Stephanie S. Filigno

Differences in Home Food and Activity Environments between Obese and Healthy Weight Families of Preschool Children

OBJECTIVE To develop and test a home food and activity instrument to discriminate between the home environments of obese and healthy weight preschool children. DESIGN A modified questionnaire about home environments was tested as an observation tool. SETTING Family homes. PARTICIPANTS A total of 35 obese children with at least 1 obese caregiver were compared with 47 healthy weight children with no obese caregivers. MAIN OUTCOME MEASURES Home observation assessments were conducted to evaluate the availability of devices supporting activity behaviors and foods based on availability, accessibility, and readiness to be eaten. ANALYSIS Agreement statistics were conducted to analyze psychometrics and MANOVAs were conducted to assess group differences, significance, P < .05. RESULTS Home observations showed acceptable agreement statistics between independent coders across food and activity items. Families of obese preschoolers were significantly less likely to have fresh vegetables available or accessible in the home, were more likely to have a television in the obese childs bedroom, and had fewer physical activity devices compared with healthy weight preschoolers. CONCLUSIONS AND IMPLICATIONS Families of young children live in home environments that were discriminatively characterized based on home observations. Future tool refinement will further clarify the impact of the home environment on early growth.

A Pilot Randomized Controlled Trial of a Behavioral Family-Based Intervention With and Without Home Visits to Decrease Obesity in Preschoolers

OBJECTIVE Tested two family-based behavioral treatments for obesity in preschool children, one meeting the Expert Committee guidelines for Stage 3 obesity intervention criteria (LAUNCH-clinic) and one exceeding Stage 3 (LAUNCH with home visit [LAUNCH-HV]), compared with a Stage 1 intervention, pediatrician counseling (PC). METHODS In all, 42 children aged 2-5 years with a body mass index (BMI) percentile of ≥95th were randomized. A total of 33 met intent-to-treat criteria. Assessments were conducted at baseline, Month 6 (posttreatment), and Month 12 (6-month follow-up).  RESULTS  LAUNCH-HV demonstrated a significantly greater decrease on the primary outcome of change in BMI z-score (BMIz) pre- to posttreatment compared with PC (p = .007), whereas LAUNCH-clinic was not significantly different from PC (p = .08). Similar results were found for secondary outcomes.  CONCLUSIONS  LAUNCH-HV, but not LAUNCH-clinic, significantly reduced BMIz compared with PC by posttreatment, indicating the need for intensive behavioral intervention, including home visitation, to address weight management in obese preschool children.

Behavioral and nutritional treatment for preschool-aged children with cystic fibrosis a randomized clinical trial

IMPORTANCE Evidence-based treatments that achieve optimal energy intake and improve growth in preschool-aged children with cystic fibrosis (CF) are a critical need. OBJECTIVE To test whether behavioral and nutritional treatment (intervention) was superior to an education and attention control treatment in increasing energy intake, weight z (WAZ) score, and height z (HAZ) score. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included 78 children aged 2 to 6 years (mean age, 3.8 years) with CF and pancreatic insufficiency (intervention, n = 36 and control, n = 42). The study was conducted at 7 CF centers between January 2006 and November 2012; all 78 participants who met intent-to-treat criteria completed through follow-up. INTERVENTIONS Behavioral intervention combined individualized nutritional counseling targeting increased energy intake and training in behavioral child management skills. The control arm provided education and served as a behavioral placebo controlling for attention and contact frequency. Both treatments were delivered in person or telehealth (via telephone). Sessions occurred weekly for 8 weeks then monthly for 4 months (6 months). Participants then returned to standard care for 1 year, with 12-month follow-up thereafter. MAIN OUTCOMES AND MEASURES Changes in energy intake and WAZ score were examined from pretreatment to posttreatment (6 months) and change in HAZ score was assessed pretreatment to follow-up (18 months). Covariates included sex, Pseudomonas aeruginosa status at baseline, and treatment modality (in person vs telehealth). RESULTS At baseline, mean (SD) energy intake was 1462 (329) kcals/d, WAZ score was -0.44 (0.81), and HAZ score was -0.55 (0.84). From pretreatment to posttreatment, the intervention increased daily energy intake by 485 calories vs 58 calories for the control group (adjusted difference, 431 calories; 95% CI, 282 to 581; P < .001) and increased the WAZ score by 0.12 units vs 0.06 for the control (adjusted difference, 0.09; 95% CI, -0.06 to 0.24; P = .25). From pretreatment to follow-up, the intervention increased the HAZ score by 0.09 units vs -0.02 for the control (adjusted difference, 0.14 units; 95% CI, 0.001 to 0.27; P = .049). Measured treatment integrity and credibility were high for both groups. CONCLUSIONS AND RELEVANCE Behavioral and nutritional intervention improved energy intake and HAZ score outcomes but not WAZ score outcomes. Our results provide evidence that behavioral and nutritional treatment may be efficacious as a nutritional intervention for preschoolers aged 2 to 6 years with CF and pancreatic insufficiency. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT00241969.

Examination of the association between lifestyle behavior changes and weight outcomes in preschoolers receiving treatment for obesity.

OBJECTIVE Preschoolers (ages 2-5 years) have been significantly underrepresented in the obesity treatment outcome literature, despite estimates that 12.1% are already obese. As such, little is known about the most important intervention targets for weight management within this age group. The aims of this study were (a) to examine lifestyle behavior changes for 30 obese preschoolers participating in a weight-control intervention and (b) to explore which lifestyle behavior changes predicted changes in body mass index (BMI) z score. METHOD Preschooler height, weight, diet (three 24-hr recalls), physical activity (accelerometry), and television use (parent report) were measured at baseline and posttreatment (6 months). A linear regression was conducted to examine pre- to posttreatment changes in diet (i.e., intake of calories, sugar-sweetened beverages, fruits and vegetables, and sweet and salty snacks) and activity (i.e., moderate-to-vigorous activity and television use) behaviors on changes in BMI z score. RESULTS Despite significant reductions in sugar-sweetened beverage intake and television use, and increases in fruit and vegetable intake, only reductions in absolute caloric intake significantly predicted reductions in BMI z score. CONCLUSION Our findings suggest that attaining healthy caloric goals may be the most important component of weight-control interventions for preschoolers. Future research using innovative methodologies, such as the Multiphase Optimization Strategy, may be helpful to prospectively identifying the lifestyle behavior changes that are most effective in helping families to achieve healthy weight outcomes for preschoolers and thereby improve intervention efficiency and decrease treatment burden for families.

The association between sleep duration and weight in treatment-seeking preschoolers with obesity.

OBJECTIVE To examine the association between nocturnal sleep duration and weight and caloric intake outcomes among preschool-aged children who are obese and enrolled in a family-based weight management program. METHODS Forty-one preschool-aged children who were obese (BMI ≥ 95th percentile) and enrolled in a weight management program completed pre- and posttreatment assessments of body mass, caloric intake, and sleep. Separate linear regression analyses examined the relationship between nocturnal sleep duration and posttreatment body mass index relative to age- and sex-linked norms (BMIz) and caloric intake. RESULTS After controlling for pretreatment BMIz, longer posttreatment nocturnal sleep was significantly associated with lower posttreatment BMIz (β=-0.21, p=0.02) and explained a significant proportion of unique variance in posttreatment BMIz (ΔR(2)=0.04). Similarly, after controlling for pretreatment caloric intake, longer nocturnal sleep duration at posttreatment was significantly associated with lower caloric intake at posttreatment (β=-0.45, p=0.003) and explained a significant proportion of unique variance in posttreatment caloric intake (ΔR(2)=0.19). CONCLUSIONS These findings extend the literature on the sleep and weight relationship and suggest that adequate sleep may be an important element in interventions for preschoolers with obesity.

Changes in Parent Motivation Predicts Changes in Body Mass Index z-Score (zBMI) and Dietary Intake Among Preschoolers Enrolled in a Family-Based Obesity Intervention

OBJECTIVES To examine whether changes in parent motivation over the course of a pediatric obesity intervention are significantly associated with long-term changes in treatment outcomes.  METHODS  Study hypotheses were tested with a secondary data analysis of a randomized controlled trial (N = 42). Study analyses tested whether baseline to posttreatment change in total score for a self-report parent motivation measure (Parent Motivation Inventory [PMI]) was significantly associated with baseline to 6-month follow-up changes in body mass index z-score (zBMI), dietary variables, and physical activity.  RESULTS  Increases in PMI were significantly associated with decreased zBMI, decreased consumption of sugar-sweetened beverages and sweets, and increased consumption of artificially sweetened beverages.  CONCLUSIONS  Given that increases in parent motivation were associated with some treatment benefits, future research should evaluate the impact of directly assessing and targeting parent motivation on weight outcomes for preschoolers participating in a weight management program.

Macronutrient intake in preschoolers with cystic fibrosis and the relationship between macronutrients and growth

BACKGROUND Adequate nutrition is essential for growth in children with cystic fibrosis (CF). The new CF Foundation Clinical Practice Guidelines bring attention to monitoring macronutrient intake as well as total energy. METHODS Dietary intake of 75 preschool children with CF and pancreatic insufficiency was examined and compared to the Clinical Practice Guidelines. Regression analyses examined relationships between macronutrient intake and growth. RESULTS Approximately 45% of children met the 110% minimum recommended dietary allowance (RDA) recommendation. Children consumed 35.3% (6.1) of total daily energy intake from fat, 12.7% (1.7) from protein, and 52.0% (6.1) from carbohydrates. Percent energy from protein was associated with height growth. CONCLUSIONS Many preschoolers with CF are not meeting nutrition benchmarks for total energy and fat. To optimize nutrition early, dietary monitoring with frequent individualized feedback is needed. Optimizing intake of macronutrients that promote growth, especially fat and protein, should be a primary clinical target.

Learning about Activity and Understanding Nutrition for Child Health (LAUNCH): Rationale, design, and implementation of a randomized clinical trial of a family-based pediatric weight management program for preschoolers

Obesity affects nearly 2 million preschool age children in the United States and is not abating. However, research on interventions for already obese preschoolers is limited. To address this significant gap in the literature, we developed an intervention targeting obesity reduction in 2 to 5year olds, Learning about Activity and Understanding Nutrition for Child Health (LAUNCH). This paper describes the rationale, design, participant enrollment, and implementation of a 3-arm randomized, parallel-group clinical trial comparing LAUNCH to a motivational-interviewing intervention (MI) and standard care (STC), respectively. Whereas LAUNCH was designed as a skills based intervention, MI focused on addressing the guardians motivation to make changes in diet and activity and providing tools to do so at the guardians level of readiness to implement changes. Child body mass index z-score was the primary outcome, assessed at pretreatment, posttreatment (Month 6), and 6 and 12month follow-ups (Months 12 and 18). Mechanisms of weight change (e.g., dietary intake, physical activity) and environmental factors associated with weight (e.g., foods available in the home, caregiver diet) were also assessed. This study is unique because it is one of the few randomized controlled trials to examine a developmentally informed, clinic and home skills based behavioral family intervention for preschoolers who are already obese. Being obese during the preschool years increases the likelihood of remaining obese as an adult and is associated with serious health conditions; if this intervention is successful, it has the potential to change the health trajectories for young children with obesity.

Quality of life in children with CF: Psychometrics and relations with stress and mealtime behaviors

The purpose of this study was to evaluate the utility of the Cystic Fibrosis Questionnaire‐Revised (CFQ‐R) with toddlers and preschool‐aged children. Clinically relevant relations between health‐related quality of life (HRQOL), stress, and mealtime behaviors have not been examined. It was hypothesized that problematic mealtime behaviors and increased stress would be negatively associated with HRQOL.

The Status of Billing and Reimbursement in Pediatric Obesity Treatment Programs

Pediatric psychologists provide behavioral health services to children and adolescents diagnosed with medical conditions. Billing and reimbursement have been problematic throughout the history of pediatric psychology, and pediatric obesity is no exception. The challenges and practices of pediatric psychologists working with obesity are not well understood. Health and behavior codes were developed as one potential solution to aid in the reimbursement of pediatric psychologists who treat the behavioral health needs of children with medical conditions. This commentary discusses the current state of billing and reimbursement in pediatric obesity treatment programs and presents themes that have emerged from discussions with colleagues. These themes include variability in billing practices from program to program, challenges with specific billing codes, variability in reimbursement from state to state and insurance plan to insurance plan, and a general lack of practitioner awareness of code issues or reimbursement rates. Implications and future directions are discussed in terms of research, training, and clinical service.