Sarah Hampl

Patient Engagement and Attrition in Pediatric Obesity Clinics and Programs: Results and Recommendations

Pediatric tertiary care institutions are well positioned to provide multidisciplinary, intensive interventions for pediatric obesity known as stage 3 treatment. One contributor to the difficulty in administering this treatment is the high rate of patient attrition. Little is known about the practices used by pediatric weight-management clinics and group-based programs to minimize attrition. Hospital members and nonmembers of FOCUS on a Fitter Future were surveyed on the methods used to engage and retain obese children in their clinics and programs. Shortly thereafter, a benchmarking activity that centered on rates of patient nonattendance at initial and follow-up clinic visits was initiated among FOCUS-group-participating hospitals. Clinic- and group-based program results were contrasted. Staff from group-based programs reported that the majority of patients did not complete even 50% of program follow-up visits. Multiple patient/family- and clinic/program-level barriers to retention were identified. Attention to successful techniques should be paid during planning for new programs and improvement of established ones.

Parent Perspectives on Attrition From Tertiary Care Pediatric Weight Management Programs

Objective. To describe parent/caregiver reasons for attrition from tertiary care weight management clinics/programs. Study design. A telephone survey was administered to 147 parents from weight management clinics/programs in the National Association of Children’s Hospitals and Related Institutions’ (now Children’s Hospital Association’s) FOCUS on a Fitter Future II collaborative. Results. Scheduling, barriers to recommendation implementation, and transportation issues were endorsed by more than half of parents as having a moderate to high influence on their decision not to return. Family motivation and mismatched expectations between families and clinic/program staff were mentioned as influential by more than one-third. Only mismatched expectations correlated with patient demographics and referral patterns. Conclusions. Although limited by small sample size, the study found that parents who left geographically diverse weight management clinics/programs reported similar reasons for attrition. Future efforts should include offering alternative visit times, more treatment options, and financial and transportation assistance and exploring family expectations.

Children's Hospital Association consensus statements for comorbidities of childhood obesity.

BACKGROUND Childhood obesity and overweight affect approximately 30% of US children. Many of these children have obesity-related comorbidities, such as hypertension, dyslipidemia, fatty liver disease, diabetes, polycystic ovary syndrome (PCOS), sleep apnea, psychosocial problems, and others. These children need routine screening and, in many cases, treatment for these conditions. However, because primary care pediatric providers (PCPs) often are underequipped to deal with these comorbidities, they frequently refer these patients to subspecialists. However, as a result of the US pediatric subspecialist shortage and considering that 12.5 million children are obese, access to care by subspecialists is limited. The aim of this article is to provide accessible, user-friendly clinical consensus statements to facilitate the screening, interpretation of results, and early treatment for some of the most common childhood obesity comorbidities. METHODS Members of the Childrens Hospital Association (formerly NACHRI) FOCUS on a Fitter Future II (FFFII), a collaboration of 25 US pediatric obesity centers, used a combination of the best available evidence and collective clinical experience to develop consensus statements for pediatric obesity-related comorbidities. FFFII also surveyed the participating pediatric obesity centers regarding their current practices. RESULTS The work group developed consensus statements for use in the evaluation and treatment of lipids, liver enzymes, and blood pressure abnormalities and PCOS in the child with overweight and obesity. The results of the FFFII survey illustrated the variability in the approach for initial evaluation and treatment as well as pattern of referrals to subspecialists among programs. CONCLUSIONS The consensus statements presented in this article can be a useful tool for PCPs in the management and overall care of children with overweight and obesity.

Parents and pediatric weight management attrition: Experiences and recommendations

BACKGROUND One of the most frequently cited challenges faced by pediatric weight management programs/clinics is attrition, with many studies reporting rates greater than 50%. Few studies have evaluated parental perspectives on recommendations for weight-management treatment enhancement. The aim of this study was to elicit perspectives on areas for improvement, discussions with staff about discontinuation, and potentially modifiable aspects of attrition from parents who prematurely discontinued stage 3 pediatric weight management treatment. METHODS This study was performed as a semistructured interview as part of a telephone survey assessing reasons for attrition. RESULTS Interviews were performed with 147 parents of children who attended programs/clinics at 13 childrens hospitals participating in the National Association of Childrens Hospitals and Related Institutions (now Childrens Hospital Association) FOCUS on a Fitter Future II collaborative. The majority of parents (65%) denied talking to staff about their decisions to stop coming. When describing what could have been done to retain families, parents most frequently discussed changing logistics (e.g., hours and locations). Parents described changes in logistics and components (i.e., nutrition education, exercise, and behavior education/support) when asked what would work best for their family for pediatric weight management. CONCLUSIONS Parental responses appeared to express frustration about flexibility with appointment times and treatment locations. The most frequently desired components were those traditionally offered by stage 3 pediatric weight management programs/clinics, and this may suggest a need for treatment delivery of these components to be more individualized. Additional discussion with families about their desire to discontinue treatment may provide a timely opportunity to address this need.

Physical Examination Findings Among Children and Adolescents With Obesity: An Evidence-Based Review.

Overweight and obesity affects 1 in 3 US children and adolescents. Clinical recommendations have largely focused on screening guidelines and counseling strategies. However, the physical examination of the child or adolescent with obesity can provide the clinician with additional information to guide management decisions. This expert-based review focuses on physical examination findings specific to children and adolescents with obesity. For each physical examination element, the authors define the finding and its prevalence among pediatric patients with obesity, discuss the importance and relevance of the finding, describe known techniques to assess severity, and review evidence regarding the need for additional evaluation. The recommendations presented represent a comprehensive review of current evidence as well as expert opinion. The goal of this review is to highlight the importance of conducting a targeted physical examination during pediatric weight management visits.

Childhood Obesity: Survey of Physician Assessment and Treatment Practices

BACKGROUND This study examined physician experience with the 2007 Expert Committee Recommendations (ECR) on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity. METHODS Pediatricians and family physicians (n = 194) practicing in the Midwest completed a survey designed to assess knowledge of, adherence to, and self-efficacy in implementing the 2007 Expert Committee recommendations. RESULTS The majority of physicians (71%) were aware of the ECR and adhered to approximately 60% of the recommendations. Adherence was significantly higher for physicians who were aware of the ECR. Differences in awareness of and adherence to the ECR were noted among physician groups by specialty and location. Self-efficacy for assessing and treating pediatric obesity was significantly positively correlated with adherence to the ECR (Pearson r = 0.46). When asked for strategies that would facilitate improved pediatric weight management, physicians most often reported desiring to learn effective methods to increase patient motivation. CONCLUSIONS Efforts to improve adherence to the Expert Committee recommendations should focus on improving physician awareness of and training in the use of the recommendations and on improved training and development of self-efficacy in pediatric weight assessment and patient counseling skills.

Making the Business Case for Coverage of Family-Based Behavioral Group Interventions for Pediatric Obesity.

BACKGROUND Pediatric obesity presents a significant burden. However, family-based behavioral group (FBBG) obesity interventions are largely uncovered by our health care system. The present study uses Return on Investment (ROI) and Internal Rate of Return (IRR) analyses to analyze the business side of FBBG interventions. METHODS ROI and IRR were calculated to determine longitudinal cost-effectiveness of a FBBG intervention. Multiple simulations of cost savings are projected using three estimated trajectories of weight change and variations in assumptions. RESULTS The baseline model of child savings gives an average IRR of 0.2% ± 0.08% and an average ROI of 20.8% ± 0.4%, which represents a break-even IRR and a positive ROI. More pessimistic simulations result in negative IRR values. CONCLUSIONS Under certain assumptions, FBBGs offer a break-even proposition. Results are limited by lack of data regarding several assumptions, and future research should evaluate changes in cost savings following changes in child and adult weight.

Adherence With Multiple National Healthy Lifestyle Recommendations in a Large Pediatric Center Electronic Health Record and Reduced Risk of Obesity

Objective: To evaluate the utility of a routine assessment of lifestyle behaviors incorporated into the electronic health record (EHR) to quantify lifestyle practices and obesity risk at a pediatric primary care center. Patients and Methods: Participants included 24,255 patients aged 2 to 18 years whose parent/caregiver completed a self‐report lifestyle assessment during a well‐child examination (January 1, 2013, through June 30, 2016). Cross‐sectional analyses of age, race/ethnicity, body mass index, and lifestyle assessment responses were performed. Outcome measures included prevalence of patients meeting consensus recommendations for physical activity; screen time; and dairy, water, and fruit/vegetable consumption and the odds of obesity based on reported lifestyle behaviors. Results: Prevalence of meeting recommendations for lifestyle behaviors was highest for physical activity (84%), followed by screen time (61%) and consumption of water (51%), dairy (27%), and fruits/vegetables (10%). Insufficient physical activity was the strongest predictor of obesity (odds ratio [OR], 1.65; 95% CI, 1.51‐1.79), followed by excess screen time (OR, 1.36; 95% CI, 1.27‐1.45). Disparities existed across ages, races/ethnicities, and sexes for multiple lifestyle habits. Youth who met 0 or 1 lifestyle recommendation were 1.45 to 1.71 times more likely to have obesity than those meeting all 5 recommendations. Conclusion: Healthy behaviors vary in prevalence, as does their association with obesity. This variation is partially explained by age, sex, and race/ethnicity. Meeting national recommendations for specific behaviors is negatively associated with obesity in a dose‐dependent manner. These findings support the assessment of lifestyle behaviors in primary care as one component of multilevel initiatives to prevent childhood obesity.

Factor Structure of a Spanish Translation of an Obesity-Specific Parent-Report Measure of Health-Related Quality of Life.

Objective Latino youth are disproportionately affected by pediatric obesity and consequently experience impaired health-related quality of life (HRQOL). Although many caregivers of Latino youth do not speak English fluently, no validated Spanish translations of obesity-specific HRQOL measures exist for this population. Therefore, non-English-speaking Latino parents have typically been excluded from analyses related to HRQOL. This study assesses the factor structure of a Spanish translation of a parent-report measure of obesity-specific HRQOL, Sizing Them Up, in a treatment-seeking sample of children with obesity. Methods Structural equation modeling was used to assess the factor structure of the 6-subscale, 22-item Sizing Them Up measure in 154 parents of treatment-seeking Latino youth (5-18 years of age). Analyses exploring internal consistency and convergent validity were also conducted. Results Acceptable measurement fit was achieved for the six-factor solution. However, the higher-order model assessing Total HRQOL did not reach acceptable levels, as results found that the Positive Social Attributes (PSA) subscale was not representative of Total HRQOL; internal consistency and convergent validity results also supported this finding. Conclusions The current study provides support for the utility of a modified version of Sizing Them Up, excluding the PSA Scale, as a parent-report measure of obesity-specific HRQOL in treatment-seeking Latino youth with obesity.

Caregiver hope and child outcomes following pediatric weight management programs

ABSTRACT The current study examined whether caregiver hope was related to child outcomes (change in weight or health behaviors, treatment sessions attended) and caregiver outcomes (weight change, willingness to make behavioral changes) in a culturally diverse sample of 202 youth with overweight and obesity and their families participating in one of three weight management programs for children 2–18 years old. Within this treatment-seeking sample, dispositional caregiver hope did not predict willingness to make behavioral changes, number of treatment sessions attended, or treatment outcomes. These findings suggest specific efforts to foster caregiver hope within such interventions may not improve outcomes and investigation of other, potentially more modifiable caregiver and child factors may be more beneficial.