skipping
Evidence supports the view that obese children and adolescents are more likely to skip breakfast than their leaner counterparts. Obese children also have been reported to eat smaller breakfasts than their nonobese peers.4
A total of 15 observational studies published between 1994 and 2004 were reviewed, including 2 longitudinal studies,36,68 2 nationally representative studies,57,69 and 11 other cross-sectional studies.42,60,70–78 The ADA concluded that the preponderance of evidence suggested that breakfast skipping may be a risk factor for increased adiposity, particularly among older children or adolescents. However, the strength of the evidence is somewhat limited because what constitutes a breakfast has not been defined consistently.4
Eating Out, Including Fast Food
Evidence supports the view that consumption of food away from home, particularly at fast food establishments, may be associated with adiposity, especially among adolescents.4 A total of 10 observational studies published between 1996 and 2004 were reviewed, including 2 longitudinal studies,36,79 1 nationally representative, cross-sectional study,57 and 7 other cross-sectional studies.40,71,74,80–83 Study sample sizes ranged from >6000083 to just over 50.80 A limiting factor in these studies is that "eating out" and "fast food" were not defined or assessed systematically. However, the evidence that is currently available suggests that frequent patronage of fast food restaurants may be a risk factor for obesity in children.4
Portion Sizes
Increased portion sizes may be associated with increased adiposity in children.4 Of note, appropriate portion sizes vary according to age, and discussions with parents about portion sizes should reflect age-specific normative values, as suggested in the Food and Drug Administration Food Guide Pyramid (available at www.mypyramid.gov).
Research indicates that portion sizes may contribute to the increasing prevalence of overweight among children by promoting excessive energy intake. Three- to 5-year-old children consumed 25% more of an entrée and 15% more energy at lunch when presented with portions that were twice as large as the age-appropriate standard size.84 In a nationally representative sample of 1-year-old children, food portions were related positively to body weight.85
A study of 16 preschool children 4 to 6 years of age found that the most powerful determinant of the amount of food consumed at meals was the amount served. These children displayed poor regulation of energy intake.86
Other investigators used the 1994–1996 and 1998 Continuing Surveys of Food Intakes by Individuals to categorize children 3 to 19 years of age according to plausible and implausible self-reported energy intake. Among children with plausible reported energy intake, meal portion size was associated positively with age-specific BMI percentiles for boys 6 to 11 years of age and adolescents 12 to 19 years of age.8 Others examined intakes of 2- to 5-year-old children in the 1994–1996 and 1998 Continuing Surveys of Food Intakes by Individuals and found that portion size accounted for 17% to 19% of the variance in energy intake.87
Snacking
Snacking frequency or snack food intake is not likely associated with adiposity in children.4 The majority of studies that examined snack food intake in a recent ADA evidence analysis found no association with adiposity.
The research on snacking is confounded by unclear definitions in the literature of what constitutes a snack or snack food.4 Nevertheless, longitudinal studies demonstrate that snacking frequency has increased concurrently with the prevalence of overweight. Snacks tend to be higher in energy density and fat content than meals, and high levels of snack consumption have been associated with greater intakes of fat, sugars, and energy.4
Since completion of the ADA evidence analysis, additional studies of children's snack behaviors have been published. In the Growing Up Today study of 9- to 14-year-old girls and boys, there was no relationship between intake of snack food and subsequent changes in BMI among the boys; there was a weak inverse association with weight change among the girls. The authors concluded that, although snack foods may have low nutritional value, they are not an important independent determinant of weight gain among children and adolescents.91 In the Growth and Development Study of 196 nonobese, premenarcheal, 8- to 12-year-old girls, energy-dense snack food intake did not influence subsequent weight status or fatness change.61 In contrast, an analysis of data from the Bogalusa Heart Study found that, among 1562 children 10 years of age, the total amount of food consumed, specifically from snacks, was associated positively with overweight status.60
Family Interactions Involving Meals and Nutrition
Family Meals
Evidence supports a positive association between frequency of family meals and dietary quality in adolescents.92,93 Increased frequency of family meals is associated with greater intakes of fruits, vegetables, and milk and lower consumption of fried food and soft drinks. It is also associated with higher nutrient intakes (including calcium, iron, vitamins, and fiber) and lower intakes of saturated and trans fats. The Growing Up Today cohort of 7784 girls and 6647 boys 9 to 14 years of age found that the frequency of family dinners was associated inversely with overweight prevalence at baseline.94
Parental Control of Child Nutrient Intake
Parental control over children's dietary intake does not consistently seem to be related to obesity in children.4 Five cross-sectional studies showed no association between parental control and adiposity.39,95–98 One study found no association between parental control and adiposity among boys but demonstrated an inverse association between parental control and adiposity among girls.99 Another study found a positive significant association of parental control with adiposity among both boys and girls in the sample.100
Physical Activity and Sedentary Behavior
Measurement of Physical Activity
It is generally accepted that the energy expenditure required to reduce total mortality rates among originally sedentary adults is 630 to 1680 kJ/day above habitual energy expenditure levels.101,102 It is more difficult to quantify the energy expenditure required to produce beneficial health effects among children and adolescents. Ultimately, the prevention of obesity requires a balance between energy intake and expenditure over time. Energy expenditure includes resting metabolic rate, thermogenesis, and physical activity, but only physical activity is amenable to clinical or community prevention programs for obesity.
Although reviews have identified many benefits of physical activity in youths, including reduced blood pressure levels, improved lipid profile, increased bone mass and density, improved self-esteem, reduction of anxiety, and reduced symptoms of depression, this report focuses on overweight and obesity prevention. Physical activity among youths is challenging to measure because the capacity to understand and to recall the concepts of time, duration, and intensity of past activity is associated inversely with age and because the nature, context, and practice of physical activity vary with age. Objective measures of physical activity used more commonly in recent studies, such as accelerometry, represent an important improvement in physical activity measurement.
Longitudinal Trends in Physical Activity
Data from the Youth Risk Behavior Survey (YRBS) suggest decreases in physical activity among US adolescents over the past decade.103,104 The proportion of adolescents in grades 9 to 12 defined as inactive increased from 10.9% in 1993 to 14.7% in 2003 for boys, but values remained stable for girls (20.8% and 22.2%, respectively).104 The odds of being inactive in 2003, compared with 1993, were increased significantly only for boys (odds ratio [OR]: 1.41; 95% confidence interval [CI]: 1.16-1.71) and for adolescents in ninth or 10th grade (ninth grade: OR: 1.63; 95% CI: 1.27-2.09; 10th grade: OR: 1.32; 95% CI: 1.06-1.63).104 In contrast, surveys conducted in Canada from 1981 to 1998 reported substantial increases in leisure time physical activity energy expenditure among youths 12 to 19 years of age.105 In addition, the prevalence in the United Kingdom of vigorous exercise at least 3 times in the past week increased from 32% to 53% for boys 12 to 13 years of age and from 36% to 49% for boys 14 to 15 years of age from 1987 to 2003. Among girls, increases were from 24% to 37% and from 20% to 31%, respectively.106
The YRBS was conducted biannually from 1993 to 2003; in each survey, inactivity increased from grades 9 to 12 and was higher in black youths than in non-Hispanic white youths and in girls than in boys. Other reports confirm that girls report less physical activity than boys, both before107 and during108,109 adolescence. Differences between girls and boys are particularly apparent for vigorous physical activity, with girls being less likely than boys to engage in vigorous physical activity during their free time, in the context of organized physical activity, during school, and outside of school.109 In addition, the decline in physical activity with increasing age103 and with lower socioeconomic status is well documented.110,111 Longitudinal studies show that only 12% of youths who originally achieve desirable levels of physical activity (5 weekly bouts of moderate or vigorous physical activity) remain as active as young adults.112
Increasing competition for classroom time has put pressure on physical education (PE) classes in schools in many countries, including Australia and the United Kingdom.106 In the United States, the YRBS indicated that participation in daily PE classes decreased from 42% in 1991 to 32% in 2001.103 The amount of time spent being active during PE classes has also decreased.113 Boys have substantially higher energy expenditures during PE classes, compared with girls.109,113,114 Although girls and boys are equally likely to be enrolled in organized physical activity and lessons outside school,115 girls are less likely to belong to sports clubs or to participate in unorganized physical activity or in school sports outside PE classes.116 Boys and girls differ substantially in their physical activity preferences117,118 and in their patterns of physical activity involvement.119–121 Participation in organized sports has declined in Australia and Sweden but seems to have remained stable in the United Kingdom.106
Individual and environmental factors do not influence all children equally.122–124 There is evidence both for and against genetic effects on sports participation and leisure time physical activity among youths.125,126 Boys and girls differ in their attitudes and beliefs regarding physical activity,127 as well as their motivation for116,128 and barriers to129,130 engaging in physical activity. Peer and family social support, perceived neighborhood opportunities, and physical features of the school environment are important determinants of children's physical activity levels.131–135
Active transport (eg, walking or cycling) can be an important method of successfully integrating physical activity into people's daily lives. However, the frequency of walking and cycling by US children decreased by 37% between 1977 and 1995.136 The proportion of schoolchildren who used active transport to or from school decreased from 50% in 1969 to 15% in 2003.137,138 Similar declines have been reported in the United Kingdom.106
Longitudinal Trends in Sedentary Behavior
A review concluded that total media use among youths in industrialized countries has remained stable in the past decades.129 The most recent data from an extensive review of the literature show that boys watch an average of 137 minutes of television each day, compared with 128 minutes for girls. Boys 0 to 6, 7 to 12, and 13 to 18 years of age watch an average of 126, 135, and 121 minutes of television each day, respectively. Girls of the same age categories watch television 126, 125, and 106 minutes per day, respectively.139 Approximately 30% of boys and 25% of girls of all ages watch 4 hours of television per day. Boys play video games twice as much as girls (59 and 23 minutes per day, respectively, on average) and spend more time using computers (38 and 26 minutes per day, respectively).139
Physical Activity and Obesity
The evidence is strong that daily moderate/vigorous physical activity helps reduce adiposity in overweight/obese youths. For normal-weight children, the evidence is inconsistent for an association of physical activity with prevention of obesity. Nevertheless, there is expert consensus that daily moderate/vigorous physical activity of 60-minute cumulative duration is likely to have a beneficial effect for normal-weight youths and is unlikely to harm them. In the following summary of studies, we include some studies in the physical activity section that also included measures of sedentary behavior, and vice versa; they appear in specific sections on the basis of the primary focus of each study.
Several reviews of observational epidemiologic studies have summarized the literature on the association between physical activity and obesity in youths. Most studies conducted between 1940 and 2000 were cross-sectional and involved highly selected patient groups, often of obese and nonobese subjects. Older studies measured energy expenditure with physical activity questionnaires only and more recent studies with heart rate monitoring, double-labeled water testing, or a combination of the 3 methods.140 The studies reviewed generally (but not universally) reported significant inverse associations between physical activity and obesity, with no significant positive associations. The authors also reviewed 2 large, nationally representative surveys, the US National Children and Youth Fitness Study II, which recruited children in grades 1 to 4 and found strong positive associations between activity and reduced skinfold thickness,141 and a Finnish survey of 15-year-old youths, which failed to find any relationship between physical activity and obesity measures.142 Of the 7 longitudinal studies reviewed, 4 found significant inverse associations with physical activity levels measured with questionnaires or energy expenditure measured with double-labeled water testing,18,19,143,144 but 3 did not.145–147
A more-recent review (including articles published between 2000 and 2004) identified 16 new cohort studies of children (age range: 3–14 years), including 11 studies with follow-up periods of >2 years and 4 studies with >1000 children.148 Of the 11 studies that used questionnaires to assess physical activity, 5 found no association between activity levels and measures of adiposity9,12,149–151 but the other 6 reported that weight gain was associated inversely with activity levels and associated positively with sedentary activities.68,152–156 Five studies used objective measures to assess energy expenditure, and all had small sample sizes (26–115 subjects). The Framingham Children's Study reported an inverse association between energy expenditure measured with heart rate monitoring and changes in BMI after 8 years of follow-up monitoring for 103 children initially 3 to 5 years of age.157 Another study of 47 subjects 4 to 9 years of age showed that energy expenditure measured with double-labeled water testing resulted in changes in fat mass measured with dual-energy x-ray absorptiometry after 1.6 years but not after 2.7 years of follow-up monitoring.158 The other 3 studies, with follow-up periods of 1 to 3 years, showed no inverse association between energy expenditure and change in fat mass.159–161
Another review assessed 11 recent trials intended to prevent unhealthy weight gain by increasing physical activity or reducing sedentary behavior in children and adolescents, including 9 trials consisting of school-based interventions and 1 trial that measured outcomes >3 months after the end of the intervention.148 Three trials showed a small intervention effect on adiposity indices, including 2 that demonstrated effects only in boys162,163 and 1 in both boys and girls.164 The other trials failed to show intervention effects on body composition, although several trials reported improvements in physical activity measures.165–172
Three other reviews of randomized trials have been published, including 9 studies not previously reviewed.129,173,174 Most of those studies were published before 2000; 8 were conducted in schools and 1 exclusively in the community. All except 3 of the intervention programs combined nutrition and physical activity components175–180; 2 trials focused exclusively on physical activity promotion181,182 and 1 focused chiefly on reduction of sedentary activities.183 Significant positive effects were reported in 5 of the 8 school-based trials,177–179,182,183 including 2 trials that showed positive effects only among girls.177,179
Finally, a comprehensive review of evidence on physical activity for school-aged youths, published in 2005, reported that programs of 30- to 60-minute duration, performed 3 to 7 days per week, demonstrated reductions in total body fat and visceral adiposity among obese children and adolescents but did not influence the percentage of body fat in normal-weight children and adolescents.184 The review also cited more-limited evidence that longer and more-intensive sessions (>80-minute duration) were more successful in reducing the percentage of fatness in normal-weight youths. This led to the consensus recommendation from the review that school-aged youths should participate every day in 60 minutes of moderate to vigorous physical activity that is developmentally appropriate and enjoyable.
Sedentary Behavior and Obesity
Evidence supports a strong association between limiting sedentary behavior (watching television and playing video/computer games) and preventing obesity, although the effect size of the association varies across studies. A review of the literature on the effect of sedentary behavior on body composition identified 52 independent studies on television and adiposity, 39 studies on television and physical activity, 6 studies on video/computer games and body weight, and 10 studies on video/computer games and physical activity. The authors concluded that, although television and video/computer games have a positive relationship with BMI and a negative impact on physical activity, these effects are small and are unlikely to be of clinical relevance.185
In contrast, more-recent cross-sectional studies report significant associations between sedentary activities and body fat. Stettler et al186 reported that, among 922 Swiss children in grades 1 to 3, use of electronic games (OR: 2.0; 95% CI: 1.6–2.6), television (OR: 2.8; 95% CI: 2.1–3.9), and physical activity (OR: 0.80; 95% CI: 0.72–0.88) were associated independently with obesity. Among a nationally representative sample of Finnish adolescents 14, 16, and 18 years of age, the ORs of being overweight were 1.4 and 2.0 for girls watching 1 to 3 hours or 4 hours of television, respectively, compared with girls who watched <1 hour per day.187 The use of computer games for >1 hour (compared with <1 hour) increased the OR by 1.5. Similar results were found for boys but did not reach statistical significance. Finally, analysis of the 1999 YRBS data indicated that watching >2 hours of television per day was associated with being overweight among white male and female youths and among Hispanic female youths.188
Three recent reports from cohorts of children and adolescents support a relationship between sedentary behavior and excess weight. A report from the 1970 British Birth Cohort, involving >11000 subjects monitored for 30 years, showed that the mean number of hours spent in front of a television set at 5 years of age predicted higher BMI z scores 25 years later, even when adjusted for television viewing at 10 years of age, birth weight, parental BMI, gender, and socioeconomic status.189 Each additional 1 hour of television watched during weekends increased the risk of adult BMI of 30 kg/m2 by 7% (OR: 1.07; 95% CI: 1.01–1.13).
Other studies that included measures of sedentary behavior as well as physical activity found, in a cohort of 
150 children initially 3 to 4 years of age who were monitored from 1986 to 1989, that physical activity and sedentary behavior (television viewing) were the only significant predictors of BMI (other than baseline BMI).119 Finally, a cohort of 355 adolescents in grade 7 in Wales were monitored for 4 years.190 Multivariate regression analysis showed that sedentary behavior and physical activity predicted BMI measured in follow-up assessments, after adjustment for several sociodemographic variables.
|
APPROACHES TO OBESITY PREVENTION |
|---|
|
TOPABSTRACTEVIDENCEAPPROACHES TO OBESITY PREVENTIONOPPORTUNITIES FOR OBESITY...RECOMMENDATIONS FOR PREVENTION...APPENDIX: 15-MINUTE OBESITY...REFERENCES |
|---|
Partnering With Parents to Prevent Childhood Obesity
Family Health Promotion
Families have a critical role in influencing children's health,191 and health is a de facto characteristic of the family lifestyle.192 Interventions in the parent-child dynamic have evolved from traditional psychotherapeutic models to direct coaching of parents as they interact with their children and to the current view of parenting through the lens of social learning theory. Social learning theory is based on the premise that changing a parent's behavior leads to a change in a child's behavior.193 Including parents as active participants with their children in lifestyle changes has produced positive long-term improvement in weight control.194 Two major reviews of obesity prevention in children by the Institute of Medicine2,3 delineated and emphasized the pivotal role of parents in obesity prevention. Specifically, parents can have a strong influence on obesity prevention in their children through direct support, such as playing with their children, paying fees for programs that promote physical activity, and transporting their children to locations in their communities where they can be active.195
Parenting Styles
"Parenting styles" describe parent-child interactions across a wide range of situations and apply to the interactions independent of content.196 The relationship between parents and children may be reflected in and affected by parenting style.197 One classification of parenting style includes the categories of authoritarian, authoritative, permissive, and disengaged. Authoritarian parents are described as valuing obedience, favoring punitive forceful measures, and not encouraging verbal "give and take."198 Authoritative parenting values both "self-will and disciplined conformity," using a reason as well as authority to discipline a child.199 A permissive parent allows a child to regulate his or her own activities and is accepting, nonpunitive, and affirmative.198 A disengaged style has been described as neglectful.199 An authoritative parenting style has been associated with reduced smoking initiation200 and increased physical activity and reduced sedentary behavior in girls.201 Parental acceptance and behavioral control are 2 dimensions that can frame these 4 parenting styles (Table 1).202
|
Infancy
Parent-child interactions regarding food and activity start at birth. There is evidence to suggest that breastfeeding has a small protective effect on later obesity.207 The mechanism of action is unclear but may involve enhancement of the infants' ability to regulate intake and the effect of mother-infant feeding interactions. Associations with parental weight, socioeconomic status, and smoking may be confounders.208 Practitioners' support of breastfeeding is recommended for obesity prevention by the American Academy of Pediatrics.209
Preschool Age
Parents are responsible for the type of food presented to young children, the portion sizes offered, and the emotional context in which food is eaten. Transitional diets of toddlers often mirror the problem areas found in parents' diets.210,211 A majority of 1- to 2-year-old children consume dessert, ice cream, and/or candy once per day, and up to one half consume sweetened beverages daily; in contrast, only 1 of 10 consume a dark green vegetable daily.212 Advice to parents to "provide a healthy array of foods in the correct portion size and allow children to decide what and how much to eat from what they are offered" has been suggested as an appropriate parental approach to feeding.213
Parents' activity level can also influence activity in children.214 Moreover, television viewing and having a television in the bedroom both have been associated with overweight in 1- to 5-year-old children.215
School Age
School age is a time when parents and children are focused on development of competence, where "rules channel behavior into productive activities."216 Although parents are transitioning self-care skills to children, parents need to recognize their continuing enormous influence over nutrition and activity. Overweight in school-aged girls has been associated with their fathers' energy intake and enjoyment of activity and their mothers' BMI.12 Parental exercise has been associated with increased fitness and extracurricular sports participation in children.217 Reduction in television viewing in the school-aged population has been associated with obesity prevention and treatment,183,218 emphasizing the continuing role of parents in managing a child's energy environment.
Adolescence
Adolescent sedentary behavior is correlated with parental sedentary behavior.219 Parental support of adolescents' activity was a stronger predictor of child activity than was parental activity. Parental support was thought to act by increasing adolescent self-advocacy, by providing resources and motivation.220
Supporting parents through their children's adolescence is important for helping them maintain efficacy in influencing and supporting their adolescents' positive lifestyle behaviors. Before the 1980s, theories on adolescent development were based on a conflict-oriented model221; since then, a more-positive approach has emphasized continuity in the adolescent-parent relationship and continued acceptance of parental values,222 with adolescents looking to adults for support and control.223
Parenting Interventions for Obesity
Each family and child is at a unique point in their readiness to accomplish lifestyle changes. Evaluating the stage of change has been recommended as a way of tailoring intervention to the family's needs. In a study of parents of obese and overweight children, 44% were in the precontemplation stage, 17% in the contemplation stage, and 38% in the preparation/action stage of change. Parents of overweight children and parents who thought that they themselves were overweight were more likely to be in the precontemplation stage. Parents of older and obese children were more likely to be in the preparation/action stage. Significantly, parents who were worried about their child's weight in the context of a health problem were more likely to be in the preparation/action stage. This effect was increased when the child's physician had commented about the effect of the child's weight on his or her health.224
In a study comparing parent-only versus child-only interventions, children in the parent-only intervention group had greater initial weight loss and follow-up weight loss at 7 years, compared with the child-only intervention group. Two patients in the child-only intervention group developed eating disorder symptoms during long-term follow-up monitoring, compared with no children in the parent-only intervention group. Weight change in the parent-only intervention group was hypothesized to be mediated through better control of the nutritional environment and possibly change toward the authoritative parenting style, which was emphasized in the intervention.225
Clinician Counseling Skills
In this section, we address ways in which clinicians can intervene in the dietary and activity behaviors discussed above, providing a concrete set of suggested strategies and approaches for obesity prevention in practice settings. Counseling in medical practice can be reduced to 4 essential skills, that is, (1) asking, (2) informing, (3) advising, and (4) listening. A framework for understanding how these skills are used in client-centered counseling was proposed by Rollnick et al.226 The framework delineates how these 4 skills manifest as 3 styles of communication, namely, following, guiding, and directing. These styles are differentiated by the skills used and the phase of the counseling encounter. The early phase is predominantly characterized by following. In the following phase, by using reflective listening and open-ended questions, the counselor gathers information from the patient to determine the position of the patient with respect to the behavior or health issue in question. The clinician establishes the basic facts of the story, often with a discussion of the behavioral history and the advantages and disadvantages of change. During this phase, the patient and counselor identify collaboratively what behaviors can be addressed. The emphasis is on building rapport and communicating that the clinician is not going to push the client to change. In the opening phase, the counselor often simply reflects what is being said; during later phases of the consultation, more-challenging reflections, which perhaps build discrepancy and move the patient toward an action plan, are used.
Once the clinician has obtained the basic story, the transition to discussing and planning change can begin. This is the hallmark of the guiding phase. In this phase, specific strategies (discussed below) to elicit change talk, such as the 0 to 10 importance/confidence rulers and a values clarification activity, are often used. The counselor gently helps guide the patient toward a behavioral decision.
Directing, the third phase, generally occurs after a patient has made a behavioral decision. The focus may shift to helping the client make concrete plans, such as setting goals and delineating an action plan. As the encounter moves from following to guiding and directing, there is generally a shift from simply listening and asking to informing, advising, problem-solving, and goal-setting.
Action reflections are key tools during the guiding and directing phases. This type of reflection involves moving the patient forward by incorporating into the reflective statements possible solutions to barriers or potential action steps. Unlike unsolicited advice and direct persuasion, action reflections use words or solutions either mentioned directly or alluded to by the patient. Reflections can involve reframing a barrier into a possible action step or listing a possible plan that the client mentioned directly or that developed logically from the discussion. The tone of the reflection often "undersells" the action step or solution, with words such as "could work" or "might consider."
When practitioners over-rely on a directing style, they overuse questions, information, and advice. This can take the form of informing patients about what the clinician thinks they should do and why they should do it. Traditional anticipatory guidance can take this form. The clinician may adopt the role of an "expert" who is attempting to persuade the patient, and the clinician overcontrols the flow of the encounter, doing the majority of talking. Conversely, when practitioners use the following and guiding styles, they rely less on persuasion and devote more time and effort to listening. Excessive directing can lead to a passive patient; when clinicians use more following and guiding modes, patients are more active and autonomous, exploring their ambivalence, motivation, and potential plans for change. The following and guiding styles are reflected strongly in patient-centered communication methods such as motivational interviewing (MI) and autonomy-supportive counseling.227–230
Each of the 3 styles can be appropriate, depending on the needs, preferences, and personalities of patients and their readiness for change. For example, although many patients report high satisfaction and improved outcomes with patient-centered communication approaches,231–233 such as MI, some individuals, particularly older patients and perhaps immigrant groups, may prefer a more-directive, educational style.234 With regard to pediatric practice, whereas younger children may be more responsive to the guiding/directing styles, adolescents, who often express resistance, may be particularly responsive to the following/guiding styles. Similarly, parents who do not see a strong need to change the diet and activity habits of their children (or themselves) may be more responsive to a less-directive mode of counseling. Because of the vast research base on MI, we use it as the model to describe and to implement patient-centered obesity prevention.
MI has been used extensively in the addiction field.235–238 Numerous randomized trials have demonstrated its clinical efficacy for addictive behaviors.239,240 In the past decade, there has been considerable interest from public health, medical, and dietetic practitioners in adapting MI to address various chronic disease behaviors.240–251 Although MI has been used to modify diet and physical activity behaviors in adults, the evidence base for obesity prevention and treatment in children is just beginning to emerge.252 In the current absence of health care-based interventions for childhood obesity prevention, using MI is an interim step clinicians can take that has some basis in evidence.
Overview of MI
MI is a patient-centered style of counseling that relies heavily on strategies such as reflective listening, shared decision-making, and agenda-setting. A key element of MI is that ambivalence is considered a normal phase in the behavior change process, rather than an obstacle to change. Patients are encouraged to express their ambivalence, while clinicians subtly place greater emphasis on exploring the potential benefits of change without dismissing or counter-arguing the barriers to change. MI seems to be particularly effective for individuals who are initially less ready to change.237,249,253,254
The tone of MI is nonjudgmental, empathetic, and encouraging. Clinicians establish a nonconfrontational and supportive climate in which patients feel comfortable expressing both positive and negative aspects of their current behavior. Many counseling models rely heavily on therapist insight, whereas traditional patient and nutrition education emphasizes information exchange. In contrast, a MI approach requires patients themselves to do much of the psychological work. MI counselors generally make no direct attempts to dismantle denial, to confront irrational or maladaptive beliefs, or to convince or to persuade patients. Instead, clinicians help patients think about and verbally express their own reasons for and against change, as well as how their current behavior or health status affects their ability to achieve their life goals or to fulfill core values. MI encourages patients to make fully informed and deeply contemplated life choices, even if the decision is not to change.
MI assumes that behavior change is affected more by motivation than by information. Although the essence of MI lies in its spirit, there are specific techniques and strategies that, when used effectively, help ensure that such a spirit is evoked. To achieve these ends, MI counselors rely heavily on reflective listening.
Reflective listening can be conceptualized as a form of hypothesis testing. The hypothesis can be stated in generic terms as "If I heard you correctly, this is what I think you are saying..." or "Where you are going with this is... ." Reflections, particularly by counselors who are new to the technique, often begin with the phrase, "It sounds like... ." More-skilled counselors often phrase their reflections as more-direct statements, such as, "You are having trouble with...," omitting the assumed, "It sounds like... ." The goals of reflecting include demonstrating that the counselor has heard and is trying to understand the client, affirming the client's thoughts and feelings, and helping the client continue the process of self-discovery. One of the most-important elements of mastering MI is suppressing the instinct to respond with questions or advice. Questions can be biased by what the counselor may be interested in hearing about, rather than what the client wants or needs to explore.
Reflecting helps ensure that the direction of the encounter remains client-driven. Reflections involve several levels of complexity or depth. The simplest level tests whether the counselor understood the content of the client's statement. Deeper levels of reflection explore the meaning or feeling behind what was said. Effective deeper-level reflections can be thought of as the next sentence or next paragraph in the story, that is, "where the client is going with it." A high level of reflective listening involves selectively reinforcing positive change talk that may be embedded in a litany of barriers. Similarly, skilled MI counselors selectively reflect statements that build efficacy, by focusing on previous successful efforts or reframing past unsuccessful attempts as practice rather than failure.
In the directing style, practitioners often provide information about the risks of continuing a behavior or the benefits of change with the intent of persuasion. For the parent of an overweight child, a traditional counseling statement might be, "It is very important that your child get control of his/her weight now, before it becomes a bigger problem." In this style of communication, the practitioner often attempts to "push" motivation by increasing perceived risk. In contrast, information is presented through MI by first eliciting the client's understanding and information needs, providing new information in a more-neutral manner, and then eliciting what this means for the client with a question such as, "How do you make sense of all this?" MI practitioners avoid persuasion with "predigested" health messages and instead allow clients to process information and to find their own personal relevance. To this end, the guideline elicit-provide-elicit has been proposed as a framework for exchanging information in the spirit of MI. An outline of a patient-centered obesity prevention counseling session using these techniques is provided in the Appendix.
Confronting patients can lead to defensiveness, rapport breakage, and, ultimately, poor outcomes. Therefore, MI counselors avoid argumentation and instead "roll with resistance." A MI encounter resembles a dance more than a wrestling match.255 For example, a parent may raise doubts that the child's weight is a problem or may suggest that the child's weight will improve on its own as the child ages. Rather than stating facts to counter such beliefs or to persuade the parent, a MI practitioner reflects the parent's doubt and then provides opportunities for the parent to voice any concerns he or she may have about the child remaining overweight or gaining weight. In cases in which a parent's resistance is severe, the practitioner may use an amplified negative reflection, such as, "It appears that you see no real problem with your child's weight," or "Having your child watch television most of the afternoon really works for you and your family." This potentially risky strategy is designed to "unstick" the entrenched client by short-circuiting the "yes-but" cycle.
A core principle of MI is that individuals are more likely to accept and to act on opinions that they voice themselves.256 Patients are therefore encouraged to express their own reasons and plans for change (or lack thereof). This process is referred to as eliciting change talk. One technique to elicit change talk is the use of importance/confidence rulers.253,255,257 This strategy begins with 2 questions. (1) "On a scale from 0 to 10, with 10 being the highest, how important is it to you to change your child's/family's (insert target behavior)?" (2) "On a scale from 0 to 10, with 10 being the highest, assuming you wanted to change this behavior in your child/family, how confident are you that you could (insert target behavior)?" These 2 questions assess the client's importance and confidence for change, respectively.235,257 Clinicians follow each of these questions with 2 probes. If the client answered "5," for example, then the counselor would probe first with the question, "Why did you not choose a lower number, like a 3 or a 4?" and then with the question, "What would it take to get you to a 6 or a 7?" These probes elicit positive change talk and ideas for potential solutions from the client.
Another strategy to elicit change talk is to help build discrepancy between the patient's personally held values and goals and his or her current health practices. The strategy can be used for counseling parents or working directly with older children or adolescents. To execute this strategy, patients select 2 or 3 values from a list provided by clinicians (Tables 2 and 3). Practitioners then probe how, if at all, changing the behavior in question can help patients achieve their goals. Conversely, practitioners can understand how, if patients do not or cannot change, such values and goals may be impeded.
|
|
Goal-Setting
Clearly defined behavioral goals for the target behaviors identified through the prevention assessment should be elicited from parents and children. Generally, initial goals should entail relatively modest changes. For example, goals could include adding 1 serving of fruits and vegetables or 15 minutes of physical activity each day or reducing 1 serving of sweetened beverages or 30 to 60 minutes of television viewing each day. Setting and achieving smaller, attainable goals may lead to increased feelings of self-efficacy, which in turn may spur additional persistence and continued progress while reducing disappointment and perceptions of failure. Having parents and/or children verbally express the behavioral goal may help solidify the behavioral contract and increase ownership over the proposed goals.
Positive Reinforcement
Children's efforts should be recognized and encouraged. Reinforcement may take the form of verbal praise for changes made or simply recognition of attempts at change. Tangible reinforcement, including financial incentives, can be considered, although there is some debate regarding whether such "extrinsic" motivation decreases long-term behavioral persistence.
Monitoring
Both clinicians and family members can monitor children's progress toward their agreed-on goals. For clinicians, this may entail inquiring about progress at subsequent visits, with simple prompts such as, "How have things gone with your eating or activity plan since we met a few months back?" If specific goals were set at a previous visit, then the clinician should refer to those goals. A more-detailed monitoring plan that entails daily charting of the child's behavioral progress can also be considered, particularly for children with BMI of 85th to 95th percentile without health complications. Generally, for healthy children following a prevention protocol (ie, BMI of <85th percentile or BMI of >85th to <95th percentile without obesity-associated complications), frequent monitoring of weight is not recommended.
Cognitive Restructuring
How children internally define their progress and interpret their actions can affect behavioral persistence significantly. One common maladaptive pattern of which clinicians should be aware is all-or-nothing thinking. All-or-nothing thinking, which is also referred to in the addiction field as abstinence-violation syndrome, entails exaggerated negative interpretation of small lapses or failures to adhere perfectly to a behavioral plan. For a child attempting dietary changes, this may take the form of "I failed at it" or "I can't do this," when in fact the child might have been successful on most days. This faulty thinking pattern tends to arise from expectations of perfect adherence, which can be anticipated and defused by clinicians and/or parents. This may entail preparing children to expect "imperfect" adherence and providing them with alternative thinking patterns, such as, "I did great most of the time, which shows I can do this." A related faulty thinking pattern that clinicians may encounter is exaggerating the negative consequences of a single event. Clinicians and parents should reinforce the child's effort and focus on successes rather than failures.
Training in Patient-Centered Communication
Extensive training in communication skills of any kind is uncommon in pregraduate and postgraduate medical training. Therefore, it is often necessary for clinicians to obtain advanced training in counseling as part of their continuing medical education. Although autodidactic resources exist (eg, DVD- and Internet-based teaching products), clinicians are encouraged to obtain "hands-on" training that includes supervised clinical practice and real and/or simulated patient encounters. Such workshops are often available at regional and national medical and behavioral health conferences.
Framework for Practice-Based Interventions
Basis of Changes
Practice-based interventions recommended to prevent obesity in children are changes to be made at the system level in the health care providers' practice and are extrapolated from experience with the National Health Disparities Collaboratives on asthma, diabetes, and depression.258–262 There is indirect evidence from these collaboratives to suggest that the following practice changes may improve care to prevent obesity in children.
Recommended Changes
Recommended practice-level changes include staff development in assessing and documenting BMI, practice-level self-assessment regarding obtaining BMI data and counseling families on appropriate interventions, quality control/quality improvement processes to evaluate practice performance, and disease management strategies adopted from the chronic care model. The chronic care model includes recommendations for self-management support, decision support, delivery-system redesign, and clinical information systems. The final issue to be addressed is reimbursement for obesity prevention visits.
Staff Development Skills
The health care provider involves the practice staff members in addressing the problem of preventing obesity in children by delegating the accurate measurement and documentation of BMI to them and by training them to perform these tasks. The Centers for Disease Control and Prevention and the US Department of Health Resources and Services Administration have established guidelines for accurate measurement and provide teaching modules on accurate measurement and BMI calculation (available at www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/index.htm and www.mchb.hrsa.gov/mchirc/dataspeak). The practice needs to obtain a reliable scale for infants and older children; regular calibration of the equipment should be assigned to a staff member. Recumbent length boards should be used for all children 
2 years of age. Wall-mounted height stadiometers should be used to measure height for children >2 years of age. Staff members need to be trained and annually updated on accurate measurement techniques. Among physicians and nurse practitioners, staff development should include training for the motivational and behavioral counseling strategies described above.
Practice Self-assessment
The practice needs to establish a mechanism to evaluate its current procedures for assessing and addressing children at risk for overweight/obesity. A chart audit is suggested for evaluation of whether BMI is being measured, calculated, and documented on the growth charts. Children who meet the criteria for overweight or obesity should have growth documented on the problem list. The chart audit would reveal whether blood pressure, Tanner stage, and family history of overweight/obesity and cardiovascular risk factors are being documented on the charts. An initial chart audit can provide the practice staff with baseline data regarding the current status of the practice in addressing the needs of children at risk of overweight/obesity and can be used to evaluate the practice after changes are implemented. Self-assessment measures regarding initiation of motivational and behavioral counseling strategies may also be considered.
Quality Control/Quality Improvement
Indirect evidence from the quality improvement literature suggests that the use of the rapid-cycle improvement model results in improved processes of change to improve practice.263,264 The rapid-cycle improvement model, built on the work of Langley et al,265 suggests that the practice needs to have a specific aim that is measurable and then needs to develop a plan to make practice changes by using the plan-do-study-act model (including assessment, documentation, and addressing of children at risk of becoming overweight). The plan-do-study-act model starts with the plan; the practice plans for the changes that need to occur to improve the prevention of overweight in youths and plans the method of measuring whether those changes are occurring. Do refers to implementing the changes that have been created to improve care for youths at risk of becoming overweight. Study refers to collecting the data on the current status of the practice and assessing the changes over time. The data are reviewed by the practice to monitor its progress. Act refers to modifying or changing the plan if the goals have not been achieved or cannot be implemented as planned. The cycle is repeated until the goals have been met; at that point, the next step is to disseminate the successful changes throughout the practice and to other practices.
Disease Management With the Chronic Care Model
Components of the Model
We propose approaching the issue of prevention of overweight/obesity in children with the disease management techniques outlined in the chronic care model. The chronic care model is a synthesis of evidence-based system changes that organizations can use to guide quality improvement and disease management activities. The model includes practice changes to provide self-management support for patients and family members, decision support for providers, delivery-system redesigns to promote better care, and clinical information systems to provide data for evaluation of the progress the practice is making in meeting its goals. Indirect evidence from the National Health Disparities Collaboratives on asthma, diabetes, and depression suggests that improved patient outcomes result from use of the chronic care model.258,260–262
Self-management Support
Self-management support empowers and prepares patients to manage their health and health care. We propose collaborative goal-setting between the patient and family and the provider, development of an action plan with the patient and family, and provision of education to the patient and family that gives them the necessary tools to monitor changes and addresses lifestyle changes needed to improve weight status.
Decision Support
Decision support refers to education for providers and support staff members regarding the latest evidence on preventing overweight in youths, assessment and monitoring of weight in children, counseling in effective techniques for behavior change, and rapid-cycle improvement to monitor practice improvement strategies. Decision support promotes clinical care that is consistent with scientific evidence and patient preferences.
One strategy is to embed available evidence-based guidelines or best-practice recommendations into daily clinical practice. We suggest ongoing continuing education for providers that updates them on recent literature and future clinical practice guidelines to promote effective care of children at risk of overweight. Support staff members may need training in calculating and documenting BMI. Primary care providers may need training in tracking the child's BMI and discussing the findings with the child and family. Another aspect of decision support is the integration of specialty expertise with primary care. Providers need to establish referral criteria so that providers know when to send patients for specialist care.
Indirect evidence from the National Health Disparities Collaboratives on diabetes suggests that ongoing provider education using interactive education strategies with case studies improves providers' knowledge and management skills. Similarly, embedding the BMI into daily practice by including the information in the daily routine and encounter forms helps to achieve the practice changes necessary to improve care.
Delivery-System Redesign
Delivery-system redesign ensures the delivery of effective, efficient, clinical care and self-management support. Indirect evidence from the National Health Disparities Collaboratives on asthma, diabetes, and depression shows improved outcomes with changes in the delivery-system design, such as planned visits that include regular patient assessment, review of the action plan, and routine updating of self-management goals.258,260–262 Delivery-system redesign strategies that may be used to provide the care include group visits, case management, and the use of primary care teams.
Indirect evidence on the use of group visits259,266 suggests that it is a cost-effective and efficient way to deliver care. The group setting allows the provider to offer information to larger groups of individuals at one time and allows family members to interact with others who are facing the same challenges.
Indirect evidence also suggests the value of case management techniques.259,262 We suggest flagging charts to identify those who are at risk of overweight or are gaining weight at an accelerated rate, so that future providers can address the effects of weight gain on the child's health. Practice changes may be needed to provide ongoing support to clients in the at-risk category. The chronic care model also suggests that providers identify community resources and make referrals to specialists when appropriate.
Another aspect of practice redesign is implementation of primary care teams.261 These are interdisciplinary teams created within the practice that include physicians, nurses, dieticians, behavioral health clinicians, and support staff members who provide the education and create tools to give patients and family members the information needed to implement changes. Each member of the team has an assigned role and duties specific to that team role. The primary care team incorporates the patient action plan into the routine clinic flow sheets, to ensure that the provider addresses the plan at each visit.
Clinical Information Systems
Clinical information systems organize patient and population data to facilitate efficient effective care.258,260,261 Clinical information systems provide timely reminders and feedback for providers and patients. Patient registries can be developed to identify subpopulations for proactive care and to facilitate individual patient care planning.
The electronic medical chart is an effective tool that practice staff members have available to facilitate the identification of children at risk for overweight and to monitor practice changes in the identification and care of overweight children. Electronic medical charts are available to calculate BMI values and to graph them on the BMI growth charts.267 Some electronic medical charts can also provide "red flags" to providers regarding patients with BMI of >85th percentile or >95th percentile. Some electronic medical charts also generate appointment cards as reminders to patients. The use of electronic medical charts also facilitates the practice of self-monitoring and use of data to evaluate progress, as part of quality improvement.267
Reimbursement
A challenge to health care providers in delivering adequate care and support to children at risk of overweight/obesity is the issue of reimbursement for health care visits. Coding for care of children at risk for obesity and related comorbidities is straightforward. The Current Procedural Terminology and International Classification of Diseases, Ninth Edition, codes (Table 2) are available for reporting of the services provided for management of pediatric overweight. However, the American Academy of Pediatrics advises practitioners that obtaining appropriate reimbursement is more complicated.265 Many insurance carriers deny claims submitted with "obesity" codes. The American Academy of Pediatrics suggests that coding for obesity-related care is a 2-step process. The first step is to submit claims with appropriate codes (Table 2); the second step involves practice-level issues of denial management and contract negotiation. The American Academy of Pediatrics has developed a strategy and a template letter to be used by practices that are in negotiation regarding denial management (available at www.aap.org/moc/loadsecure.cfm/reimburse/denialtemplateltr.pdf). Diagnostic codes that may be appropriate for the initial and recurring assessments performed by the provider are presented in Table 3.
|
OPPORTUNITIES FOR OBESITY PREVENTION IN THE COMMUNITY AND ENVIRONMENT |
|---|
|
TOPABSTRACTEVIDENCEAPPROACHES TO OBESITY PREVENTIONOPPORTUNITIES FOR OBESITY...RECOMMENDATIONS FOR PREVENTION...APPENDIX: 15-MINUTE OBESITY...REFERENCES |
|---|
