Childhood Obesity Risks and Parental Motivations to Make

Changes

The Promoting Healthy Families Project

Ardis L.Olson MD, Cecelia Gaffney MEd, Pam Lee PhD, Pam Starr MS

Clinicians Enhancing Child Health (CECH) practice based research network

Depts. of Pediatrics, & Community and Family Medicine, Dartmouth Medical School, Lebanon, NH

Supported by NICHD funding

Background

• Childhood Obesity has been identified as a major public health problem where we are making little progress.

• During childhood the primary care office is the only setting that accesses both parent and child over time.

• Pediatric clinicians are urged to counsel to prevent and treat obesity but feel ineffective and frustrated.

• Restructuring the well visit is needed to discuss specific obesity risks while still addressing other topics.

Promoting Healthy Families Study DesignPromoting Healthy Families Study Design

Healthy Families Project • 4 community practices in rural New Hampshire with Pediatric and

Family Medicine health providers (population 2,000 to 15,000)

• 1585 parents at well visits of their children ages 4 to 10 years have completed pre-visit screening utilizing a hand held computer (PDA)

• Clinicians training to use brief motivational interviewing techniques and provided via the PDA:

1) child’s BMI and BMI Percentile

2) obesity related health risks,

3) each parent’s motivation to change for nutrition and activity,

4) counseling prompts for motivational interviewing

• Enrollment of parents of children with obesity risks and BMI >85% is completed and now collecting follow up data on the cohort at 6 months after enrollment

What Clinician knows at start the visit using the PDA

• If BMI % for age is 85% - 94% or ≥ 95% • Health behavior risks (Nutrition, Activity, Family risk) • Any issues about development/behavior/school/safety • Social and parental depression risks • Readiness to change eating/physical activity • Parent view of importance to change for both physical activity and nutrition (1-10) • Parent view of confidence to change for both physical activity and nutrition (1-10)

PDA Screener Format

•

Changes in the Visit with the PDA• Parental data routinely gathered for major areas of well child visit are determined before the start of the visit for clinician review

• More obesity risk factors assessed than routine visitsClinician can expand on topicsCan support good choices

• Prepares parent for discussionConcerns re common topicsClear than eating and activity important to clinicianReadiness to make change for child’s eating and activity

• Efficient use of visit timeCompleted in 3-4 minutesChildren often have hearing/vision screening in this age group and can complete then.

Clinician Counseling cues if ready to change

Risk Present Normal Weight

At Risk Weight (BMI 85-94%)

Overweight (BMI>95%)

Chi Sq P value

On a typical weekday < 3 Servings vegetables 76% 73% 77% ns < 2 Servings fruit 22% 23% 30% <.05 < 1 Glass of water 4% 3% 3% ns Daily sweet/salty snack 90% 90% 90% ns > 1 Soda/sweet/juice drinks 32% 41% 38% <.05 During a typical week < 2 Family dinners 3% 5% 9% <.01 > 1 Fast food meals 13% 12 % 18% <.05

Take Home Message: Overall 98% of all children have one or more daily nutrition risks.

Nutrition risks by weight category

•

Risk Present Normal Weight

At Risk Weight (BMI 85-94%)

Overweight (BMI>95%)

Chi Sq P value

On a typical weekday >1hour TV/DVD/video time 47% 56% 64% <.001 >1hour video games/computer time 16% 14% 26% <.001 < 1 hour active play 18% 21% 29% <.001

Take Home Message: 65% of all children have at least one physical activity risk behavior every day.

Physical activity risks by weight category

•

The Ingredients of Readiness to Change

Importance (Why should I change?)

Confidence

Readiness

(Can I do it?)

Rollnick, Mason, & Butler, 2003

•

Normal

Weight N=1045

At Risk Weight (BMI 85-94%) N=260

Overweight (BMI>95%) N=278

Chi Sq P value

>1 Nutrition risks

98% 98% 99% ns

Among families where at least one nutrition risk is present( n=1585) % Interested in making changes now for child to eat healthier

36% 44% 55% <.001

Among parents interested in making a change now for their child to eat healthier (n= 634) % Who considered nutrition change important (7-10)

52% 52% 79% <.001

% With high confidence(7-10) in making nutrition change

48% 57% 43% ns

Parental interest and confidence to make nutrition changes

Normal Weight N=1045

At Risk Weight (BMI 85-94%) N=260

Overweight (BMI>95%) N=278

Chi Sq P value

1 or more Activity risks

61% 70% 78% <.001

Among families where at least one physical activity risk is present( n=1032) % Interested in making changes now for child to be more active

36% 21% 43% <.001

Among parents interested in making changes for child to be more active now (n= 269) % Who considered PA change important (7-10)

62% 50% 63% ns

% With high confidence (7-10) in making PA Change

62% 55% 45% ns (.059)

Parental interest and confidence to change their child’s physical activity

•

1010

ImportanceImportance

ConfidenceConfidence

1010

00

High

HighHighLowLow

Success

Importance and Confidence Reflect Commitment to Change

Frustrated

SkepticalUnaware or Cynical

Moving: helping

If interested in making a change,Who is ready to take action?

•

High Importance Low Confidence

44% (n=66)

High Importance High Confidence

35% (n=52)

Low Importance Low Confidence

13% (n=19)

Low Importance High Confidence

8% (n=12)

High Importance Low Confidence 32% (n=37)

High Importance High Confidence 32% (n=37)

Low Importance Low Confidence 23% (n=27)

Low Importance High Confidence 14% (n=16)

Nutrition

PhysicalActivity

Confidence

Importance

Importance

Children with BMI > 95%

Parental concerns by child weight category

NoNormal

Wweight At Risk Weight (BMI 85-94%)

Overweight (BMI>95%)

Chi Sq P value

Average # of concerns (0-9 total concerns possible)

0.63 0.72 1.11 <.001

High concern level ( defined as 2-4 total concerns)

16% 18% 31% <.001

Specific concerns* Growth or Weight 8% 15% 38% <.001 Behavior or Mood 15% 17% 23% <.01 Constipation/Diarrhea 4% 5% 7% <.05 *Concerns about relationship with friends, bedwetting/toileting, sleep, school/preschool progress, language/speech, and neighborhood safety were not significantly different by weight.

•

Implications for clinical care

Parental stage of motivation varies and needs to be addressed to more effectively engage parents in making family changes in nutrition and activity

Few clinicians have received training in brief motivational interviewing approaches

The common approach of giving information and handouts not likely to be effective for families who consider issue of low importance or lack confidence

•

Implications for clinical care Challenges: Multiple specific nutrition and activity risk factors need to addressed during obesity related counseling in all well visits

Limited time in well visits and more concerns of parents of obese children are more likely to have other concerns as well

Low cost technology assists by:

Visit changed from majority of time on data gathering to discussion of issues

Allow clinician to prioritize issues and plan counseling approach and understand which families may need another visit

Parents have been prepared to discuss these issues

Knowing if other psychosocial and developmental issues are playing a role

•

Conclusions

• Obesity risk factors are very common in children and primary care interventions are needed for both normal weight and overweight children

• Parental interest in taking action, as well as motivational factors, vary by weight status and differ for nutrition and activity

• New approaches that use low cost technology to efficiently gather data are feasible in busy primary care settings

• This is a major clinical and public health problem that is important for practice based research networks to study creative, practical approaches