pediatric collections
Stigma Experienced by
Children and Adolescents
With Obesity
Prevalence of Obesity
and Severe Obesity in US
Children, 1999–2016
Th e Role of the
Pediatrician in Primary
Prevention of Obesity
Cost-Effectiveness of
a Clinical Childhood
Obesity Intervention
FEATURES
Obesity: Stigma, Trends, and Interventions
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APC008
ISBN: 978-1-61002-182-1
iObesity: Stigma, Trends, and Interventions
1 Introduction
Stigma
2 ‘Words Can Heal or Do Harm’: Policy Addresses Ways to Reduce Weight Stigma
AAP News • Original Publication • November-20-2017
4 Stigma Experienced by Children and Adolescents With Obesity
From the American Academy of Pediatrics • Original Publication •
December-1-2017
15 Th e Role of Children’s Movies Weighs Heavily in the Tackling and Fumbling of Obesogenic Issues
Journals Blog • Original Publication • November-23-2017
16 Obesogenic Behavior and Weight-Based Stigma in Popular Children’s Movies, 2012 to 2015
Article • Original Publication • December-1-2017
Trends/Characteristics
24 Study: Public Health Efforts Fail to Make Dent in Childhood Obesity
AAP News • Original Publication • February-26-2018
TABLE OF CONTENTS
go.aap.org/connect
About AAP Pediatric CollectionsPediatric Collections is a series of selected
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pediatric collectionsObesity: Stigma, Trends, and Interventions
AAP PEDIATRIC COLLECTIONSii
TABLE OF CONTENTS
26 Weighing in on Obesity Trends in US Children: Th e News Is Not Good
Journals Blog • Original Publication • February-28-2018
27 Epidemic Childhood Obesity: Not Yet the End of the Beginning
Commentary • Original Publication • February-1-2018
29 Prevalence of Obesity and Severe Obesity in US Children, 1999–2016
Article • Original Publication • March-1-2018
49 Young Children With Severe Obesity: Who Are Th ey and What Might We Do Differently to Help Th em
Journals Blog • Original Publication • March-1-2018
50 Characteristics of Children 2 to 5 Years of Age With Severe Obesity
Article • Original Publication • March-1-2018
58 Racial and Ethnic Disparities in Early Childhood Obesity
Article • Original Publication • January-1-2018
Intervention/Prevention
73 Th e Role of the Pediatrician in Primary Prevention of Obesity
From the American Academy of Pediatrics • Original Publication • July-1-2015
91 How to Prevent Obesity Without Encouraging Eating Disorders
AAP News • Original Publication • August-22-2016
93 Preventing Obesity and Eating Disorders in Adolescents
From the American Academy of Pediatrics • Original Publication • August-1-2016
103 An Integrated Clinic-Community Partnership for Child Obesity Treatment: A Randomized Pilot Trial
Article • Original Publication • January-1-2018
iiiObesity: Stigma, Trends, and Interventions
117 A Home Visiting Parenting Program and Child Obesity: A Randomized Trial
Article • Original Publication • February-1-2018
127 A Tailored Family-Based Obesity Intervention: A Randomized Trial
Article • Original Publication • August-1-2015
136 Cost-Effectiveness of a Clinical Childhood Obesity Intervention
Article • Original Publication • November-1-2017
TABLE OF CONTENTS
1 Obesity: Stigma, Trends, and Interventions
Obesity is one of the defi ning health challenges of our generation. Studies project that, if current
trends continue, more than 50% of the US population will have obesity within the next 20 years.
Alarmingly, severe obesity appears to be increasing in prevalence faster than overweight or “routine”
obesity. Illness associated with obesity, such as diabetes, cardiovascular disease, steatohepatitis,
and sleep apnea, is experiencing a commensurate increase in prevalence and severity. The obesity
health crisis threatens to overwhelm our health care system, shorten life expectancy for the fi rst time
in recorded history, and reduce quality of life for millions. The most successful and cost-effective
approaches to this epidemic involve the prevention and treatment of pediatric obesity. Additionally,
obesity is affected by a myriad of factors, including individual genetics, personal behaviors, family
habits, school and community programs, state and federal policy, and environmental factors.
The American Academy of Pediatrics (AAP) and the AAP Section on Obesity approach obesity by
suggesting policies to prevent and treat obesity. Additionally, they provide support to pediatric obesity
specialists, pediatricians who serve as practice and community leaders in the fi ght against pediatric
obesity, and general pediatricians who encounter patients with overweight, obesity, and severe
obesity.
The AAP Section on Obesity is grateful to the AAP for compiling this collection on obesity topics
that cover policies and principles that seek to reduce obesity and its impact on our nation’s health.
Obesity is one of the most complicated disease processes pediatricians deal with. It is a disease
that is brought about by a myriad of causes and a disease that affects nearly every organ system in
the body. This collection will give you easy access to topics that help you manage this challenging
disease.
Introduction
—Christopher F. Bolling, MD, FAAP, ChairpersonAAP Section on Obesity
2 AAP PEDIATRIC COLLECTIONS
:: November-20-2017
‘Words Can Heal or Do Harm’: Policy Addresses Ways to Reduce Weight Stigma Stephen J. Pont, MD, MPH, FAAP and Rebecca Puhl, PhD
“Fat Bias Starts Early and Takes a Serious Toll” (New York Times, Aug. 21, 2017)
“High School Senior Bullied for Her Weight Commits Suicide” (US Weekly,
Dec. 2, 2016)
“Fat Shaming Can Lead to a Host of Health Problems” (CBS News, Jan. 31, 2017)
“Obesity, Bias and Stigma in the Doctor’s Offi ce” (Huffi ngton Post, Nov. 2, 2016)
Obesity is highlighted frequently in news media, but headlines increasingly are
focusing on the societal stigma that many people face because of their weight. The
phenomenon of weight stigma is real and has been documented by decades of
research.
Unfortunately, this stigma extends to children and adolescents. Body weight
has become one of the most common reasons that youths are teased, bullied and
victimized. The harm these experiences cause for children’s health provides an
important opportunity for pediatric health professionals to help address this problem.
The new AAP policy statement Stigma Experienced by Children and Adolescents
With Obesity addresses a timely but often neglected issue affecting the quality of life of
children with obesity. The statement, from the AAP Section on Obesity and The Obesity
Society, is available at https://doi.org/10.1542/peds.2017-3034 and will be published in
the December issue of Pediatrics.
Weight stigma often is propagated and tolerated in society because of beliefs that
stigma and shame will motivate people to lose weight. However, rather than motivate
positive change, this stigma contributes to behaviors such as binge eating, social
isolation, avoidance of health care services, decreased physical activity and increased
weight gain, which worsen obesity and create additional barriers to healthy behavior
change.
Furthermore, experiences of weight stigma also dramatically impair quality of life,
especially for youths who are vulnerable to weight-based bullying and victimization.
Health care professionals continue to seek effective strategies and resources to
prevent and treat obesity; however, they also frequently exhibit weight bias and
stigmatizing behaviors.
Dr. Pont, a lead author of the policy, is past chair of the AAP Section on Obesity Executive Committee.
Dr. Puhl, also a lead author, is a fellow of Th e Obesity Society.
AAP PEDIATRIC COLLECTIONS4
Stigma Experienced by Children and Adolescents With ObesityStephen J. Pont, MD, MPH, FAAP, a, b Rebecca Puhl, PhD, FTOS, c Stephen R. Cook, MD, MPH, FAAP, FTOS, d Wendelin Slusser, MD, MS, FAAP, e SECTION ON OBESITY, THE OBESITY SOCIETY
The stigmatization of people with obesity is widespread and causes harm.
Weight stigma is often propagated and tolerated in society because
of beliefs that stigma and shame will motivate people to lose weight.
However, rather than motivating positive change, this stigma contributes
to behaviors such as binge eating, social isolation, avoidance of health care
services, decreased physical activity, and increased weight gain, which
worsen obesity and create additional barriers to healthy behavior change.
Furthermore, experiences of weight stigma also dramatically impair quality
of life, especially for youth. Health care professionals continue to seek
effective strategies and resources to address the obesity epidemic; however,
they also frequently exhibit weight bias and stigmatizing behaviors. This
policy statement seeks to raise awareness regarding the prevalence and
negative effects of weight stigma on pediatric patients and their families
and provides 6 clinical practice and 4 advocacy recommendations regarding
the role of pediatricians in addressing weight stigma. In summary, these
recommendations include improving the clinical setting by modeling best
practices for nonbiased behaviors and language; using empathetic and
empowering counseling techniques, such as motivational interviewing, and
addressing weight stigma and bullying in the clinic visit; advocating for
inclusion of training and education about weight stigma in medical schools,
residency programs, and continuing medical education programs; and
empowering families to be advocates to address weight stigma in the home
environment and school setting.
abstract
More children in the United States suffer from obesity than from any
other chronic condition, with one-third of US children and youth having
overweight or obesity and 17% of children 2 to 19 years of age having
obesity.1 In some pediatric populations, such as children living in
economically challenged communities, as many as two-thirds of children
have overweight or obesity.2 Although some promising signs suggest the
prevalence of obesity may be stabilizing, rates remain unacceptably high,
To cite: Pont SJ, Puhl R, Cook SR, et al, AAP SECTION ON
OBESITY, THE OBESITY SOCIETY. Stigma Experienced by Chil-
dren and Adolescents With Obesity. Pediatrics. 2017;140(6):
e20173034
aTexas Center for the Prevention and Treatment of Childhood Obesity, Dell Children’s Medical Center of Central Texas, Ascension, Austin, Texas; bDepartment of Pediatrics, Dell Medical School; Center for Health Communication, Moody College of Communication; Department of Nutritional Sciences; University of Texas at Austin, Austin Texas; cRudd Center for Food Policy and Obesity and Department of Human Development and Family Studies, University of Connecticut, Storrs, Connecticut; dDepartment of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York; and eJane and Terry Semel Healthy Campus Initiative, David Geffen School of Medicine and Jonathan and Karin Fielding School of Public Health, University of Los Angeles, Los Angeles, California
Dr Pont conceptualized the report; Drs Pont and Puhl led the writing of the manuscript; Drs Cook and Slusser served as contributing authors; and all authors contributed to drafts and revisions and approved the final manuscript.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Organizational Principles to Guide and Define the Child Health Care System
and/or Improve the Health of all ChildrenPOLICY STATEMENT
15 AAP PEDIATRIC COLLECTIONS
:: November-23-2017
Th e Role of Children’s Movies Weighs Heavily in the Tackling and Fumbling of Obesogenic IssuesLewis First, MD, MA, Editor in Chief, Pediatrics
The media’s infl uence both positively and negatively on children is a frequent
topic of study in our journal and others. This week, we add to that evidence-base
with a study by Howard et al. (10.1542/peds.2017-2126) looking at the prevalence of
obesity-promoting behaviors or stigma as displayed in recent popular children’s movies.
The authors looked at the 31 top-grossing fi lms from 2012-2015 and for each ten-minute
segment of a fi lm, raters identifi ed and described what was being eaten, the activity
and whether there was weight-related dialogue being observed in a fi lm. The results
are concerning to us and will likely be to you as well. 100% of the fi lms studied had
obesity-promoting content involving unhealthy foods, larger than recommended portion
sizes, plenty of sugar-sweetened beverages being drunk, and more weigh-based stigma
such as verbal insults about someone being overweight or obese. Even more concerning
was that these fi ndings were not isolated ones in each of the 31 fi lms, but occurred
repeatedly in each.
Do you talk about fi lms seen by your patients with your patients? Do you tell them
to focus on the healthy and unhealthy behaviors being observed and then share their
thoughts on these behaviors with their families or with you? Perhaps this study will
trigger increased awareness of what our children are being exposed to in fi lms and lead
to better preventive strategies starting with what they choose to snack on when they
do go to the movies. We certainly know the infl uence of smoking and other risk-taking
behaviors depicted in fi lms viewed by teens, but this study now opens the door to
additional themes we might not have thought about before thanks to the information
one should digest fi rst by reading this study and then sharing what you learn with your
patients-especially those who are at risk for becoming increasingly overweight or obese.
JOURNALS BLOG
AAP PEDIATRIC COLLECTIONS16 ARTICLE
Obesogenic Behavior and Weight-Based Stigma in Popular Children’s Movies, 2012 to 2015Janna B. Howard, MPH, a, b Asheley Cockrell Skinner, PhD, b, c, d Sophie N. Ravanbakht, BA, a, b Jane D. Brown, PhD, e Andrew J. Perrin, PhD, f Michael J. Steiner, MD, MPH, g Eliana M. Perrin, MD, MPHa, b
BACKGROUND: Obesity-promoting content and weight-stigmatizing messages are common
in child-directed television programming and advertisements, and 1 study found similar
trends in G- and PG-rated movies from 2006 to 2010. Our objective was to examine the
prevalence of such content in more recent popular children’s movies.
METHODS: Raters examined 31 top-grossing G- and PG-rated movies released from 2012 to
2015. For each 10-minute segment (N = 302) and for movies as units, raters documented
the presence of eating-, activity-, and weight-related content observed on-screen. To assess
interrater reliability, 10 movies (32%) were coded by more than 1 rater.
RESULTS: The result of Cohen’s κ test of agreement among 3 raters was 0.65 for binary
responses (good agreement). All 31 movies included obesity-promoting content; most
common were unhealthy foods (87% of movies, 42% of segments), exaggerated portion
sizes (71%, 29%), screen use (68%, 38%), and sugar-sweetened beverages (61%, 24%).
Weight-based stigma, such as a verbal insult about body size or weight, was observed in
84% of movies and 30% of segments.
CONCLUSIONS: Children’s movies include much obesogenic and weight-stigmatizing content.
These messages are not shown in isolated incidences; rather, they often appear on-screen
multiple times throughout the entire movie. Future research should explore these trends
over time, and their effects.
abstract
NIH
Departments of aPediatrics and cMedicine and bDuke Center for Childhood Obesity Research, School of
Medicine, Duke University, Durham, North Carolina; dDuke Clinical Research Institute, Durham, North Carolina;
and eSchool of Media and Journalism and Departments of fSociology and gPediatrics, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina
Ms Howard helped to conceptualize and design the study, helped design the data collection
instruments, coordinated and supervised data collection, drafted the initial manuscript, and
revised the manuscript; Dr Skinner helped to conceptualize and design the study, designed
the data collection instruments, collected data, conducted the data analysis, and reviewed
and revised the manuscript; Ms Ravanbakht helped to design the data collection instruments,
collected data, and reviewed and revised the manuscript; Dr Brown helped to conceptualize
and design the study, designed the data collection instruments, collected data, and reviewed
and revised the manuscript; Dr A. Perrin secured funding for the study, conceptualized and
designed the study, assembled the team, secured funding for the project, designed the data
collection instruments, supervised data collection, collected data, and reviewed and revised
the manuscript; Dr Steiner helped to conceptualize the study, helped to design the study, and
reviewed and revised the manuscript; Dr E. Perrin secured funding for the study, conceptualized
and designed the study, assembled the team, secured funding for the project, supervised data
collection, designed the data collection instruments, collected data, and reviewed and revised
the manuscript; and all authors approved the final manuscript as submitted and agree to be
accountable for all aspects of the work.
WHAT’S KNOWN ON THIS SUBJECT: Screen time is
associated with obesity. Media impacts children’s
behaviors in many health-related domains, including
tobacco use, alcohol use, and sexual activity. The
authors of a study of movies from several years ago
found that obesogenic behaviors and weight stigma
were often depicted simultaneously.
WHAT THIS STUDY ADDS: In this study, we show
that obesogenic and obesity-stigmatizing content
continues to be highly prevalent in recent top-
grossing children’s movies. We also provide a
framework to investigate trends in the prevalence
of obesogenic and stigmatizing content in children’s
movies over time.
To cite: Howard JB, Skinner AC, Ravanbakht SN, et al.
Obesogenic Behavior and Weight-Based Stigma in Popular
Children’s Movies, 2012 to 2015. Pediatrics. 2017;140(6):
e20172126
ARTICLE
Prevalence of Obesity and Severe Obesity in US Children, 1999–2016Asheley Cockrell Skinner, PhD, a, b Sophie N. Ravanbakht, BA, c, d Joseph A. Skelton, MD, MS, e, f, g Eliana M. Perrin, MD, MPH, c, d Sarah C. Armstrong, MDb, c, d
OBJECTIVES: To provide updated prevalence data on obesity trends among US children and
adolescents aged 2 to 19 years from a nationally representative sample.
METHODS: We used the NHANES for years 1999 to 2016. Weight status was determined
by using measured height and weight from the physical examination component of the
NHANES to calculate age- and sex-specific BMI. We report the prevalence estimates
of overweight and obesity (class I, class II, and class III) by 2-year NHANES cycles and
compared cycles by using adjusted Wald tests and linear trends by using ordinary least
squares regression.
RESULTS: White and Asian American children have significantly lower rates of obesity than
African American children, Hispanic children, or children of other races. We report a
positive linear trend for all definitions of overweight and obesity among children 2–19
years old, most prominently among adolescents. Children aged 2 to 5 years showed a sharp
increase in obesity prevalence from 2015 to 2016 compared with the previous cycle.
CONCLUSIONS: Despite previous reports that obesity in children and adolescents has remained
stable or decreased in recent years, we found no evidence of a decline in obesity prevalence
at any age. In contrast, we report a significant increase in severe obesity among children
aged 2 to 5 years since the 2013–2014 cycle, a trend that continued upward for many
subgroups.
abstract
Departments of aPopulation Health Sciences and cPediatrics, and dDuke Center for Childhood Obesity
Research, Duke University, Durham, North Carolina; bDuke Clinical Research Institute, Durham, North Carolina;
Departments of eDivision of Public Health Sciences, Epidemiology and Prevention and fPediatrics, School of
Medicine, Wake Forest University, Winston-Salem, North Carolina; and gBrenner Families In Training Program,
Brenner Children’s Hospital, Winston-Salem, North Carolina
Dr Skinner made substantial contributions to the conception and design of the study, acquisition
of data, analysis of the data, and interpretation of data, drafted the article, revised it critically for
important intellectual content, and ensures that questions related to the accuracy or integrity
of any part of the work are appropriately investigated and resolved; Ms Ravanbakht and Dr
Armstrong contributed to the interpretation of data, drafted portions of the article, and revised
it in its entirety for intellectual content; Dr Skelton contributed to the conception of the study
and interpretation of data and drafted and revised the article; Dr Perrin contributed to the
interpretation of data and revised the manuscript in its entirety for intellectual content; and all
authors approved the final manuscript as submitted and agree to be accountable for all aspects
of the work.
DOI: https:// doi. org/ 10. 1542/ peds. 2017- 3459
Accepted for publication Nov 30, 2017
Address correspondence to Asheley Cockrell Skinner, PhD, Department of Population Health
Sciences, Duke University, 2200 W Main St, Suite 720-A, Durham, NC 27705. E-mail: asheley.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
WHAT’S KNOWN ON THIS SUBJECT: The US
prevalence of child and adolescent obesity has
been increasing for 4 decades. Some reports reveal
stabilization across the population and decreases
among young children aged 2 to 5 years, although
severe obesity has increased, with adverse health
effects.
WHAT THIS STUDY ADDS: We detail the prevalence
of obesity and severe obesity by age and race and/
or ethnicity, including Asian American youth, in a
nationally representative sample. Despite significant
public health initiatives, obesity and severe obesity
continue to increase, with a sharp increase being
noted in preschool-aged children.
To cite: Skinner AC, Ravanbakht SN, Skelton JA, et al.
Prevalence of Obesity and Severe Obesity in US Children,
1999–2016. Pediatrics. 2018;141(3):e20173459
31Obesity: Stigma, Trends, and Interventions
version 15.0 (StataCorp, College
Station, TX).
Readers should use the following
information as guidance when
interpreting our findings. We
present results from multiple
significance tests but do not make
any adjustments for multiple testing,
which reduces the chance of a type
II error but increases the chance
of a type I error. Readers should
consider the chance for both type
I and type II errors. To reduce the
chance of a type II error (indicating
as significant a relationship that
does not exist), we present all ad hoc
data without choosing only those
that are significant. We include P
values for reference but encourage
readers not to focus on P < .05 and
instead to consider the body of data.
In the supplemental appendices, we
present confidence intervals (CIs)
to allow readers to draw their own
conclusions about more nuanced
comparisons. The chance of a type I
error (not identifying a relationship
that does exist) should be considered,
particularly in our comparisons
between the 2013–2014 and 2015–2016 cycles. Although the sample
size allows for the identification
of relatively small differences in
the prevalence of the full sample,
subgroup analyses should be
considered more carefully. We have
provided sample sizes throughout
the tables to assist readers in their
assessments.
RESULTS
Prevalence
Table 1 presents the prevalence of
overweight and all classes of obesity
by demographic characteristics in the
most recent NHANES cycle, 2015–2016. Non-Hispanic African American
and Hispanic children had higher
prevalence rates of overweight
and all classes of obesity compared
with other races. Asian American
children had markedly lower rates of
overweight and all classes of obesity.
The prevalence of overweight
and obesity increased with age,
with 41.5% of 16- to 19-year-old
adolescents having obesity and 4.5%
meeting criteria for class III obesity.
Trends in the 1999–2000 and 2015–2016 Cycles
Table 2 shows the prevalence
of overweight and all classes of
obesity by ordinal 2-year cycles
(1999–2016) for females, males,
and both sexes. A positive linear
trend is significant for overweight
(P = .003), class I obesity (P = .008),
class II obesity (P = .019), and
class III obesity (P < .001) for both
sexes, with all ages combined. The
increasing linear trend from 1999
to 2016 is most apparent among
Hispanic females (Table 3). Similar
to those of females, there are large
increases in overweight and class
II obesity among Hispanic males
(Table 4). All 95% CIs are included
in Supplemental Tables 5–9.
Differences From the Last Cycle
There are few differences in the
prevalence of overweight and all
classes of obesity since the last
NHANES cycle, 2013–2014 and
2016–2016. One exception is a sharp
increase in the prevalence of class
I obesity among 2- to 5-year-olds,
particularly in young males. Another
notable increase is for overweight,
from 36% to 48%, in among older
adolescent females. There were
no other significant changes from
the 2013–2014 and 2015–2016
cycles for any of the race and/or
TABLE 1 Prevalence of Overweight and Obesity Among Children and Adolescents, 2015–2016
Total Overweight Class I Obesity Class II Obesity Class III Obesity
n = 3340 n = 1213 n = 652 n = 213 n = 73
n % % 95% CI P % 95% CI P % 95% CI P % 95% CI P
Total — — 35.1 31.9 to 38.4 18.5 15.8 to 21.2 6.0 4.3 to 7.6 1.9 1.0 to 2.9
Age
2–5 y 814 20.7 26.0 21.3 to 30.7 .005 13.7 11.4 to 16.0 .239 1.8 0.6 to 3.0 0.006 0.2 −0.1 to 0.4 .059
6–8 y 655 17.2 32.8 27.1 to 38.5 — 18.8 13.1 to 24.5 — 5.1 3.2 to 7.1 — 1.4 0.5 to 2.3 — 9–11 y 613 16.5 35.6 30.7 to 40.6 — 18.5 14.8 to 22.3 — 5.3 2.9 to 7.7 — 1.0 0.4 to 1.7 — 12–15 y 675 24.9 38.7 32.7 to 44.7 — 20.6 15.6 to 25.6 — 7.5 4.2 to 10.8 — 2.2 0.9 to 3.4 — 16–19 y 583 20.7 41.5 37.1 to 45.9 — 20.5 15.5 to 25.5 — 9.5 5.8 to 13.1 — 4.5 1.7 to 7.4 —Sex
Female 1644 48.9 35.5 31.6 to 39.5 .691 17.8 15.3 to 20.3 .408 5.2 3.3 to 7.1 0.243 1.8 0.8 to 2.8 .668
Male 1696 51.1 34.8 31.1 to 38.4 — 19.1 15.5 to 22.7 — 6.7 4.4 to 8.9 — 2.0 0.9 to 3.2 —Race
White 925 51.9 29.9 27.4 to 32.4 <.001 14.1 11.8 to 16.5 <.001 3.9 2.8 to 5.0 <0.001 1.1 0.2 to 2.0 .001
African
American
767 13.9 37.8 32.4 to 43.1 — 22.2 16.4 to 27.9 — 9.0 6.0 to 12.1 — 3.8 1.8 to 5.9 —
Hispanic 1126 23.9 45.9 41.8 to 50.0 — 25.8 22.6 to 29.0 — 9.1 6.7 to 11.6 — 3.3 2.0 to 4.6 — Asian
American
288 4.7 23.2 17.8 to 28.7 — 10.7 6.8 to 14.6 — 1.4 −0.3 to 3.1 — 0.0 — —
Other 234 5.6 41.5 31.7 to 51.2 — 25.3 13.3 to 37.3 — 7.6 0.0 to 15.3 — 0.7 −0.3 to 1.6 ——, not applicable.
AAP PEDIATRIC COLLECTIONS50 ARTICLE
Characteristics of Children 2 to 5 Years of Age With Severe ObesityJune M. Tester, MD, MPH, a Thao-Ly T. Phan, MD, MPH, b Jared M. Tucker, PhD, c Cindy W. Leung, ScD, MPH, d Meredith L. Dreyer Gillette, PhD, e Brooke R. Sweeney, MD, e Shelley Kirk, PhD, RD, LD, f Alexis Tindall, RD, LD, g Susan E. Olivo-Marston, PhD, MPH, h Ihuoma U. Eneli, MD, MSg
BACKGROUND AND OBJECTIVES: As a distinct group, 2- to 5-year-olds with severe obesity (SO) have
not been extensively described. As a part of the Expert Exchange Workgroup on Childhood
Obesity, nationally-representative data were examined to better characterize children with
SO.
METHODS: Children ages 2 to 5 (N = 7028) from NHANES (1999–2014) were classified
as having normal weight, overweight, obesity, or SO (BMI ≥120% of 95th percentile).
Sociodemographics, birth characteristics, screen time, total energy, and Healthy Eating
Index 2010 scores were evaluated. Multinomial logistic and linear regressions were
conducted, with normal weight as the referent.
RESULTS: The prevalence of SO was 2.1%. Children with SO had higher (unadjusted) odds of
being a racial and/or ethnic minority (African American: odds ratio [OR]: 1.7; Hispanic:
OR: 2.3). They were from households with lower educational attainment (OR: 2.4), that
were single-parent headed (OR: 2.0), and that were in poverty (OR: 2.1). Having never been
breastfed was associated with increased odds of obesity (OR: 1.5) and higher odds of SO
(OR: 1.9). Odds of >4 hours of screen time were 1.5 and 2.0 for children with obesity and
SO. Energy intake and Healthy Eating Index 2010 scores were not significantly different in
children with SO.
CONCLUSIONS: Children ages 2 to 5 with SO appear to be more likely to be of a racial and/or
ethnic minority and have greater disparities in social determinants of health than their
peers and are more than twice as likely to engage in double the recommended screen time
limit.
abstract
NIH
aUniversity of California, San Francisco Benioff Children’s Hospital Oakland, Oakland, California; bDepartment
of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, Delaware; cHealthy Weight Center,
Helen DeVos Children’s Hospital, Grand Rapids, Michigan; dDepartment of Nutritional Sciences, School of
Public Health, University of Michigan, Ann Arbor, Michigan; eDepartment of Pediatrics, Children’s Mercy Kansas
City and School of Medicine, University of Missouri–Kansas City, Kansas City, Missouri; fCincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio; gNationwide Children’s Hospital Center for Healthy Weight and
Nutrition, Columbus, Ohio; and hDivision of Epidemiology, College of Public Health, The Ohio State University,
Columbus, Ohio
Dr Tester conceptualized and designed the study, conducted the majority of the data analysis,
drafted the initial manuscript, and reviewed and revised the manuscript; Dr Leung conducted
key data analyses required for calculation of Healthy Eating Index 2010 diet data, contributed
expertise to the data analysis approach, and reviewed and revised the manuscript; Drs Phan,
Tucker, Dreyer Gillette, Sweeney, and Kirk and Ms Tindall contributed topical expertise in pediatric
obesity for preparation of the manuscript, assisted with analysis interpretation, and reviewed
and revised the manuscript; Dr Olivo-Marston contributed to early data analysis for the study
and reviewed and revised the final manuscript; Dr Eneli contributed to initial conceptualization of
WHAT’S KNOWN ON THIS SUBJECT: Preschool-aged
children with severe obesity are a group with high
risk of future comorbidity; however, they are poorly
characterized as a distinct group.
WHAT THIS STUDY ADDS: In this study using
nationally representative data, preschool-aged
children with severe obesity were found to have
greater disparities in social determinants of health
and a particularly high level of screen time use
compared with their peers.
To cite: Tester JM, Phan T-L-T-, Tucker JM, et al. Char-
acteristics of Children 2 to 5 Years of Age With Severe
Obesity. Pediatrics. 2018;141(3):e20173228
AAP PEDIATRIC COLLECTIONS58 ARTICLE
Racial and Ethnic Disparities in Early Childhood ObesityInyang A. Isong, MD, MPH, ScD, a, b Sowmya R. Rao, PhD, c Marie-Abèle Bind, PhD, d Mauricio Avendaño, PhD, b, e Ichiro Kawachi, MD, PhD, b Tracy K. Richmond, MD, MPHa
OBJECTIVES: The prevalence of childhood obesity is significantly higher among racial and/or
ethnic minority children in the United States. It is unclear to what extent well-established
obesity risk factors in infancy and preschool explain these disparities. Our objective was
to decompose racial and/or ethnic disparities in children’s weight status according to
contributing socioeconomic and behavioral risk factors.
METHODS: We used nationally representative data from ∼10 700 children in the Early
Childhood Longitudinal Study Birth Cohort who were followed from age 9 months through
kindergarten entry. We assessed the contribution of socioeconomic factors and maternal,
infancy, and early childhood obesity risk factors to racial and/or ethnic disparities in
children’s BMI z scores by using Blinder-Oaxaca decomposition analyses.
RESULTS: The prevalence of risk factors varied significantly by race and/or ethnicity. African
American children had the highest prevalence of risk factors, whereas Asian children had
the lowest prevalence. The major contributor to the BMI z score gap was the rate of infant
weight gain during the first 9 months of life, which was a strong predictor of BMI z score at
kindergarten entry. The rate of infant weight gain accounted for between 14.9% and 70.5%
of explained disparities between white children and their racial and/or ethnic minority
peers. Gaps in socioeconomic status were another important contributor that explained
disparities, especially those between white and Hispanic children. Early childhood risk
factors, such as fruit and vegetable consumption and television viewing, played less
important roles in explaining racial and/or ethnic differences in children’s BMI z scores.
CONCLUSIONS: Differences in rapid infant weight gain contribute substantially to racial and/or
ethnic disparities in obesity during early childhood. Interventions implemented early in life
to target this risk factor could help curb widening racial and/or ethnic disparities in early
childhood obesity.
abstract
NIH
aBoston Children’s Hospital, Boston, Massachusetts; bDepartment of Social and Behavioral Sciences, Harvard
T.H Chan School of Public Health and dDepartment of Statistics, Faculty of Arts and Sciences, Harvard
University, Cambridge, Massachusetts; cDepartment of Surgery, Boston University, Boston, Massachusetts; and eDepartment of Social Science, Health and Medicine, King’s College London, London, United Kingdom
Drs Rao and Bind helped with data analysis, interpretation of the results, and revision of the
manuscript; Drs Avendaño, Kawachi, and Richmond helped with the concept and design, data
interpretation, and drafting and revision of the manuscript; Dr Isong helped with the concept,
design, data analysis, interpretation of the data, and drafting and revision of the manuscript;
and all authors approved the fi nal manuscript as submitted and agree to be accountable for all
aspects of the work
DOI: https:// doi. org/ 10. 1542/ peds. 2017- 0865
Accepted for publication Oct 2, 2017
WHAT’S KNOWN ON THIS SUBJECT: Childhood
obesity is a signifi cant public health challenge.Early
childhood obesity prevalence is disproportionately
higher among racial and/or ethnic minority children
compared with their white peers. It is unclear which
specifi c obesity risk factors underlie and explain
these disparities.
WHAT THIS STUDY ADDS: Differences in rapid infant
weight gain contribute substantially to racial and/or
ethnic disparities in obesity during early childhood.
To cite: Isong IA, Rao SR, Bind M-A, et al. Racial and Ethnic
Disparities in Early Childhood Obesity. Pediatrics. 2018;
141(1):e20170865
91Obesity: Stigma, Trends, and Interventions
:: August-22-2016
How to Prevent Obesity Without Encouraging Eating Disorders Neville H. Golden, MD, FAAP
Many eating disorders (EDs) programs have noted a marked increase in the number
of teens who previously were obese or overweight presenting with frank eating dis-
orders. In their attempt to lose weight, these adolescents may have resorted to unhealthy
and unsustainable methods such as skipping meals or using diet pills or laxatives.
Even though their weight now is in the normal range, these individuals have medical
and psychologic fi ndings similar to those with classic anorexia nervosa. They may
present to the pediatrician with severe bradycardia or orthostasis, signs of medical
instability.
A new AAP clinical report addresses the interaction between obesity prevention and
EDs in teenagers. It also provides pediatricians with evidence-informed tools to identify
behaviors that predispose to both obesity and EDs and guidance on messaging.
The report Preventing Obesity and Eating Disorders in Adolescents, from the AAP
Committee on Nutrition, Committee on Adolescence and Section on Obesity, is available
at http://pediatrics.aappublications.org/content/early/2016/08/18/peds.2016-1649 and
will be published in the September issue of Pediatrics.
BEHAVIORS LINKED TO WEIGHT PROBLEMSWhile most adolescents who develop an eating disorder were not previously over-
weight, some teens may develop an eating disorder as they try to lose weight.
Research has shown that certain behaviors such as dieting, weight talk and weight
teasing predispose to both obesity and EDs in teens, while frequent family meals are
protective of both conditions.
Research has shown that frequent family meals protect against obesity and eating
disorders in teens. A new AAP clinical report recommends that families eat together as a
way to model healthy food choices.
Dieting, defi ned as caloric restriction with the goal of weight loss, was associated
with a twofold increased risk of becoming overweight and a 1.5-fold increased risk
of binge eating fi ve years later in a large prospective study of healthy teens
(Neumark-Sztainer DR, et al. Am J Prev Med. 2007;33:359-369).
Another study found that normal weight girls who dieted in ninth grade were three
times more likely to be overweight in 12th grade compared with non-dieters (Stice E, et al.
J Consult Clin Psychol. 1999;67:967-974).
Dr. Golden is lead author of the clinical report and a member of the AAP Committee on Nutrition.
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Preventing Obesity and Eating Disorders in AdolescentsNeville H. Golden, MD, FAAP, Marcie Schneider, MD, FAAP, Christine Wood, MD, FAAP, COMMITTEE ON NUTRITION, COMMITTEE ON ADOLESCENCE, SECTION ON OBESITY
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.
DOI: 10.1542/peds.2016-1649
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they do not have a fi nancial relationship relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
abstractObesity and eating disorders (EDs) are both prevalent in adolescents. There
are concerns that obesity prevention efforts may lead to the development of
an ED. Most adolescents who develop an ED did not have obesity previously,
but some teenagers, in an attempt to lose weight, may develop an ED. This
clinical report addresses the interaction between obesity prevention and
EDs in teenagers, provides the pediatrician with evidence-informed tools
to identify behaviors that predispose to both obesity and EDs, and provides
guidance about obesity and ED prevention messages. The focus should be
on a healthy lifestyle rather than on weight. Evidence suggests that obesity
prevention and treatment, if conducted correctly, do not predispose to EDs.
INTRODUCTION
The prevalence of childhood obesity has increased dramatically over the
past few decades in the United States and other countries, and obesity
during adolescence is associated with significant medical morbidity
during adulthood. 1 Eating disorders (EDs) are the third most common
chronic condition in adolescents, after obesity and asthma. 2 Most
adolescents who develop an ED did not have obesity previously, but
some adolescents may misinterpret what “healthy eating” is and engage
in unhealthy behaviors, such as skipping meals or using fad diets in an
attempt to “be healthier, ” the result of which could be the development
of an ED. 3 Messages from pediatricians addressing obesity and reviewing
constructive ways to manage weight can be safely and supportively
incorporated into health care visits. Avoiding certain weight-based
language and using motivational interviewing (MI) techniques may
improve communication and promote successful outcomes when
providing weight-management counseling. 4
This clinical report complements existing American Academy of
Pediatrics (AAP) reports on EDs 5 and obesity prevention. 6 The aim is to
address the interaction between obesity prevention and EDs in teenagers
and to stress that obesity prevention does not promote the development
To cite: Golden NH, Schneider M, Wood C, AAP COMMITTEE
ON NUTRITION. Preventing Obesity and Eating Disorders in
Adolescents. Pediatrics. 2016;138(3):e20161649
CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
103Obesity: Stigma, Trends, and Interventions ARTICLE
An Integrated Clinic-Community Partnership for Child Obesity Treatment: A Randomized Pilot TrialJessica Hoffman, BS, a Leah Frerichs, PhD, b Mary Story, PhD, RD, c Jason Jones, CPRP, CPO, d Kiah Gaskin, MSW, MPH, e Annie Apple, BS, e Asheley Skinner, PhD, f Sarah Armstrong, MDe
BACKGROUND AND OBJECTIVES: Effective treatment of childhood obesity remains elusive.
Integration of clinical and community systems may achieve effective and sustainable
treatment. However, the feasibility and effectiveness of this integrated model are unknown.
METHODS: We conducted a randomized clinical trial among children aged 5 to 11 presenting
for obesity treatment. We randomized participants to clinical care or clinical care plus
community-based programming at a local parks and recreation facility. Primary outcomes
were the change in child BMI at 6 months and the intensity of the program in treatment
hours. Secondary outcomes included health behaviors, fitness, attrition, and quality of life.
RESULTS: We enrolled 97 children with obesity, and retention at 6 months was 70%.
Participants had a mean age of 9.1 years and a mean baseline BMI z score of 2.28, and 70%
were living in poverty. Intervention participants achieved more treatment hours than
controls (11.4 vs 4.4, SD: 15.3 and 1.6, respectively). We did not observe differences in child
BMI z score or percent of the 95th percentile at 6 months. Intervention participants had
significantly greater improvements in physical activity (P = .010) and quality of life
(P = .008).
CONCLUSIONS: An integrated clinic-community model of child obesity treatment is feasible to
deliver in a low-income and racially diverse population. As compared with multidisciplinary
treatment, the integrated model provides more treatment hours, improves physical activity,
and increases quality of life. Parks and recreation departments hold significant promise as
a partner agency to deliver child obesity treatment.
abstract
aSchool of Medicine, cGlobal Health Institute, eDepartment of Pediatrics, and fClinical Research Institute, Duke
University, Durham, North Carolina; bCenter for Health Equity Research, University of North Carolina at Chapel
Hill, Chapel Hill, North Carolina; and dDurham Parks and Recreation, Durham, North Carolina;
Ms Hoffman was involved in the project design, designed the database and managed data
collection, recruited participants, conducted baseline and follow-up assessments of participants,
and drafted the initial manuscript; Dr Frerichs conceptualized and designed the study, designed
the data collection instruments, conducted feasibility subanalyses, conducted initial analyses,
and reviewed and revised the manuscript; Dr Story was involved in the project design, served
as a mentor throughout the study, and reviewed and revised the manuscript; Mr Jones was
involved in the project design and reviewed and revised the manuscript; Ms Gaskin and Ms Apple
were involved in the project design, supervised the intervention delivered at the community
site, and reviewed and revised the manuscript; Dr Skinner was involved in the project design,
conducted all initial and fi nal analyses, and reviewed and revised the manuscript; Dr Armstrong
conceptualized and designed the study, coordinated and supervised data collection at the clinical
site, and critically reviewed and revised the manuscript; and all authors approved the fi nal
manuscript as submitted and agree to be accountable for all aspects of the work.
This trial has been registered at www. clinicaltrials. gov (identifi er NCT02573142).
WHAT’S KNOWN ON THIS SUBJECT: Childhood
obesity treatment guidelines are challenging to
deliver in real-world settings. Integrated clinic-
community partnerships may increase the intensity
of treatment, yet little is known about the feasibility
and effectiveness of these integrated models.
WHAT THIS STUDY ADDS: When compared with
clinical obesity treatment alone, an integrated
clinic-community model, delivered at a parks and
recreation facility, is engaging among a low-income,
racially diverse population and is associated with
improvements in physical activity and quality of life.
To cite: Hoffman J, Frerichs L, Story M, et al. An Integrated
Clinic-Community Partnership for Child Obesity Treatment:
A Randomized Pilot Trial. Pediatrics. 2018;141(1):e20171444
AAP PEDIATRIC COLLECTIONS110
We observed an unexpected
significant increase in sugar-
sweetened beverage consumption
in the intervention group. Potential
explanations include increased
consumption of sports beverages or
sugary drinks because of increased
physical activity or increased
usage of vending machines with
sugar-sweetened beverages located
on-site at the parks and recreation
facility. Recall bias could also
explain this observation, because
Bull City Fit provides nutrition
education, and intervention parents
might have monitored and reported
their drink consumption more
closely.
There are several limitations to
our study. The initial exclusion
of monolingual Spanish-speaking
families, because of limited
study resources, excluded a large
proportion of the catchment
population of interest. 41 This
exclusion made recruitment
unfeasible, but the addition
of resources later during the
recruitment phase allowed us to
include Spanish-speaking families.
However, deviating from the initial
protocol may have affected study
outcomes. The adaptation of our
trial highlights the importance of
designing interventions to meet
the linguistic and cultural needs
of the population of interest.
This is necessary not only for the
generalizability of study outcomes
but also to ensure that treatment
interventions are appropriate for
and inclusive of the population
being served.
Because Bull City Fit primarily
serves a low-income and diverse
population, the curricula were
designed to be flexible, engaging
for all ages, and relatively
unstructured. For example,
attendance expectations discussed
at enrollment were adaptable to
each family’s individual schedule.
This flexibility is a strength in
terms of inclusivity, but the lack
of structure and accountability is
also a limitation. Incorporating
personalized text messaging
boosted attendance, and additional
structured accountability measures
should be considered in the future
to improve intensity.
Although a randomized controlled
trial design was a strength, another
limitation was the relatively high
drop-out among participants
randomly assigned to the control
group who wanted access to the
intervention (n = 7).
We are building on our work from
this pilot through a larger study
recently funded by the American
Heart Association to evaluate the
implementation of the integrated
model in diverse community
settings. This randomized
controlled clinical trial (n = 350)
will compare the clinic-community
integrated model with standard
primary care obesity treatment
over a 12-month period. This
design will expand our sample size
and duration of the intervention
and will incorporate the texting
protocol and the inclusion of
monolingual Spanish-speakers to
enhance recruitment and reduce
dropout. Enrollment is expected to
begin in January 2018.
CONCLUSIONS
In this study, we demonstrate
the feasibility of delivering an
integrated clinic-community
partnership for child obesity
treatment, delivered at a parks and
recreation facility. The integrated
model leads to greater engagement
than clinical care alone and results
FIGURE 2Change in quality of life on Sizing Me Up 27 between baseline and 6 months. A, Intervention. B, Control. No signifi cant between-group differences were observed at baseline. We observed statistically signifi cant improvements (P < .05) in the intervention versus control in total quality of life and the positive attributes subscale.
113Obesity: Stigma, Trends, and Interventions
SUPPLEMENTAL TABLE 4 Treatment Arms
Control Intervention
Healthy Lifestyles Only Healthy Lifestyles + Bull City Fit
Healthy Lifestyles Healthy Lifestyles: same as control
Children aged 0–22 y with a BMI ≥95th
percentile are referred by their primary
care provider
Bull City Fit
All members of multidisciplinary treatment
team are trained in motivational
interviewing
Free, unlimited access
Study visits conducted at baseline, 3-mo visit
(10–16 wk), and 6-mo visit (23–29 wk)
All family and/or household members of the
Healthy Lifestyles patient are invited to attend.
At least 1 parent or guardian must be on-site
per session
Baseline visit (2 h) Open Monday–Thursday from 6–8 PM and
Saturday–Sunday from 1–3 PM
Introduction to the program Up to 312 h of programming over 6 mo is
possible (2 h per session, 6 sessions
offered per wk)
Baseline laboratories, measurements Participants must first attend a 1-h orientation
session, offered several times per mo, before
attending regular sessions
Medical evaluation: detailed history,
examination, treatment goals
Different activities each session, led by
trained staff and volunteers. Most staff
are undergraduate students (paid through
undergraduate work-study program in
partnership with Healthy Lifestyles)
Physical therapy evaluation: history, fitness
and physical functioning, fitness goals
Types of activities offered (on average)
Second visit (∼1 h at 2 wk–1 mo) Sports (soccer, basketball, etc): 6 d/wk
Medical evaluation: review laboratories,
review goals, decide treatment approach
Swimming (pool on-site, lessons offered): 2
d/wk
Registered dietitian evaluation: detailed
history, nutrition goals
Active games (tag, relay races, handball,
sharks and minnows, etc): 6 d/wk
Monthly visits for 1 y (∼1 h) with
multidisciplinary team, individualized for
each patient
Yoga: 1 d/wk
Medical provider ± registered dietitian,
physical therapist, mental health
counselor
Nutrition and/or cooking classes (for both
children and parents, along with parent-
specific cooking classes): 1 d/wk
All participants had at least 2 h of clinical
treatment from the baseline enrollment
visit, and up to 6 additional hours if all 6
recommended monthly visits were attended
Peer support groups: 1 d/wk
Clinical sessions could be more frequently
than monthly on an individual basis if
recommended by the medical team or
desired by the family
Gardening: 1 d/wk during the summer months
Additional visits at least every 1 y, with shorter
intervals as needed
Parents and guardians can participate in
activities with children or exercise on own
Supplemental Information
ARTICLE
A Home Visiting Parenting Program and Child Obesity: A Randomized TrialMonica Roosa Ordway, PhD, APRN, PPCNP-BC, a Lois S. Sadler, PhD, RN, FAAN, a, b Margaret L. Holland, PhD, MPH, a Arietta Slade, PhD, b Nancy Close, PhD, b Linda C. Mayes, MDb
BACKGROUND: Young children living in historically marginalized families are at risk for
becoming adolescents with obesity and subsequently adults with increased obesity-related
morbidities. These risks are particularly acute for Hispanic children. We hypothesized that
the prevention-focused, socioecological approach of the “Minding the Baby” (MTB) home
visiting program might decrease the rate of childhood overweight and obesity early in life.
METHODS: This study is a prospective longitudinal cohort study in which we include data
collected during 2 phases of the MTB randomized controlled trial. First-time, young
mothers who lived in medically underserved communities were invited to participate in
the MTB program. Data were collected on demographics, maternal mental health, and
anthropometrics of 158 children from birth to 2 years.
RESULTS: More children in the intervention group had a healthy BMI at 2 years. The rate
of obesity was significantly higher (P < .01) in the control group (19.7%) compared with
the intervention group (3.3%) at this age. Among Hispanic families, children in the
MTB intervention were less likely to have overweight or obesity (odds ratio = 0.32;
95% confidence interval: 0.13–0.78).
CONCLUSIONS: Using the MTB program, we significantly lowered the rate of obesity among
2-year-old children living in low-socioeconomic-status communities. In addition, children
of Hispanic mothers were less likely to have overweight or obesity at 2 years. Given the
high and disproportionate national prevalence of Hispanic young children with overweight
and obesity and the increased costs of obesity-related morbidities, these findings have
important clinical, research, and policy implications.
abstract
NIH
aSchool of Nursing, Yale University, Orange, Connecticut; bChild Study Center, School of Medicine, Yale University,
New Haven, Connecticut
Dr Ordway conceptualized and designed the cohort study, conducted the initial analyses, and
drafted the initial manuscript; Drs Sadler, Slade, Close, and Mayes codesigned and directed the
“Minding the Baby” program and the 2 phases of the randomized clinical trial and reviewed and
revised the manuscript; Dr Holland reviewed the initial analyses, conducted the fi nal analyses,
and reviewed and revised the manuscript; and all authors approved the fi nal manuscript as
submitted and agree to be accountable for all aspects of the work.
This trial has been registered at www. clinicaltrials. gov (identifi er NCT01458145).
DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1076
Accepted for publication Nov 1, 2017
Address correspondence to Monica Roosa Ordway, PhD, APRN, PPCNP-BC, Yale School of Nursing,
PO Box 27399, West Haven, CT 06516-7399. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2018 by the American Academy of Pediatrics
WHAT’S KNOWN ON THIS SUBJECT: Although overall
obesity rates have plateaued nationwide, there is a
widening racial and/or ethnic disparity in childhood
overweight and obesity, particularly among Hispanic
children early in life. There are few programs that
address obesity in this age group.
WHAT THIS STUDY ADDS: Children living in families
who received a 27-month parenting home visiting
intervention were signifi cantly less likely to be
obese at 2 years of life. Hispanic children in the
intervention families were also less likely to have a
BMI >85%.
To cite: Ordway MR, Sadler LS, Holland ML, et al. A Home
Visiting Parenting Program and Child Obesity: A Randomized
Trial. Pediatrics. 2018;141(2):e20171076
119Obesity: Stigma, Trends, and Interventions
(6) no major medical illness in the
mother. In the current study cohort,
we included 158 children (92
intervention and 66 control) from
both phases of the RCT with complete
anthropometric data collected at 24
months of age (see Fig 1). Additional
details of design, recruitment, and
retention procedures are available
in the report on the pilot study
findings 32 and the efficacy trial. 36
Procedures
The MTB program provided home
visiting by a master’s-prepared
social worker and pediatric nurse
weekly from the third trimester
of pregnancy until the child’s first
birthday and biweekly through
the child’s second birthday. The
home visits were typically 1 hour in
duration, but this varied according
to the dyad’s life circumstances. The
clinician pairs were varied between
families and CHCs to reduce threats
to internal validity. They received
weekly supervision and participated
in team case presentations to ensure
fidelity. During the 2 phases, there
were 2 nurses and 5 part-time social
workers at various points in time.
Further details on the manualized
MTB program have been published
previously. 24, 32, 37, 38 Research ethics
approval was obtained through the
university and CHCs.
Measures
Main Exposure
The main exposures in this study
were the group status (intervention
or control) and race and/or
ethnicity. At the time of consent, all
participants were pregnant women
who self-reported their race and/or
ethnicity after random assignment.
Potential Covariates
We considered several early life
risk factors known to be associated
with childhood obesity as potential
covariates: maternal mental health, 39
rapid infant weight gain, 40, 41
and feeding other than exclusive
breastfeeding. 42 In this study, mothers
in both groups met with research
staff to complete questionnaires at 24
months and a semistructured interview
prenatally and at 24 months to assess
maternal mental health, including
depressive symptoms (Center for
Epidemiologic Studies Depression
Scale), 43 parenting stress (Parenting
Stress Index), 44 posttraumatic stress
symptoms (Mississippi Scale), 45 and
maternal RF (Pregnancy Interview and
Parent Development Interview). 46, 47
Details on the instruments, reliability,
and validity have been reported
elsewhere.32 Rapid infant weight gain
was defined as a change in weight-
for-age z score >0.67 SD on the basis
of World Health Organization growth
data (between birth and age 12
months), which is interpreted clinically
as crossing centile lines on a growth
chart. 48 Data were collected on weeks
of exclusive breastfeeding. 42, 49
Outcome Measures
The primary outcome is the prevalence
of overweight (≥85th percentile) or
obesity (≥95th percentile) in children
at 2 years, which was assessed by using
the Centers for Disease Control and
Prevention reference data, adjusting
for age and sex (z score). 50 Weight and
height data at birth, 12 months, and
24 months were collected via medical
chart review.
Families Without Complete Data
There were 75 families excluded
from this study because of a
combination of dropout from MTB
and incomplete anthropometric
growth data in the children’s medical
charts at 24 months. There was no
difference in the number of families
in the intervention and control
groups among those excluded. There
were no significant differences in
any demographic variables between
included and excluded families (see
Supplemental Table 4).
Statistical Analysis
We compared demographic
characteristics, maternal mental
FIGURE 1MTB combined phase 1 and 2 Consolidated Standards of Reporting Trials fl owchart.
123Obesity: Stigma, Trends, and Interventions
ever-rising US health care spending 59
on obesity-related morbidities. 60, 61
Recently, in the White House
Task Force Report, “Solving the
Problem of Childhood Obesity
Within a Generation, ” 62 as well
as in 2 subsequent Institute of
Medicine reports, 63, 64 the need for
interventions early in life to prevent
obesity has been emphasized. On
the basis of our findings, we suggest
that home visiting programs that
focus on the whole child and on the
early mother-child relationship using
a socioecological approach may
be in the best position to build the
foundation for healthy development.
Much more empirical evidence is
required to confirm this hypothesis,
but with our results, we suggest
that this approach may be highly
beneficial in lowering rates of obesity
in at-risk populations.
ACKNOWLEDGMENTS
We thank Denise Webb and Tanika
Simpson for their thoughtful review
and editorial assistance. We also
thank the CHCs and families who
generously provided their time and
trust in our program.
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FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.
FUNDING: Supported by The FAR Fund, the Irving B. Harris Foundation, the Pritzker Early Childhood Foundation, the Seedlings Foundation, the Child Welfare Fund,
the Stavros Niarchos Foundation, The Patrick and Catherine Weldon Donaghue Foundation, The Edlow Family Fund, the Schneider Family, The New York Community
Trust, the National Institute of Nursing Research (P30NR08999, K23NR16277, T32NR008346), the Eunice Kennedy Shriver National Institute of Child Health and
Human Development (R21HD048591, RO1HD057947), the Jonas Center for Nursing and Veterans Healthcare, and the National Center for Advancing Translational
Sciences (KL2 TR000140). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
ABBREVIATIONS
CHC: community health clinic
CI: confidence interval
ICC: interclass correlation
MTB: Minding the Baby
OR: odds ratio
RCT: randomized controlled trial
RF: reflective functioning
A Tailored Family-Based ObesityIntervention: A Randomized TrialRachael W. Taylor, PhDa, Adell Cox, MA, PGDipClPsb, Lee Knight, PGDipClPs, PhDb, Deirdre A. Brown, PhD, PGDipClPsc,Kim Meredith-Jones, PhDa, Jillian J. Haszard, PhDd, Anna M. Dawson, PhDe, Barry J. Taylor, MBChB, FRACPe,Sheila M. Williams, DScf
abstractOBJECTIVE: To determine whether a 2-year family-based intervention using frequent contact andlimited expert involvement was effective in reducing excessive weight compared with usualcare.
METHODS:Two hundred and six overweight and obese (BMI$85th percentile) children aged 4 to8 years were randomized to usual care (UC) or tailored package (TP) sessions at universityresearch rooms. UC families received personalized feedback and generalized advice regardinghealthy lifestyles at baseline and 6 months. TP families attended a single multidisciplinarysession to develop specific goals suitable for each family, then met with a mentor each monthfor 12 months, and every third month for another 12 months to discuss progress and providesupport. Outcome measurements (anthropometry, questionnaires, dietary intake,accelerometry) were obtained at 0, 12, and 24 months.
RESULTS:BMI at 24 months was significantly lower in TP compared with UC children (difference,95% confidence interval: –0.34, –0.65 to –0.02), as was BMI z score (–0.12, –0.20 to –0.04) andwaist circumference (–1.5, –2.5 to –0.5 cm). TP children consumed more fruit and vegetables(P = .038) and fewer noncore foods (P = .020) than UC children, and fewer noncore foods wereavailable in the home (P = .002). TP children were also more physically active (P = .035). Nodifferences in parental feeding practices, parenting, quality of life, child sleep, or behaviorwere observed.
CONCLUSIONS: Frequent, low-dose support was effective for reducing excessive weight inpredominantly mild to moderately overweight children over a 2-year period. Such initiativescould feasibly be incorporated into primary care.
WHAT’S KNOWN ON THIS SUBJECT: Althoughtreatment programs for childhood obesity candemonstrate success, long-term outcomes haveseldom been evaluated. The benefit ofintervention when overweight is identified ina screening assessment and parentalrecognition of the problem is minimal isunderstudied.
WHAT THIS STUDY ADDS: A low-dose (sessionsevery 1–3 months), but long-term (2 years),family-based intervention was effective atreducing BMI compared with usual care inchildren recruited via a weight screeninginitiative in which many parents had beenunaware their child was overweight.
Departments of aMedicine, dHuman Nutrition, eWomen’s and Children’s Health, and fPreventive and SocialMedicine, University of Otago, Dunedin, New Zealand; bPaediatric Services, Southern District Health Board,Dunedin, New Zealand; and cSchool of Psychology, Victoria University of Wellington, Dunedin, New Zealand
Dr R.W. Taylor was the principal investigator of the Motivational Interviewing and Treatment studyand had overall responsibility for it; she conceptualized and designed the study and drafted theinitial manuscript; Ms Cox and Drs Brown and Knight provided the clinical psychologist supervisionof the mentors; they also contributed to study design, reviewed and revised the manuscript, andapproved the final manuscript as submitted. Dr Dawson developed phase 1 of the project inconjunction with Drs Brown and Knight, and reviewed and revised the manuscript; Dr Meredith-Jones was the exercise specialist and reviewed and revised the manuscript; Dr Haszard wasa mentor and reviewed and revised the manuscript; Dr Williams designed and undertook allstatistical analyses and reviewed and revised the manuscript; Dr B.J. Taylor contributed to studydesign, provided pediatric consultant services when required, and reviewed and revised themanuscript; and all authors approved the final manuscript as submitted.
This trial has been registered with the Australian New Zealand Clinical Trials Registry(ACTRN12609000749202).
www.pediatrics.org/cgi/doi/10.1542/peds.2015-0595
DOI: 10.1542/peds.2015-0595
Accepted for publication Apr 30, 2015
ARTICLE
AAP PEDIATRIC COLLECTIONS136
Cost-Effectiveness of a Clinical Childhood Obesity InterventionMona Sharifi, MD, MPH, a Calvin Franz, PhD, b Christine M. Horan, MPH, c Catherine M. Giles, MPH, d Michael W. Long, ScD, e Zachary J. Ward, MPH, d Stephen C. Resch, PhD, f Richard Marshall, MD, g Steven L. Gortmaker, PhD, d Elsie M. Taveras, MD, MPHc, h
OBJECTIVES: To estimate the cost-effectiveness and population impact of the national
implementation of the Study of Technology to Accelerate Research (STAR) intervention for
childhood obesity.
METHODS: In the STAR cluster-randomized trial, 6- to 12-year-old children with obesity
seen at pediatric practices with electronic health record (EHR)-based decision support
for primary care providers and self-guided behavior-change support for parents had
significantly smaller increases in BMI than children who received usual care. We used a
microsimulation model of a national implementation of STAR from 2015 to 2025 among all
pediatric primary care providers in the United States with fully functional EHRs to estimate
cost, impact on obesity prevalence, and cost-effectiveness.
RESULTS: The expected population reach of a 10-year national implementation is ∼2 million
children, with intervention costs of $119 per child and $237 per BMI unit reduced. At
10 years, assuming maintenance of effect, the intervention is expected to avert 43 000
cases and 226 000 life-years with obesity at a net cost of $4085 per case and $774 per life-
year with obesity averted. Limiting implementation to large practices and using higher
estimates of EHR adoption improved both cost-effectiveness and reach, whereas decreasing
the maintenance of the intervention’s effect worsened the former.
CONCLUSIONS: A childhood obesity intervention with electronic decision support for clinicians
and self-guided behavior-change support for parents may be more cost-effective than
previous clinical interventions. Effective and efficient interventions that target children
with obesity are necessary and could work in synergy with population-level prevention
strategies to accelerate progress in reducing obesity prevalence.
abstract
NIH
aDepartment of Pediatrics, Section of General Pediatrics, Yale University School of Medicine, New Haven,
Connecticut; bEastern Research Group Inc, Lexington, Massachusetts; cDivision of General Academic Pediatrics,
Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts; Departments
of dSocial and Behavioral Sciences and hNutrition, and fCenter for Health Decision Science, Harvard T.H. Chan
School of Public Health, Harvard University, Boston, Massachusetts; eDepartment of Prevention and Community
Health, Milken Institute School of Public Health, George Washington University, Washington, District of
Columbia; and gDepartment of Pediatrics, Harvard Vanguard Medical Associates and Atrius Health Inc, Boston,
Massachusetts
Dr Sharifi conceptualized and designed the study, drafted the initial manuscript, and reviewed
and revised the manuscript; Dr Franz assisted with the cost analysis of the Study of Technology
to Accelerate Research (STAR) trial and critically reviewed and revised the manuscript;
Ms Horan assisted with the acquisition of cost data for the STAR trial and critically reviewed the
manuscript; Ms Giles and Drs Long, Resch, and Marshall contributed to the conceptualization
and design of the study and critically reviewed and revised the manuscript; Mr Ward contributed
to the conceptualization and design of the study, conducted the microsimulation modeling, and
critically reviewed and revised the manuscript; Dr Gortmaker contributed to the conceptualization
and design of the study, led the Childhood Obesity Intervention Cost-Effectiveness Study as
WHAT’S KNOWN ON THIS SUBJECT: Excess health care
costs attributable to obesity demand effective and
efficient strategies. To facilitate appropriate resource
allocation, economic evaluations can aid explicit
assessments of intervention efficiency and allow for
comparisons between interventions. Such analyses
are lacking in pediatric obesity management.
WHAT THIS STUDY ADDS: A childhood obesity
intervention involving electronic decision support
in primary care improved BMI at a cost of $119
per child and $237 per BMI unit reduced. National
implementation over 10 years could reach >2 million
children and avert 43 000 obesity cases.
To cite: Sharifi M, Franz C, Horan CM, et al. Cost-Effectiveness
of a Clinical Childhood Obesity Intervention. Pediatrics.
2017;140(5):e20162998
ARTICLE
145Obesity: Stigma, Trends, and Interventions
ARTICLE
Supplemental Information
SUPPLEMENTAL FIGURE 2Logic pathway linking the STAR intervention to change in obesity-related health care costs. Δ, change; PA, physical activity; SSB, sugar-sweetened beverages.
SUPPLEMENTAL FIGURE 3Hierarchical representation of the target population for the national implementation of the STAR intervention.
