Family systems approaches in pediatric obesity management: a scoping review.

Family-based obesity management interventions targeting child, adolescent and parental lifestyle behaviour modifications have shown promising results. Further intervening on the family system may lead to greater improvements in obesity management outcomes due to the broader focus on family patterns and dynamics that shape behaviours and health. This review aimed to summarize the scope of pediatric obesity management interventions informed by family systems theory (FST). Medline, Embase, CINAHL and PsycInfo were searched for articles where FST was used to inform pediatric obesity management interventions published from January 1980 to October 2023. After removal of duplicates, 6053 records were screened to determine eligibility. Data were extracted from 50 articles which met inclusion criteria; these described 27 unique FST-informed interventions. Most interventions targeted adolescents (44%), were delivered in outpatient hospital settings (37%), and were delivered in person (81%) using group session modalities (44%). Professionals most often involved were dieticians and nutritionists (48%). We identified 11 FST-related concepts that guided intervention components, including parenting skills, family communication, and social/family support. Among included studies, 33 reported intervention effects on at least one outcome, including body mass index (BMI) (n = 24), lifestyle behaviours (physical activity, diet, and sedentary behaviours) (n = 18), mental health (n = 12), FST-related outcomes (n = 10), and other outcomes (e.g., adiposity, cardiometabolic health) (n = 18). BMI generally improved following interventions, however studies relied on a variety of comparison groups to evaluate intervention effects. This scoping review synthesises the characteristics and breadth of existing FST-informed pediatric obesity management interventions and provides considerations for future practice and research.

The Aim2Be mHealth Intervention for Children With Overweight or Obesity and Their Parents: Person-Centered Analyses to Uncover Digital Phenotypes.

BACKGROUND: Despite the growing number of mobile health (mHealth) interventions targeting childhood obesity, few studies have characterized user typologies derived from individuals' patterns of interactions with specific app features (digital phenotypes). OBJECTIVE: This study aims to identify digital phenotypes among 214 parent-child dyads who used the Aim2Be mHealth app as part of a randomized controlled trial conducted between 2019 and 2020, and explores whether participants' characteristics and health outcomes differed across phenotypes. METHODS: Latent class analysis was used to identify distinct parent and child phenotypes based on their use of the app's behavioral, gamified, and social features over 3 months. Multinomial logistic regression models were used to assess whether the phenotypes differed by demographic characteristics. Covariate-adjusted mixed-effect models evaluated changes in BMI z scores (zBMI), diet, physical activity, and screen time across phenotypes. RESULTS: Among parents, 5 digital phenotypes were identified: socially engaged (35/214, 16.3%), independently engaged (18/214, 8.4%) (socially and independently engaged parents are those who used mainly the social or the behavioral features of the app, respectively), fully engaged (26/214, 12.1%), partially engaged (32/214, 15%), and unengaged (103/214, 48.1%) users. Married parents were more likely to be fullyengaged than independently engaged (P=.02) or unengaged (P=.01) users. Socially engaged parents were older than fullyengaged (P=.02) and unengaged (P=.01) parents. The latent class analysis revealed 4 phenotypes among children: fully engaged (32/214, 15%), partially engaged (61/214, 28.5%), dabblers (42/214, 19.6%), and unengaged (79/214, 36.9%) users. Fully engaged children were younger than dabblers (P=.04) and unengaged (P=.003) children. Dabblers lived in higher-income households than fully and partiallyengaged children (P=.03 and P=.047, respectively). Fully engaged children were more likely to have fully engaged (P<.001) and partiallyengaged (P<.001) parents than unengaged children. Compared with unengaged children, fully and partiallyengaged children had decreased total sugar (P=.006 and P=.004, respectively) and energy intake (P=.03 and P=.04, respectively) after 3 months of app use. Partially engaged children also had decreased sugary beverage intake compared with unengaged children (P=.03). Similarly, children with fully engaged parents had decreased zBMI, whereas children with unengaged parents had increased zBMI over time (P=.005). Finally, children with independently engaged parents had decreased caloric intake, whereas children with unengaged parents had increased caloric intake over time (P=.02). CONCLUSIONS: Full parent-child engagement is critical for the success of mHealth interventions. Further research is needed to understand program design elements that can affect participants' engagement in supporting behavior change. TRIAL REGISTRATION: ClinicalTrials.gov NCT03651284; https://clinicaltrials.gov/ct2/show/NCT03651284. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-020-4080-2.

Pediatric ambulatory appointment scheduling: a qualitative study of stakeholders' perceptions and experiences.

OBJECTIVE: Scheduling ambulatory clinic appointments includes a complex set of factors and diverse stakeholders. Families, administrative staff and clinicians may have varied experiences with scheduling clinic appointments. The objective of our study was to understand stakeholders' perceptions and experiences with scheduling pediatric ambulatory clinic appointments. DESIGN: Guided methodologically by qualitative description, focus groups were conducted separately with three stakeholder groups and analyzed using qualitative content analysis. SETTING: This qualitative study was completed at a children's hospital in Alberta, Canada. PARTICIPANTS: Parents, administrative professionals and clinicians who used the pediatric ambulatory scheduling system regularly to elicit perceptions and experiences about issues and areas where improvements could be made. RESULTS: Across 12 focus groups, parents (n = 11), administrative professionals (n = 23) and clinicians (n = 13) discussed areas for improvement related to the pediatric ambulatory scheduling system. The perceived areas for improvement were grouped into three categories regarding levels of influence: (i) 'intrapersonal': knowledge, skills and behaviors (e.g. insufficient training of administrative professionals); (ii) 'interpersonal': communication processes (e.g. parents not receiving confirmation letters); and (iii) 'institutional': structures and processes (e.g. varying practices and processes across clinics). CONCLUSIONS: Stakeholders provided a rich description of the interrelated factors and processes that influenced the scheduling of pediatric ambulatory clinic appointments. Multilevel, experimental interventions are needed to test whether the findings described herein can enhance the structure and function of pediatric ambulatory appointment scheduling.

The Edmonton Obesity Staging System for Pediatrics: A proposed clinical staging system for paediatric obesity.

Traditionally, clinical recommendations for assessing and managing paediatric obesity have relied on anthropometric measures, such as body mass index (BMI), BMI percentile and/or BMI z-score, to monitor health risks and determine weight management success. However, anthropometric measures do not always accurately and reliably identify children and youth with obesity-related health risks or comorbidities. The authors propose a new clinical staging system (the Edmonton Obesity Staging System for Pediatrics, EOSS-P), adapted from the adult-oriented EOSS. The EOSS-P is used to stratify patients according to severity of obesity-related comorbidities and barriers to weight management into four graded categories (0 to 3) within four main health domains: metabolic, mechanical, mental health and social milieu (the 4Ms). The EOSS-P is based on common clinical assessments that are widely available and routinely completed by clinicians, and has the potential to provide clinical and prognostic information to help evaluate and inform the management of paediatric obesity.

D'ordinaire, les recommandations cliniques pour évaluer et prendre en charge l'obésité juvénile reposent sur des mesures anthropométriques, telles que l'indice de masse corporelle (IMC), le percentile d'IMC ou l'écart réduit de l'IMC, pour surveiller les risques sur la santé et déterminer la bonne gestion du poids. Cependant, les mesures anthropométriques ne permettent pas toujours de déterminer avec précision et fiabilité les enfants et les adolescents présentant des risques de santé ou des comorbidités liés à l'obésité. Les auteurs proposent un nouveau système clinique d'établissement du stade de l'obésité (le système d'Edmonton pour évaluer le stade de l'obésité, ou EOSS-P), adapté de l'EOSS destiné aux adultes. L'EOSS-P est utilisé pour stratifier les patients selon la gravité des comorbidités liées à l'obésité et les obstacles à la gestion du poids en quatre catégories (0 à 3) tirées de quatre grands domaines de santé : métabolique, mécanique, santé mentale et milieu social (les 4M). L'EOSS-P, qui repose sur des évaluations cliniques courantes généralisées souvent remplies par les cliniciens, peut fournir de l'information clinique et pronostique pour contribuer à évaluer et étayer la prise en charge de l'obésité juvénile.

Modest treatment effects and high program attrition: The impact of interdisciplinary, individualized care for managing paediatric obesity.

BACKGROUND: There is an urgent need to identify effective weight management interventions in real-world, clinical settings to improve the health of children with obesity. OBJECTIVES: To determine the impact of individualized, interdisciplinary care on the weight status of children with obesity; to assess the relationship between clinical interactions and change in participants' weight status; and to document the degree of program attrition. METHODS: A retrospective medical record review of clinical and administrative data from a paediatric weight management clinic in Edmonton, Alberta, was performed, which included data from a group of five- to 18-year-olds (body mass index [BMI] ≥85th percentile) collected from 2008 to 2012. Demographic, anthropometric and attendance data were retrieved from baseline and follow-up at three-, seven- and 11-month timepoints. The primary outcomes were participants' BMI z-score and change in BMI z-score over time. RESULTS: Data from 165 individuals were included. Among those with follow-up anthropometric data, weight stabilization occurred at three (n=127) and seven months (n=84). For individuals with follow-up anthropometric data at 11 months (n=44), BMI z-score tended to decrease over time (-0.05±0.12 units; P=0.06). Program attrition increased over time (23%, 49% and 73% at three-, seven- and 11-month follow-ups, respectively). Between presentation and three-month follow-up, there was an inverse relationship between the number of clinical appointments attended and change in BMI z-score (r= -0.18; P=0.04), an association that became nonsignificant at seven and 11 months (both P>0.05). CONCLUSION: An individualized, interdisciplinary weight management intervention led to weight stabilization and a modest weight reduction in children with obesity. Strategies to minimize program attrition are needed to optimize family engagement in care and success in managing paediatric obesity.

HISTORIQUE: Il est urgent de trouver des interventions efficaces de gestion du poids en milieu clinique pour améliorer la santé des enfants obèses. OBJECTIFS: Déterminer les effets de soins personnalisés et interdisciplinaires sur le poids d'enfants obèses, évaluer le lien entre les interactions cliniques et les modifications au poids des participants et établir le taux d'abandon du programme. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers médicaux et des données administratives d'une clinique pédiatrique de gestion du poids d'Edmonton, en Alberta, qui incluait les données d'un groupe de jeunes de cinq à 18 ans (indice de masse corporelle [IMC] ≥85e percentile) colligées entre 2008 et 2012. Ils ont extrait les données démographiques, anthropométriques et de participation initiales, puis aux suivis de trois, sept et 11 mois. Les résultats primaires étaient l'écart réduit de l'IMC et le changement à cet écart au fil du temps. RÉSULTATS: Les données de 165 personnes ont été incluses dans l'étude. Parmi les personnes qui possédaient des données anthropométriques de suivi, on a observé une stabilisation du poids au bout de trois (n=127) et sept mois (n=84). Chez les personnes qui possédaient des données anthropométriques au suivi de 11 mois (n=44), l'écart réduit de l'IMC avait tendance à diminuer au fil du temps (−0,05±0,12 unités; P=0,06). L'abandon du programme a augmenté dans le temps (23 %, 49 % et 73 % au suivi de trois, sept et 11 mois, respectivement). Entre la présentation et le suivi de trois mois, le lien entre le nombre de rendez-vous cliniques auquel les patients avaient assisté était inversement proportionnel à la modification de l'écart réduit de l'IMC (r= −0,18; P=0,04), une association qui n'était plus significative au suivi de sept et 11 mois (tous deux P>0,05). CONCLUSION: Une intervention personnalisée et interdisciplinaire a suscité la stabilisation du poids et une légère perte de poids chez des enfants obèses. Des stratégies pour réduire au minimum l'abandon du programme s'imposent pour optimiser la participation familiale aux soins et réussir à gérer l'obésité en pédiatrie.

Adolescent and Caregiver Perspectives on Family Navigation to Improve Healthcare Access and Use for Managing Pediatric Obesity.

We interviewed families to explore their views on the role of family navigation (FN) to improve access to and use of health services for managing pediatric obesity. From March to December, 2020, we conducted individual, structured telephone interviews with adolescents with obesity (13-17 years old) and their caregivers from Edmonton and Calgary, Canada. Among our 37 participants (14 adolescents, 23 caregivers), most (n = 27; 73.0%) reported FN could improve their access to obesity management. Participants recommended several activities to support healthcare access and use, including appointment reminders, evening/weekend appointments, parking/transportation support, and in-clinic childcare, all of which help families to attend appointments over an extended period to support obesity management. Most participants preferred FN be offered by healthcare professional 'navigators' who were approachable, empathic, and compassionate since issues regarding health and obesity can be sensitive, emotional topics to discuss. Overall, families supported integrating FN into multidisciplinary pediatric obesity management to improve healthcare access and use by navigators who apply a range of practical strategies and relational skills to enhance long-term access and adherence to care.

Lessons Learned From Using Focus Groups to Refine Digital Interventions.

There is growing interest in applying novel eHealth approaches for the prevention and management of various health conditions, with the ultimate goal of increasing positive patient outcomes and improving the effectiveness and efficiency of health services delivery. Coupled with the use of innovative approaches is the possibility for adverse outcomes, highlighting the need to strategically refine digital practices prior to implementation with patients. One appropriate method for modification purposes includes focus groups. Although it is a well-established method in qualitative research, there is a lack of guidance regarding the use of focus groups for digital intervention refinement. To address this gap, the purpose of our paper is to highlight several lessons our research team has learned in using focus groups to help refine digital interventions prior to use with patients.

Working With Parents to Prevent Childhood Obesity: Protocol for a Primary Care-Based eHealth Study.

BACKGROUND: Parents play a central role in preventing childhood obesity. There is a need for innovative, scalable, and evidence-based interventions designed to enhance parents' motivation to support and sustain healthy lifestyle behaviors in their children, which can facilitate obesity prevention. OBJECTIVE: (1) Develop an online screening, brief intervention, and referral to treatment (SBIRT) eHealth tool to enhance parents' concern for, and motivation to, support children's healthy lifestyle behaviors, (2) refine the SBIRT eHealth tool by assessing end-user acceptability, satisfaction, and usability through focus groups, and (3) determine feasibility and preliminary effectiveness of the refined SBIRT eHealth tool through a randomized controlled trial. METHODS: This is a three-phase, multi-method study that includes SBIRT eHealth tool development (Phase I), refinement (Phase II), and testing (Phase III). Phase I: Theoretical underpinnings of the SBIRT tool, entitled the Resource Information Program for Parents on Lifestyle and Education (RIPPLE), will be informed by concepts applied within existing interventions, and content will be based on literature regarding healthy lifestyle behaviors in children. The SBIRT platform will be developed in partnership between our research team and a third-party intervention development company. Phase II: Focus groups with parents, as well as health care professionals, researchers, and trainees in pediatrics (n=30), will explore intervention-related perceptions and preferences. Qualitative data from the focus groups will inform refinements to the aesthetics, content, structure, and function of the SBIRT. Phase III: Parents (n=200) of children-boys and girls, 5 to 17 years old-will be recruited from a primary care pediatric clinic while they await their children's clinical appointment. Parents will be randomly assigned to one of five groups-four intervention groups and one control group-as they complete the SBIRT. The randomization function is built into the tool. Parents will complete the eHealth SBIRT using a tablet that will be connected to the Internet. Subsequently, parents will be contacted via email at 1-month follow-up to assess (1) change in concern for, and motivation to, support children's dietary and physical activity behaviors (primary outcome), and (2) use of online resources and referrals to health services for obesity prevention (secondary outcome). RESULTS: This research was successfully funded and received ethics approval. Development of the SBIRT started in summer 2012, and we expect all study-related activities to be completed by fall 2016. CONCLUSIONS: The proposed research is timely and applies a novel, technology-based application designed to enhance parents concern for, and motivation to, support children's healthy lifestyle behaviors and encourage use of online resources and community services for childhood obesity prevention. Overall, this research builds on a foundation of evidence supporting the application of SBIRTs to encourage or "nudge" individuals to make healthy lifestyle choices. Findings from Phase III of this project will directly inform a cluster randomized controlled trial to study the effectiveness of our intervention across multiple primary care-based settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02330588; http://clinicaltrials.gov/ct2/show/NCT02330588 (Archived by WebCite at http://www.webcitation.org/6WyUOeRlr).

It's like rocket science only more complex: challenges and experiences related to managing pediatric obesity in Canada.

Pediatric obesity is an urgent and complex public health issue. Approximately one-third of Canadian children are overweight or obese, a proportion that highlights the need for effective and accessible services to improve short- and long-term health risks. In our experience, we have encountered a number of challenges common in pediatric obesity management across our clinical and research centers. For the purpose of this review, these challenges and our real-world experiences are grouped as issues that span (i) caring for children, adolescents, and families, (ii) collaborating with colleagues and (iii) working within the health care system. Collectively, we highlight a number of lessons learned from our years of experience and detail ongoing initiatives designed to optimize health services for managing obesity for children and adolescents in Canada.

One-on-one lifestyle coaching for managing adolescent obesity: Findings from a pilot, randomized controlled trial in a real-world, clinical setting.

BACKGROUND: Interventions for obese adolescents in real-world, clinical settings need to be evaluated because most weight management care occurs in this context. OBJECTIVES: To determine whether a lifestyle intervention that includes motivational interviewing and cognitive behavioural therapy (Health Initiatives Program [HIP]) leads to weight management that is superior to a similar lifestyle intervention (Youth Lifestyle Program [YLP]) that does not include these techniques; and to determine whether the HIP and YLP interventions are superior to a wait list control (WLC) group. METHODS: Obese adolescents were randomly assigned to a YLP (n=15), HIP (n=17) or WLC (n=14) group. The YLP and HIP were 16-session, one-on-one interventions. The primary outcome was the percentage change of body mass index z-score. RESULTS: Completers-only analyses revealed 3.9% (YLP) and 6.5% (HIP) decreases in the percentage change of body mass index z-score compared with a 0.8% (WLC) increase (P<0.001). Levels of attrition did not differ among groups, but were relatively high (approximately 20% to 40%). CONCLUSION: Lifestyle interventions delivered in a real-world, clinical setting led to short-term improvements in the obesity status of adolescents.

A protocol for a systematic review of knowledge translation strategies in the allied health professions.

BACKGROUND: Knowledge translation (KT) aims to close the gap between knowledge and practice in order to realize the benefits of research through (a) improved health outcomes, (b) more effective health services and products, and (c) strengthened healthcare systems. While there is some understanding of strategies to put research findings into practice within nursing and medicine, we have limited knowledge of KT strategies in allied health professions. Given the interprofessional nature of healthcare, a lack of guidance for supporting KT strategies in the allied health professions is concerning. Our objective in this study is to systematically review published research on KT strategies in five allied health disciplines. METHODS: A medical research librarian will develop and implement search strategies designed to identify evidence that is relevant to each question of the review. Two reviewers will perform study selection and quality assessment using standard forms. For study selection, data will be extracted by two reviewers. For quality assessment, data will be extracted by one reviewer and verified by a second. Disagreements will be resolved through discussion or third party adjudication. Within each profession, data will be grouped and analyzed by research design and KT strategies using the Effective Practice and Organisation of Care Review Group classification scheme. An overall synthesis across professions will be conducted. SIGNIFICANCE: A uniprofessional approach to KT does not represent the interprofessional context it targets. Our findings will provide the first systematic overview of KT strategies used in allied health professionals' clinical practice, as well as a foundation to inform future KT interventions in allied healthcare settings.

An interdisciplinary, family-centered approach to treating pediatric obesity in an 11-year-old female: a case report.

Pediatric obesity has become increasingly prevalent over the past 2-3 decades. Recently-published clinical practice guidelines and expert recommendations provide guidance for obesity treatment, but therapy is often complicated by a host of medical, behavioural, psychosocial, and interpersonal issues. We report the case of an 11-year-old obese girl and her family referred for weight management. Our case underscores the need for an interdisciplinary, family-centered approach to the assessment and treatment of pediatric obesity, and highlights the value of understanding familial complexities that often accompany this health issue. The importance of utilizing multiple health indicators to assess weight management 'success' is discussed.