Intervention in Primary Care for Obese Children (Text Version)

On September 28, 2010, Ellen Wald made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (835 KB). 

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Slide 1

Intervention in Primary Care for Obese Children

Ellen R. Wald, MD

UWHealth
American Family Children's Hospital

University of Wisconsin
School of Medicine and Public Health

Conflict of Interest: I have no relationships to declare. I do not intend to reference unlabeled/unapproved uses of drugs or products.

Slide 2

Background

• 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.

Slide 3

Background

• 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.

Slide 4

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.

Slide 5

Eligibility

Study Participants:

Children were:

• 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.

Slide 6

Exclusions

• Severe medical condition such as pseudotumor cerebri, sleep apnea, etc.
• Cognitive impairments-prohibiting participation.

Slide 7

Entry to Program:

• Directly referred from primary care provider (PCP).
• Review of electronic medical record (EMR)—informational letter from PCP inviting them to call the study coordinator.

Slide 8

Recruitment

• 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".

Slide 9

Recruitment

• 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.

Slide 10

Intervention

• 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.

Slide 11

Intervention

• 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.

Slide 12

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.

Slide 13

Stoplight Diet*

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

Slide 14

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.

Slide 15

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.

Slide 16

Statistical Analysis

• Intervention vs control at 15 weeks.
• Intervention pre- and post-baseline, 15 weeks, 12 months, and 24 months:
  • Intention to treat.
  • Per protocol.

Slide 17

Flow Diagram

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).

Slide 18

Flow Diagram

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).

Slide 19

Child Characteristics

Characteristics	Intervention	Control
Number	78	23
Age (years)	10.7	10.3
% Female	64	61
% Caucasian	68	83
% Any college	87	83

Slide 20

Outcome at 15 Weeks (P=0.18): Intention to Treat Analysis for BMI-z Score

	Intervention N=78	Control N=23
Baseline	2.03 (0.21)	2.07 (0.22)
15 weeks	1.93 (0.29)	2.04 (0.24)

Slide 21

Outcome at 15 Weeks (P=0.006): Per protocol analysis for BMI-z score

	Intervention N=55	Control N=23
Baseline	1.99 (0.20)	2.07 (0.22)
15 weeks	1.85 (0.28)	2.04 (0.24)

Slide 22

Weight Change from Baseline to 15 Weeks

Analysis Group	Weight Change (lbs)
Intention-to-treat	-0.4 ± 5.64
Per protocol	-2.4 ± 5.24
Control	+3.5 ± 4.31

Slide 23

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.

Slide 24

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.

Slide 25

Intent-to-Treat Analysis

Image: Two line graphs compare the intervention and control groups according to intent-to-treat analysis and per-protocol analysis for 24 months.

Slide 26

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.

Slide 27

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.

Slide 28

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.

Slide 29

Addressing Child Nutrition and Physical Activity in the Primary Care Setting 2

Principal Investigator:	Ellen R. Wald, M.D.
Co-Investigators:	Linda J. Ewing, Ph.D., RN
Project Coordinator:	Stacey Moyer, RN
Research Staff:	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