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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