Susan J. Woolford

Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT

BACKGROUND AND OBJECTIVE: Few studies have tested the impact of motivational interviewing (MI) delivered by primary care providers on pediatric obesity. This study tested the efficacy of MI delivered by providers and registered dietitians (RDs) to parents of overweight children aged 2 through 8. METHODS: Forty-two practices from the Pediatric Research in Office Settings Network of the American Academy of Pediatrics were randomly assigned to 1 of 3 groups. Group 1 (usual care) measured BMI percentile at baseline and 1- and 2-year follow-up. Group 2 (provider only) delivered 4 MI counseling sessions to parents of the index child over 2 years. Group 3 (provider + RD) delivered 4 provider MI sessions plus 6 MI sessions from a RD. The primary outcome was child BMI percentile at 2-year follow up. RESULTS: At 2-year follow-up, the adjusted BMI percentile was 90.3, 88.1, and 87.1 for groups 1, 2, and 3, respectively. The group 3 mean was significantly (P = .02) lower than group 1. Mean changes from baseline in BMI percentile were 1.8, 3.8, and 4.9 across groups 1, 2, and 3. CONCLUSIONS: MI delivered by providers and RDs (group 3) resulted in statistically significant reductions in BMI percentile. Research is needed to determine the clinical significance and persistence of the BMI effects observed. How the intervention can be brought to scale (in particular, how to train physicians to use MI effectively and how best to train RDs and integrate them into primary care settings) also merits future research.

Incremental hospital charges associated with obesity as a secondary diagnosis in children

Objective: The objective was to evaluate the association of obesity as a comorbidity with hospital charges, by comparing charges for pediatric hospitalizations with vs. without obesity as a secondary diagnosis.

Study design and baseline description of the BMI 2 trial: reducing paediatric obesity in primary care practices

This study will test the efficacy of motivational interviewing (MI) conducted by primary care providers and dieticians among children ages 2‐8 years old with a body mass index (BMI) ≥85th and ≤97th percentile.

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.

Waist circumference percentile thresholds for identifying adolescents with insulin resistance in clinical practice

Abstract: We formally evaluated waist circumference (WC) percentile cutoffs for predicting insulin resistance (IR) and whether different cutoffs should be used for adolescents of different race/ethnicities. Analysis was performed for 1575 adolescents aged 12–18 yr from the National Health and Nutrition Examination Survey 1999–2002. Adolescents were classified as having IR if they had a homeostasis model assessment‐insulin resistance level, a validated measure of IR, of >4.39, and WC percentile was classified according to previously published universal (all races combined) and race/ethnicity‐specific WC percentile cutoffs. Receiver operating characteristic curves for predicting IR were constructed comparing the race/ethnicity‐specific vs. universal WC percentile cutoffs, and area under the curve (AUC) was calculated. Comparing universal with race/ethnicity‐specific WC percentiles, there were no significant differences in AUC for Black, Mexican‐American, or White adolescents. Because race/ethnicity‐specific thresholds did not discriminate better than universal WC thresholds, universal WC thresholds may be used effectively to identify adolescents with IR in primary care practices. A WC ≥75th or ≥90th percentile for all race/ethnicities combined would be appropriate to apply in clinical practice for identification of adolescents with IR, a risk factor for development of type 2 diabetes.

Sleep Duration Predicts Cardiometabolic Risk in Obese Adolescents

OBJECTIVE To examine the independent contributions of objectively measured sleep duration and fragmentation on cardiometabolic risk accumulation in free-living obese adolescents. STUDY DESIGN Characteristics of metabolic syndrome (waist circumference, mean arterial pressure, fasting high-density lipoprotein cholesterol, triglycerides, glucose) were measured in obese adolescents and standardized residuals (z-scores) were summed (inverse high-density lipoprotein cholesterol) to create a continuous cardiometabolic risk score (cMetScore), adjusted for age, sex, and race. Sleep and physical activity were objectively measured in habitual, free-living conditions for 7 days (SenseWear Pro3, BodyMedia, Pittsburgh, Pennsylvania; n = 37; 54% female, ages 11-17 years). Associations between sleep duration and cMetScore were assessed via multiple linear regression. RESULTS Body mass index, total sleep time, and sleep session length were each correlated with cMetScore (P < .05 all). Total sleep time was inversely and independently associated with cMetScore (r = -0.535, P = .001) and was the best independent predictor of metabolic risk. CONCLUSIONS Sleep duration inversely predicts cardiometabolic risk in obese adolescents, even when we controlled for various measures of physical activity, anthropometry, and adiposity. Further research should investigate the biological mechanism of this relationship and the potential treatment effect of sleep intervention in decreasing cardiometabolic risk in this population.

Results From a Clinical Multidisciplinary Weight Management Program

Background/Objective: Published data regarding outcomes of pediatric behavioral weight management are mainly from research interventions. The authors wished to explore outcomes from a clinical program. Methods: A retrospective analysis of data from obese adolescents enrolled in the Michigan Pediatric Outpatient Weight Evaluation and Reduction program (April 2007 to June 2008). The multidisciplinary program included group sessions, individual visits, and exercise classes. Linear regression was used to explore associations between change in body mass index (BMI) and age, sex, race, and insurance. Results: N = 67. Mean age was 14.5 years; 71% female, 50% Medicaid enrollees, and 30% African American. Mean initial BMI was 40. Mean change in BMI was -2.3 for those completing the 24-week program (n = 48; P < .01). Reduction in BMI was not associated with participants’ demographic characteristics. Conclusions: A clinical multidisciplinary weight loss program for adolescents can lead to decreases in BMI after 24 weeks. Further work is needed to assess long-term outcomes.

Persistent gap of incremental charges for obesity as a secondary diagnosis in common pediatric hospitalizations

OBJECTIVE To use hospitalization data from 2003 to determine whether prior findings, showing higher charges and longer lengths-of-stay (LOSs) for children with obesity versus those without, were stable over time and whether the magnitude of differences was consistent over a 4-year period. METHODS Using the 2000 and 2003 Agency for Healthcare Research and Quality (AHRQ) Kids Inpatient Database (KID), we examined discharges for the top 4 nonpregnancy-related principal discharge diagnoses for children aged 2-18 years (asthma, pneumonia, affective disorders, and appendicitis), classified as with or without obesity based on the presence of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 278.0x as a secondary diagnosis. We compared mean charges for hospitalizations with obesity listed as secondary diagnosis versus those without. Results are presented in 2003 dollars. RESULTS Among childrens discharges in 2000 and 2003, 1.1% and 1.6%, respectively, listed obesity as a secondary diagnosis. In 2003, for all 4 diagnoses, adjusted mean hospital charges were statistically significantly higher and adjusted mean LOS was statistically significantly longer for discharges with obesity as a secondary diagnosis versus those without. Additionally, the magnitude of the differences for both charges and LOS was generally somewhat greater in 2003 than in 2000 (asthma 9%, pneumonia 17%, affective disorders 121%, and appendicitis 3%) although it did not achieve statistical significance (P > 0.05). CONCLUSIONS These findings suggest a widening gap of incremental charges and LOS associated with obesity as a comorbidity. This implies a financial imperative for further research to evaluate factors that contribute to greater resource utilization among obese children.

Physicians' Perspectives on Increasing the Use of BMI Charts for Young Children

The objective of the study was to explore the barriers and facilitators to using body mass index (BMI) for preschoolers. A survey was administered to a random sample of 600 pediatricians and family physicians in Michigan addressing usual practice for BMI charting, barriers, perceived influence of BMI chart innovations on the likelihood of increasing use of BMI and participating in training regarding obesity management. The response rate was 52%. Few respondents report that they generally use BMI charts for preschoolers (24%). The most frequently endorsed barrier was time and complexity involved in explaining BMI (70%). Respondents endorsed innovations such as color-coded charts (60%), and the inclusion of management recommendations (61%) as strong influences on the likelihood of using BMI more often. Frequently endorsed training modalities were workshops (47%), online (45%), and DVD (43%). Efforts to increase physician use of BMI should address methods to simplify communication of BMI, such as with color-coded charts, and provision of management recommendations based on BMI findings.

A Picture May Be Worth a Thousand Texts: Obese Adolescents' Perspectives on a Modified Photovoice Activity To Aid Weight Loss

BACKGROUND In an effort to enhance the vividness and personal relevance of a text messaging intervention to promote weight loss among obese adolescents, a modified Photovoice process was evaluated with adolescents in a weight management program. METHODS Photovoice is a method using photography to generate relevant images and stories from users. Participants were recruited from the Michigan Pediatric Outpatient Weight Evaluation and Reduction (MPOWER) program, a multidisciplinary weight management program for obese adolescents and their parents. Twenty-three adolescents with a mean BMI of 40 were asked to take pictures on three to five randomly assigned weight-related topics, such as “something that reminds you to exercise,” and to text them to a research assistant. Adolescents then engaged in semistructured interviews about the experience. Detailed notes of the interviews were analyzed to identify themes. RESULTS Participants generally provided high ratings of the process, indicating that (1) deciding what pictures to take caused them to reflect on their weight loss experience, and (2) a mobile intervention incorporating personally relevant images (e.g., basketball as their favorite sport rather than sports in general) would increase treatment adherence. The submitted photographs frequently featured family members and friends, and participants indicated that family and friends played a major role in motivating and supporting them. CONCLUSIONS This study suggests that a Photovoice component has the potential to enhance weight management programs for teens as part of a text messaging intervention and as an independent entity. Further work should evaluate the effect of this promising intervention on weight loss.