Family-centeredness of childhood obesity interventions: psychometrics & outcomes of the family-centered care assessment tool.

BACKGROUND: Incorporating family-centered care principles into childhood obesity interventions is integral for improved clinical decision making, better follow-through, and more effective communication that leads to better outcomes and greater satisfaction with services. The purpose of this study is to evaluate the psychometric properties of a modified version of the Family Centered-Care Assessment (mFCCA) tool and to assess the family-centeredness of two clinical-community childhood obesity interventions. METHODS: Connect for Health was a randomized trial testing the comparative effectiveness of two interventions that enrolled 721 children, ages 2-12 years, with a body mass index (BMI) ≥ 85th percentile. The two arms were (1) enhanced primary care; and (2) enhanced primary care plus contextually-tailored, health coaching. At the end of the one-year intervention, the mFCCA was administered. We used Rasch analyses to assess the tool's psychometrics and examined differences between the groups using multiple linear regression. RESULTS: 629 parents completed the mFCCA resulting in an 87% response rate. The mean (SD) age of children was 8.0 (3.0) years. The exploratory factor analysis with 24 items all loaded onto a single factor. The Rasch modeling demonstrated good reliability as evidenced by the person separation reliability coefficient (0.99), and strong validity as evidenced by the range of item difficulty and overall model fit. The mean (SD, range) mFCCA score was 4.14 (0.85, 1-5). Compared to parents of children in the enhanced primary care arm, those whose children were in the enhanced primary care plus health coaching arm had higher mFCCA scores indicating greater perception of family-centeredness (ß = 0.61 units [95% CI: 0.49, 0.73]). CONCLUSIONS: Using the mFCCA which demonstrated good psychometric properties for the assessment of family-centered care among parents of children with obesity, we found that individualized health coaching is a family-centered approach to pediatric weight management. TRIAL REGISTRATION: Clinicaltrials.gov NCT02124460.

Evaluating the Implementation of a Before-School Physical Activity Program: A Mixed-Methods Approach in Massachusetts, 2018.

PURPOSE AND OBJECTIVES: Our aim was to evaluate the implementation of a widely available, before-school, physical activity program in a low-resource, racially/ethnically and socioeconomically diverse, urban school setting to identify adaptations needed for successful implementation. INTERVENTION APPROACH: We used a collaborative effort with stakeholders to implement the Build Our Kids' Success (BOKS) program in 3 schools in Revere, Massachusetts. Program structure followed a preexisting curriculum, including 60-minute sessions, 3 mornings per week, over 2 sessions (spring and fall 2018). Programs had a capacity of 40 students per school per session and the ability to adapt as needed. EVALUATION METHODS: We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RE-AIM domains were assessed by use of baseline and follow-up student measures, parent interviews, and program administrative records. RESULTS: From a district of 11 schools, 3 schools (2 elementary, 1 middle) implemented the BOKS program. Program enrollment reached 82% capacity (188 of 230 potential participants). Of the 188 enrolled students, 128 (68%) had parental consent for study participation. Among the 128 study participants, 61 (48%) were male, 52 (41%) identified as Hispanic/Latino, and mean age was 9.3 years (SD, 2.2). Program duration varied by school (25-60 minutes), with a mean of 33% (SD, 16%) of the session spent in actigraphy-measured moderate-to-vigorous physical activity (MVPA), or mean 16.3 (SD, 9.3) minutes of MVPA. Participants attended a median 90% (interquartile range [IQR], 56%-97%) of sessions. We observed no change in body mass index (BMI) z score or self-reported quality of life from baseline to follow-up assessment. Parents reported positive program effects. Enrollment was sustained in elementary schools and decreased in the middle school during the study period, expanding to 3 additional schools for spring 2019. IMPLICATIONS FOR PUBLIC HEALTH: Implementation and evaluation of an evidence-based physical activity program, in a low-resource setting, are feasible and yield relevant information about program adaptations and future dissemination of similar programs.

The role of neighborhood characteristics and the built environment in understanding racial/ethnic disparities in childhood obesity.

BACKGROUND: Childhood obesity prevalence remains high and racial/ethnic disparities may be widening. Studies have examined the role of health behavioral differences. Less is known regarding neighborhood and built environment mediators of disparities. The objective of this study was to examine the extent to which racial/ethnic disparities in elevated child body mass index (BMI) are explained by neighborhood socioeconomic status (SES) and built environment. METHODS: We collected and analyzed race/ethnicity, BMI, and geocoded address from electronic health records of 44,810 children 4 to 18years-old seen at 14 Massachusetts pediatric practices in 2011-2012. Main outcomes were BMI z-score and BMI z-score change over time. We used multivariable linear regression to examine associations between race/ethnicity and BMI z-score outcomes, sequentially adjusting for neighborhood SES and the food and physical activity environment. RESULTS: Among 44,810 children, 13.3% were black, 5.7% Hispanic, and 65.2% white. Compared to white children, BMI z-scores were higher among black (0.43units [95% CI: 0.40-0.45]) and Hispanic (0.38 [0.34-0.42]) children; black (0.06 [0.04-0.08]), but not Hispanic, children also had greater increases in BMI z-score over time. Adjusting for neighborhood SES substantially attenuated BMI z-score differences among black (0.30 [0.27-0.34]) and Hispanic children (0.28 [0.23-0.32]), while adjustment for food and physical activity environments attenuated the differences but to a lesser extent than neighborhood SES. CONCLUSIONS: Neighborhood SES and the built environment may be important drivers of childhood obesity disparities. To accelerate progress in reducing obesity disparities, interventions must be tailored to the neighborhood contexts in which families live.

Development and Implementation of an Interactive Text Messaging Campaign to Support Behavior Change in a Childhood Obesity Randomized Controlled Trial.

Text messaging is a promising means of intervening on an array of health issues among varied populations, but little has been published about the development of such interventions. The authors describe the development and implementation of an interactive text messaging campaign for parents to support behavior change among children in a childhood obesity randomized controlled trial. The authors invited 160 parents to participate in a text messaging intervention that provided behavior change support in conjunction with health coaching phone calls and mailed materials on behavioral goals. Throughout the 1-year intervention, the authors sent 1-2 text messages per week. The first asked how the child did with a target behavior the day before; parents who replied received an immediate feedback message tailored to their response. The second included a tip about how to work toward a behavioral goal. Baseline surveys indicate that text messaging is a common means of communication for parents, and many are willing to use text messaging to support behavior change for their child. Results at 1 year indicate a high level of engagement with the text messaging intervention, with nearly two thirds responding to 75% or more of the questions they were sent by text.

Participant characteristics and intervention processes associated with reductions in television viewing in the High Five for Kids study.

OBJECTIVE: To evaluate the High Five for Kids intervention effect on television within subgroups, examine participant characteristics associated with process measures and assess perceived helpfulness of television intervention components. METHOD: High Five (randomized controlled trial of 445 overweight/obese 2-7 year-olds in Massachusetts [2006-2008]) reduced television by 0.36 h/day. 1-year effects on television viewing, stratified by subgroup, were assessed using linear regression. Among intervention participants (n=253), associations of intervention component helpfulness with television reduction were examined using linear regression and associations of participant characteristics with processes linked to television reduction (choosing television and completing intervention visits) were examined using logistic regression. RESULTS: High Five reduced television across subgroups. Parents of Latino (versus white) children had lower odds of completing ≥2 study visits (Odds Ratio: 0.39 [95% Confidence Interval: 0.18, 0.84]). Parents of black (versus white) children had higher odds of choosing television (Odds Ratio: 2.23 [95% Confidence Interval: 1.08, 4.59]), as did parents of obese (versus overweight) children and children watching ≥2 h/day (versus <2) at baseline. Greater perceived helpfulness was associated with greater television reduction. CONCLUSION: Clinic-based motivational interviewing reduces television viewing in children. Low cost education approaches (e.g., printed materials) may be well-received. Parents of children at higher obesity risk could be more motivated to reduce television.

The cost of a primary care-based childhood obesity prevention intervention.

BACKGROUND: United States pediatric guidelines recommend that childhood obesity counseling be conducted in the primary care setting. Primary care-based interventions can be effective in improving health behaviors, but also costly. The purpose of this study was to evaluate the cost of a primary care-based obesity prevention intervention targeting children between the ages of two and six years who are at elevated risk for obesity, measured against usual care. METHODS: High Five for Kids was a cluster-randomized controlled clinical trial that aimed to modify children's nutrition and TV viewing habits through a motivational interviewing intervention. We assessed visit-related costs from a societal perspective, including provider-incurred direct medical costs, provider-incurred equipment costs, parent time costs and parent out-of-pocket costs, in 2011 dollars for the intervention (n = 253) and usual care (n =192) groups. We conducted a net cost analysis using both societal and health plan costing perspectives and conducted one-way sensitivity and uncertainty analyses on results. RESULTS: The total costs for the intervention group and usual care groups in the first year of the intervention were $65,643 (95% CI [$64,522, $66,842]) and $12,192 (95% CI [$11,393, $13,174]). The mean costs for the intervention and usual care groups were $259 (95% CI [$255, $264]) and $63 (95% CI [$59, $69]) per child, respectively, for a incremental difference of $196 (95% CI [$191, $202]) per child. Children in the intervention group attended a mean of 2.4 of a possible 4 in-person visits and received 0.45 of a possible 2 counseling phone calls. Provider-incurred costs were the primary driver of cost estimates in sensitivity analyses. CONCLUSIONS: High Five for Kids was a resource-intensive intervention. Further studies are needed to assess the cost-effectiveness of the intervention relative to other pediatric obesity interventions.

Ketamine for postoperative avoidance of depressive symptoms: the K-PASS feasibility randomised trial.

Background: Surgical patients with previous depression frequently experience postoperative depressive symptoms. This study's objective was to determine the feasibility of a placebo-controlled trial testing the impact of a sustained ketamine infusion on postoperative depressive symptoms. Methods: This single-centre, triple-blind, placebo-controlled randomised clinical trial included adult patients with depression scheduled for inpatient surgery. After surgery, patients were randomly allocated to receive ketamine (0.5 mg kg-1 over 10 min followed by 0.3 mg kg-1 h-1 for 3 h) or an equal volume of normal saline. Depressive symptoms were measured using the Montgomery-Asberg Depression Rating Scale. On post-infusion day 1, participants guessed which intervention they received. Feasibility endpoints included the fraction of patients approached who were randomised, the fraction of randomised patients who completed the study infusion, and the fraction of scheduled depression assessments that were completed. Results: In total, 32 patients were allocated a treatment, including 31/101 patients approached after a protocol change (31%, 1.5 patients per week). The study infusion was completed without interruption in 30/32 patients (94%). In each group, 7/16 participants correctly guessed which intervention they received. Depression assessments were completed at 170/192 scheduled time points (89%). Between baseline and post-infusion day 4 (pre-specified time point of interest), median depressive symptoms decreased in both groups, with difference-in-differences of -1.00 point (95% confidence interval -3.23 to 1.73) with ketamine compared with placebo. However, the between-group difference did not persist at other time points. Conclusions: Patient recruitment, medication administration, and clinical outcome measurement appear to be highly feasible, with blinding maintained. A fully powered trial may be warranted. Clinical trial registration: NCT05233566.

Leveraging text messaging and mobile technology to support pediatric obesity-related behavior change: a qualitative study using parent focus groups and interviews.

BACKGROUND: Text messaging (short message service, SMS) is a widely accessible and potentially cost-effective medium for encouraging behavior change. Few studies have examined text messaging interventions to influence child health behaviors or explored parental perceptions of mobile technologies to support behavior change among children. OBJECTIVE: Our aim was to examine parental acceptability and preferences for text messaging to support pediatric obesity-related behavior change. METHODS: We conducted focus groups and follow-up interviews with parents of overweight and obese children, aged 6-12 years, seen for "well-child" care in eastern Massachusetts. A professional moderator used a semistructured discussion guide and sample text messages to catalyze group discussions. Seven participants then received 3 weeks of text messages before a follow-up one-on-one telephone interview. All focus groups and interviews were recorded and transcribed verbatim. Using a framework analysis approach, we systematically coded and analyzed group and interview data to identify salient and convergent themes. RESULTS: We reached thematic saturation after five focus groups and seven follow-up interviews with a total of 31 parents of diverse race/ethnicity and education levels. Parents were generally enthusiastic about receiving text messages to support healthy behaviors for their children and preferred them to paper or email communication because they are brief and difficult to ignore. Participants anticipated high responsiveness to messaging endorsed by their child's doctor and indicated they would appreciate messages 2-3 times/week or more as long as content remains relevant. Suggestions for maintaining message relevance included providing specific strategies for implementation and personalizing information. Most felt the negative features of text messaging (eg, limited message size) could be overcome by providing links within messages to other media including email or websites. CONCLUSIONS: Text messaging is a promising medium for supporting pediatric obesity-related behavior change. Parent perspectives could assist in the design of text-based interventions. TRIAL REGISTRATION: Clinicaltrials.gov NCT01565161; http://clinicaltrials.gov/show/NCT01565161 (Archived by WebCite at http://www.webcitation.org/6LSaqFyPP).

Parent and Pediatrician Perspectives on Physical Activity Promotion in Pediatric Primary Care: A Preliminary Mixed Methods Study.

PURPOSE: To elicit preliminary pediatrician and parent perspectives on physical activity (PA) counseling and identify opportunities for improvement. DESIGN: Mixed methods, including a cross-sectional survey and semi-structured interviews. SETTING AND PARTICIPANTS: Primary care pediatricians (N = 73; 40% response rate) within a single large healthcare system and parents of students (N = 20) participating in a local school-based PA program in eastern Massachusetts. METHODS: Electronic survey of pediatricians assessing opinions of American Academy of Pediatrics (AAP) PA guidelines and potential PA promotion tools; semi-structured qualitative interviews with parents assessing overall discussion, education, and recommendations relating to PA. ANALYSIS: We report descriptive statistics for survey items and bivariate analyses comparing responses by physician characteristics. We performed thematic analysis of qualitative interviews and present results through an implementation science framework. RESULTS: In this preliminary study, pediatricians reported adoption, appropriateness, and lower perceived effectiveness of PA counseling. School-based programs and educational materials were most often chosen as PA promotion tools. Responses varied by pediatrician characteristics. While parents reported satisfaction, opportunities for improvement included connections with community resources and continued conversations with the child about PA. CONCLUSIONS: Pediatricians and parents highlighted gaps in PA counseling in primary care. While results are preliminary given small sample size, this study provides actionable targets to support PA promotion as a preventive health priority in this setting.

Psilocybin desynchronizes brain networks.

1The relationship between the acute effects of psychedelics and their persisting neurobiological and psychological effects is poorly understood. Here, we tracked brain changes with longitudinal precision functional mapping in healthy adults before, during, and for up to 3 weeks after oral psilocybin and methylphenidate (17 MRI visits per participant) and again 6+ months later. Psilocybin disrupted connectivity across cortical networks and subcortical structures, producing more than 3-fold greater acute changes in functional networks than methylphenidate. These changes were driven by desynchronization of brain activity across spatial scales (area, network, whole brain). Psilocybin-driven desynchronization was observed across association cortex but strongest in the default mode network (DMN), which is connected to the anterior hippocampus and thought to create our sense of self. Performing a perceptual task reduced psilocybin-induced network changes, suggesting a neurobiological basis for grounding, connecting with physical reality during psychedelic therapy. The acute brain effects of psilocybin are consistent with distortions of space-time and the self. Psilocybin induced persistent decrease in functional connectivity between the anterior hippocampus and cortex (and DMN in particular), lasting for weeks but normalizing after 6 months. Persistent suppression of hippocampal-DMN connectivity represents a candidate neuroanatomical and mechanistic correlate for psilocybin's pro-plasticity and anti-depressant effects.

Emergence of racial/ethnic and socioeconomic differences in objectively measured sleep-wake patterns in early infancy: results of the Rise & SHINE study.

STUDY OBJECTIVES: To characterize objectively assessed sleep-wake patterns in infants at approximately 1 month and 6 months and examine the differences among infants with different racial/ethnic backgrounds and household socioeconomic status (SES). METHODS: Full-term healthy singletons wore an ankle-placed actigraph at approximately 1 month and 6 months and parents completed sleep diaries. Associations of racial/ethnic and socioeconomic indices with sleep outcomes were examined using multivariable analyses. Covariates included sex, birth weight for gestational age z-score, age at assessment, maternal education, household income, bed-sharing, and breastfeeding. RESULTS: The sample included 306 infants, of whom 51% were female, 42.5% non-Hispanic white, 32.7% Hispanic, 17.3% Asian, and 7.5% black. Between 1 month and 6 months, night sleep duration increased by 65.7 minutes (95% CI: 55.4, 76.0), night awakenings decreased by 2.2 episodes (2.0, 2.4), and daytime sleep duration decreased by 73.3 minutes (66.4, 80.2). Compared to change in night sleep duration over this development period for white infants (82.3 minutes [66.5, 98.0]), night sleep increased less for Hispanic (48.9 minutes [30.8, 66.9]) and black infants (31.6 minutes [-5.9, 69.1]). Night sleep duration also increased less for infants with lower maternal education and household income. Asian infants had more frequent night awakenings. Adjustment for maternal education and household income attenuated all observed day and night sleep duration differences other than in Asians, where persistently reduced nighttime sleep at 6 months was observed. CONCLUSIONS: Racial/ethnic differences in sleep emerge in early infancy. Night and 24-hour sleep durations increase less in Hispanic and black infants compared to white infants, with differences largely explained by SES.

Emergence of racial/ethnic differences in infant sleep duration in the first six months of life.

OBJECTIVE: Examine the emergence of differences in sleep duration between infants from different racial/ethnic backgrounds and extent to which differences are explained by socioeconomic status (SES) and sleep continuity. METHODS: Sleep duration and continuity (number of night wakings and longest nighttime stretch of sleep) were assessed for 394 infants in the Rise & Sleep Health in Infancy & Early Childhood (SHINE) birth cohort at one- and six-months using the Brief Infant Sleep Questionnaire (BISQ). Multivariable regression was used to estimate associations of race/ethnicity with sleep duration adjusting for individual-level covariates, SES, and sleep continuity. RESULTS: The sample was 40% non-Hispanic white, 33% Hispanic, 11% Black, and 15% Asian. Mean (SD) durations for daytime, nighttime, and total sleep at one-month were 6.3 (2.0), 8.9 (1.5), and 15.2 (2.7) hours, respectively. Corresponding durations at six-months were 3.0 (1.4), 9.9 (1.3), and 13.0 (1.9) hours. At one-month, Hispanic infants had shorter nighttime sleep than white infants [ß: -0.44 h (95% CI: -0.80, -0.08)]. At six-months, Hispanic [ß: -0.96 h (-1.28, -0.63)] and Black [ß: -0.60 h (-1.07, -0.12)] infants had shorter nighttime sleep than white infants. The near 1-h differential in night sleep among Hispanics resulted in shorter total sleep [ß: -0.66 h (-1.16, -0.15)]. Associations across all racial/ethnic groups were attenuated after adjustment for SES at one- and six months. Sleep continuity attenuated associations with nighttime and total sleep duration by 20-60% for Hispanic infants at six-months. CONCLUSIONS: Differences in sleep duration emerge early in life among racial/ethnic groups and are in part explained by SES and sleep continuity.

Presence of Small Screens in Bedrooms Is Associated With Shorter Sleep Duration and Later Bedtimes in Children With Obesity.

BACKGROUND: The presence of small screens in the sleep environment has been associated with shorter sleep duration and later bedtimes in children of normal weight, but the role these devices play in the sleep environment of overweight children is unclear. We sought to examine the association of small screen presence in the sleep environment with sleep behaviors among school-age children with obesity. METHODS: We surveyed 526 parents of children ages 6 to 12 years old with a body mass index ≥95th percentile who were participating in a randomized trial to treat childhood obesity. Twelve months after enrollment, parents were asked how frequently their child slept with or near a small screen (defined as a cellphone, smartphone, or texting/chat-capable device). We used multivariable linear regression to examine associations of the presence of small screens with sleep duration, waketime, and bedtime. RESULTS: Compared with children who rarely/never slept with a small screen in their bedroom, children who did so 1 day or more per week had shorter sleep durations and later bedtimes. After we adjusted for television presence in the bedroom, small screen presence was still associated with shorter sleep duration (-9.9 minutes; P = .02) and later weekday (8.8 minutes; P = .03) and weekend (12.0 minutes; P = .03) bedtimes. CONCLUSIONS: Children with obesity and a small screen present in their sleep environment have shorter sleep durations and later bedtimes than children who rarely/never sleep with a small screen. Pediatricians should consider inquiring about small screens in the bedroom when counseling on healthy sleep and weight management habits.

Parents' Willingness to Pay for Pediatric Weight Management Programs.

OBJECTIVE: To examine parents' interest in continuing and willingness to pay (WTP) for 2 pediatric weight management programs following their participation. METHODS: Participants were parents of 2- to 12-year-old children with body mass index ≥ 85th percentile who participated in the Connect for Health trial. One group received enhanced primary care (EPC) and the other received EPC plus individualized coaching (EPC+C). At 1 year, we assessed parents' self-reported WTP for a similar program and the maximum amount ($/month) they would pay. We used multivariable regression to examine differences in WTP and WTP amount by intervention arm and by individual and family-level factors. RESULTS: Of 638 parents who completed the survey, 85% were interested in continuing and 38% of those parents were willing to pay (31% in the EPC group and 45% in the EPC+C group). The median amount parents were willing to pay was $25/month (interquartile range, $15-$50). In multivariable models, the EPC+C parents were more likely to endorse WTP than the EPC parents (odds ratio, 1.53; 95% confidence interval, 1.05-2.22). Parents of children with Hispanic/Latino versus white ethnicity and those reporting higher satisfaction with the program were also more likely to endorse WTP. CONCLUSIONS: Most parents of children in a weight management program were interested in continuing it after it ended, but fewer were willing to pay out of pocket for it. A greater proportion of parents were willing to pay if the program included individualized health coaching.

Neighborhood social cohesion and sleep outcomes in the Native Hawaiian and Pacific Islander National Health Interview Survey.

Study Objective: Native Hawaiians and Pacific Islanders (NHPIs) have the lowest attainment of healthy sleep duration among all racial and ethnic groups in the United States. We examined associations of neighborhood social cohesion with sleep duration and quality. Methods: Cross-sectional analysis of 2464 adults in the NHPI National Health Interview Survey (2014). Neighborhood social cohesion was categorized as a continuous and categorical variable into low (<12), medium (12-14), and high (>15) according to tertiles of the distribution of responses. We used multinomial logistic regression to examine the adjusted odds ratio of short and long sleep duration relative to intermediate sleep duration. We used binary logistic regression for dichotomous sleep quality outcomes. Sleep outcomes were modeled as categorical variables. Results: Forty percent of the cohort reported short (<7 hours) sleep duration and only 4% reported long (>9 hours) duration. Mean (SE, range) social cohesion score was 12.4 units (0.11, 4-16) and 23% reported low social cohesion. In multivariable models, each 1 SD decrease in neighborhood social cohesion score was associated with higher odds of short sleep duration (odds ratio [OR]: 1.14, 95% confidence interval [CI]: 1.02, 1.29). Additionally, low social cohesion was associated with increased odds of short sleep duration (OR: 1.53, 95% CI: 1.10, 2.13). No associations between neighborhood social cohesion and having trouble falling or staying asleep and feeling well rested were found. Conclusion: Low neighborhood social cohesion is associated with short sleep duration in NHPIs.

Cost-Effectiveness of a Clinical Childhood Obesity Intervention.

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.

Comparative Effectiveness of Clinical-Community Childhood Obesity Interventions: A Randomized Clinical Trial.

IMPORTANCE: Novel approaches to care delivery that leverage clinical and community resources could improve body mass index (BMI) and family-centered outcomes. OBJECTIVE: To examine the extent to which 2 clinical-community interventions improved child BMI z score and health-related quality of life, as well as parental resource empowerment in the Connect for Health Trial. DESIGN, SETTING, AND PARTICIPANTS: This 2-arm, blinded, randomized clinical trial was conducted from June 2014 through March 2016, with measures at baseline and 1 year after randomization. This intent-to-treat analysis included 721 children ages 2 to 12 years with BMI in the 85th or greater percentile from 6 primary care practices in Massachusetts. INTERVENTIONS: Children were randomized to 1 of 2 arms: (1) enhanced primary care (eg, flagging of children with BMI ≥ 85th percentile, clinical decision support tools for pediatric weight management, parent educational materials, a Neighborhood Resource Guide, and monthly text messages) or (2) enhanced primary care plus contextually tailored, individual health coaching (twice-weekly text messages and telephone or video contacts every other month) to support behavior change and linkage of families to neighborhood resources. MAIN OUTCOMES AND MEASURES: One-year changes in age- and sex-specific BMI z score, child health-related quality of life measured by the Pediatric Quality of Life 4.0, and parental resource empowerment. RESULTS: At 1 year, we obtained BMI z scores from 664 children (92%) and family-centered outcomes from 657 parents (91%). The baseline mean (SD) age was 8.0 (3.0) years; 35% were white (n = 252), 33.3% were black (n = 240), 21.8% were Hispanic (n = 157), and 9.9% were of another race/ethnicity (n = 71). In the enhanced primary care group, adjusted mean (SD) BMI z score was 1.91 (0.56) at baseline and 1.85 (0.58) at 1 year, an improvement of -0.06 BMI z score units (95% CI, -0.10 to -0.02) from baseline to 1 year. In the enhanced primary care plus coaching group, the adjusted mean (SD) BMI z score was 1.87 (0.56) at baseline and 1.79 (0.58) at 1 year, an improvement of -0.09 BMI z score units (95% CI, -0.13 to -0.05). However, there was no significant difference between the 2 intervention arms (difference, -0.02; 95% CI, -0.08 to 0.03; P = .39). Both intervention arms led to improved parental resource empowerment: 0.29 units (95% CI, 0.22 to 0.35) higher in the enhanced primary care group and 0.22 units (95% CI, 0.15 to 0.28) higher in the enhanced primary care plus coaching group. Parents in the enhanced primary care plus coaching group, but not in the enhanced care alone group, reported improvements in their child's health-related quality of life (1.53 units; 95% CI, 0.51 to 2.56). However, there were no significant differences between the intervention arms in either parental resource empowerment (0.07 units; 95% CI, -0.02 to 0.16) or child health-related quality of life (0.89 units; 95% CI, -0.56 to 2.33). CONCLUSIONS AND RELEVANCE: Two interventions that included a package of high-quality clinical care for obesity and linkages to community resources resulted in improved family-centered outcomes for childhood obesity and improvements in child BMI. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02124460.

Correlates of Resource Empowerment among Parents of Children with Overweight or Obesity.

BACKGROUND: Few studies have examined correlates of resource empowerment among parents of children with overweight or obesity. METHODS: We studied baseline data of 721 parent-child pairs participating in the Connect for Health randomized trial being conducted at six pediatric practices in Massachusetts. Parents completed the child weight management subscale (n = 5 items; 4-point response scale) of the Parent Resource Empowerment Scale; items were averaged to create a summary empowerment score. We used linear regression to examine the independent effects of child (age, sex, and race/ethnicity), parent/household characteristics (age, education, annual household income, BMI category, perceived stress, and their ratings of their healthcare quality), and neighborhood median household income, on parental resource empowerment. RESULTS: Mean (SD) child age was 7.7 years (2.9) and mean (SD) BMI z-score was 1.9 (0.5); 34% of children were white, 32% black, 22% Hispanic, 5% Asian, and 6% multiracial/other. The mean parental empowerment score was 2.95 (SD = 0.56; range = 1-4). In adjusted models, parents of older children [ß -0.03 (95% CI: -0.04, -0.01)], Hispanic children [-0.14 (-0.26, -0.03)], those with annual household income less than $20,000 [-0.16 (-0.29, -0.02)], those with BMI ≥30.0 kg/m2 [-0.17 (-0.28, -0.07)], and those who reported receiving lower quality of obesity-related care [-0.05 (-0.07, -0.03)] felt less empowered about resources to support their child's healthy body weight. CONCLUSIONS: Parental resource empowerment is influenced by parent and child characteristics as well as the quality of their obesity-related care. These findings could help inform equitable, family-centered approaches to improve parental resource empowerment.

Two-year follow-up of a primary care-based intervention to prevent and manage childhood obesity: the High Five for Kids study.

BACKGROUND: The obesity epidemic has spared no age group, even young infants. Most childhood obesity is incident by the age of 5 years, making prevention in preschool years a priority. OBJECTIVE: To examine 2-year changes in age- and sex-specific BMI z-scores and obesity-related behaviours among 441 of the 475 originally recruited participants in High Five for Kids, a cluster randomized controlled trial in 10 paediatric practices. METHODS: The intervention included a more intensive 1-year intervention period (four in-person visits and two phone calls) followed by a less intensive 1-year maintenance period (two in-person visits) among children who were overweight or obese and age 2-6 years at enrolment. The five intervention practices restructured care to manage these children including motivational interviewing and educational modules targeting television viewing and intakes of fast food and sugar-sweetened beverages. RESULTS: After 2 years, compared with usual care, intervention participants had similar changes in BMI z-scores (-0.04 units; 95% CI -0.14, 0.06), television viewing (-0.20 h/d; -0.49 to 0.09) and intakes of fast food (-0.09 servings/week; -0.34 to 0.17) and sugar-sweetened beverages (-0.26 servings/day; -0.67 to 0.14). CONCLUSION: High Five for Kids, a primarily clinical-based intervention, did not affect BMI z-scores or obesity-related behaviours after 2 years.

Connect for Health: Design of a clinical-community childhood obesity intervention testing best practices of positive outliers.

BACKGROUND: The Connect for Health study is designed to assess whether a novel approach to care delivery that leverages clinical and community resources and addresses socio-contextual factors will improve body mass index (BMI) and family-centered, obesity-related outcomes of interest to parents and children. The intervention is informed by clinical, community, parent, and youth stakeholders and incorporates successful strategies and best practices learned from 'positive outlier' families, i.e., those who have succeeded in changing their health behaviors and improve their BMI in the context of adverse built and social environments. DESIGN: Two-arm, randomized controlled trial with measures at baseline and 12 months after randomization. PARTICIPANTS: 2-12 year old children with overweight or obesity (BMI ≥ 85th percentile) and their parents/guardians recruited from 6 pediatric practices in eastern Massachusetts. INTERVENTION: Children randomized to the intervention arm receive a contextually-tailored intervention delivered by trained health coaches who use advanced geographic information system tools to characterize children's environments and neighborhood resources. Health coaches link families to community-level resources and use multiple support modalities including text messages and virtual visits to support families over a one-year intervention period. The control group receives enhanced pediatric care plus non-tailored health coaching. MAIN OUTCOME MEASURES: Lower age-associated increase in BMI over a 1-year period. The main parent- and child-reported outcome is improved health-related quality of life. CONCLUSIONS: The Connect for Health study seeks to support families in leveraging clinical and community resources to improve obesity-related outcomes that are most important to parents and children.