Family-Based Telehealth Initiative to Improve Nutrition and Physical Activity for Children With Obesity and Its Utility During COVID-19: A Mixed Methods Evaluation.

Guidelines recommend primary care providers refer children with obesity to behavioral interventions, but given limited program availability, access, and parental engagement, referrals remain rare. We developed telehealth coaching interventions for families whose children received care at a health system in Pennsylvania, United States in 2019-2020. Intervention referrals were facilitated by the pediatrician and/or project team for 6-12-year-old children with obesity following well-child visits. Participants chose one of three 26-week interventions focused on healthy eating, physical activity, or a hybrid clinical/nutrition intervention. Interventions engaged parents as change agents, enhancing self-efficacy to model and reinforce behavior and providing resources to help create a healthy home environment. We enrolled 77 of 183 eligible parent/child dyads. We used mixed methods to evaluate the interventions. Repeated measures models among participants showed significant reductions in obesogenic nutrition behaviors post-intervention and at 1-year follow-up, including a reduction in sugar-sweetened beverage intake of 2.14 servings/week (95% confidence interval: -3.45, -0.82). There were also improvements in obesoprotective nutrition behaviors (e.g., frequency of family meals, parental self-efficacy related to meal management). One year post-baseline, we observed no significant differences in changes in body mass index (BMI) z-scores comparing child participants with matched controls. Given potential impacts of COVID-19 community restrictions on study outcomes, we conducted qualitative interviews with 13 participants during restrictions, which exemplified how disrupted routines constrained children's healthy behaviors but that intervention participation prepared parents by providing cooking and physical activities at home. Findings support the potential of a telehealth-delivered nutrition intervention to support adoption of healthy weight behaviors.

Effects of Dietary App-Supported Tele-Counseling on Sodium Intake, Diet Quality, and Blood Pressure in Patients With Diabetes and Kidney Disease.

OBJECTIVES: The aim of this study is to examine the effect of a telehealth intervention that used a dietary app, educational website, and weekly dietitian tele-counseling on sodium intake, diet quality, blood pressure, and albuminuria among individuals with diabetes and early-stage chronic kidney disease. DESIGN AND METHODS: We examined the effects of a dietary app-supported tele-counseling intervention in a single center, single arm study of 44 participants with type 2 diabetes and stage 1-3a chronic kidney disease. Participants recorded and shared dietary data via MyFitnessPal with registered dietitians, who used motivational interviewing to provide telephone counseling weekly for 8 weeks. After the 8-week intensive intervention, participants were followed at 6 and 12 months. Outcomes included 24-hour urine sodium (2 collections per timepoint), Healthy Eating Index 2015 score (three 24-hour dietary recalls per timepoint), 24-hour systolic blood pressure (SBP) and diastolic blood pressure (DBP), and 24-hour urine albumin excretion. RESULTS: Out of 44 consented participants (mean age 60.3 ± 11.9 years, 43% female, 89% white, median estimated glomerular filtration rate was 78.5 mL/min/1.73 m2, median urine albumin excretion 52.9 mg/day, 84% hypertension), 32 (73%) completed 8-week follow-up, 27 (61%) completed 6-month follow-up, and 25 (57%) completed 12-month follow-up. Among participants who completed 12-month follow-up, reported sodium intake decreased by 638 mg/day from baseline of 2,919 mg/day (P < .001). The 24-hour mean urine sodium and albumin excretion did not decline over the study period. Healthy Eating Index 2015 score improved by 7.76 points at 12 months from a mean baseline of 54.6 (P < .001). Both 24-hour SBP and DBP declined at 12 months from baseline (SBP -5.7 mm Hg, 95% confidence interval -10.5 to -1.0, P = .02; DBP -4.1 mm Hg, 95% confidence interval -7.2 to -1.1, P = .01). CONCLUSIONS: Overall, this study demonstrates that a short, intensive, remotely delivered dietary intervention for adults with type 2 diabetes and early chronic kidney disease at high risk for disease progression and cardiovascular complications led to improvement in blood pressure and self-reported sodium intake and diet quality, but no improvement in albuminuria. Future research studies are needed to examine whether remotely delivered dietary interventions can ultimately improve kidney health over time.

Effects of sustained weight loss on outcomes associated with obesity comorbidities and healthcare resource utilization.

OBJECTIVE: Determine the impact of long-term non-surgical weight loss maintenance on clinical relevance for osteoarthritis, cancer, opioid use, and depression/anxiety and healthcare resource utilization. METHODS: A cohort of adults receiving primary care within Geisinger Health System between 2001-2017 was retrospectively studied. Patients with ≥3 weight measurements in the two-year index period and obesity at baseline (BMI ≥30 kg/m2) were categorized: Obesity Maintainers (reference group) maintained weight within +/-3%; Weight Loss Rebounders lost ≥5% body weight in year one, regaining ≥20% of weight loss in year two; Weight Loss Maintainers lost ≥5% body weight in year one, maintaining ≥80% of weight loss. Association with development of osteoarthritis, cancer, opioid use, and depression/anxiety, was assessed; healthcare resource utilization was quantified. Magnitude of weight loss among maintainers was evaluated for impact on health outcomes. RESULTS: In total, 63,567 patients were analyzed including 67% Obesity Maintainers, 19% Weight Loss Rebounders, and 14% Weight Loss Maintainers; median follow-up was 9.7 years. Time until osteoarthritis onset was delayed for Weight Loss Maintainers compared to Obesity Maintainers (Logrank test p <0.0001). Female Weight Loss Maintainers had a 19% and 24% lower risk of developing any cancer (p = 0.0022) or obesity-related cancer (p = 0.0021), respectively. No significant trends were observed for opioid use. Weight loss Rebounders and Maintainers had increased risk (14% and 25%) of future treatment for anxiety/depression (both <0.0001). Weight loss maintenance of >15% weight loss was associated with the greatest decrease in incident osteoarthritis. Healthcare resource utilization was significantly higher for Weight Loss Rebounders and Maintainers compared to Obesity Maintainers. Increased weight loss among Weight Loss Maintainers trended with lower overall healthcare resource utilization, except for hospitalizations. CONCLUSIONS: In people with obesity, sustained weight loss was associated with greater clinical benefits than regained short-term weight loss and obesity maintenance. Higher weight loss magnitudes were associated with delayed onset of osteoarthritis and led to decreased healthcare utilization.

Telehealth versus self-directed lifestyle intervention to promote healthy blood pressure: a protocol for a randomised controlled trial.

INTRODUCTION: Weight loss, consumption of a Dietary Approaches to Stop Hypertension dietary pattern, reduced sodium intake and increased physical activity have been shown to lower blood pressure (BP). Use of web-based tools and telehealth to deliver lifestyle counselling could be potentially scalable solutions to improve BP through behavioural modification though limited data exists to support these approaches in clinical practice. METHODS AND ANALYSIS: This randomised controlled trial will compare the efficacy of a telehealth versus self-directed lifestyle intervention in lowering 24-hour SBP in patients with overweight/obesity (body mass index ≥25 kg/m2) and 24-hour SBP 120-160 mm Hg. All participants receive personalised recommendations to improve dietary quality based on a web-based Food Frequency Questionnaire, access to an online comprehensive weight management programme and a smartphone dietary app. The telehealth arm additionally includes weekly calls with registered dietitian nutritionists who use motivational interviewing. The primary outcome is change from baseline to 12 weeks in 24-hour SBP. Secondary outcomes include changes from baseline in 24-hour diastolic BP, daytime SBP, nighttime SP, daytime diastolic BP, nighttime diastolic BP, total Healthy Eating Index-2015 score, weight, waist circumference and physical activity. Other prespecified outcomes will include change in individual components of the Healthy Eating Index-2015 score, and satisfaction with the Healthy BP research study measured on a 5-point Likert scale. ETHICS AND DISSEMINATION: The study has been approved by the Geisinger Institutional Review Board. Results will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03700710.

Development, Applications, and Refinement of the Family Nutrition and Physical Activity (FNPA) Child Obesity Prevention Screening.

Concerns regarding the continued high prevalence of childhood overweight and obesity have created a need for proactive approaches to behavior change. The Family Nutrition and Physical Activity (FNPA) screening tool was developed for research and clinical use to identify home environments and behaviors that could predispose youth to increased weight. FNPA scores have been shown to correlate with body mass index (BMI) percentiles in first-grade students and to predict unique variance in change in BMI percentiles from first to second grade. The FNPA has been used for family behavior counseling and is now a standard component of well-child visits throughout the Geisinger Health System in Pennsylvania. Parents complete the FNPA prior to annual visits, and providers can discuss areas of concern based on screening results. Children of parents who complete the FNPA have shown smaller increases in BMI z-scores over the following year than children of parents who did not complete the FNPA. The FNPA is also used to inform the arrangement of family-centered obesity treatment for children. Recently, the FNPA has undergone a systematic update to ensure its continued relevance and utility. The updated tool is provided, and current and future users can access more information about the tool at myfnpa.org.

Effects of Enhancing School-Based Body Mass Index Screening Reports with Parent Education on Report Utility and Parental Intent To Modify Obesity Risk Factors.

BACKGROUND: School-based body mass index screenings (SBMIS) have been controversial. We aimed to determine if parents would indicate improved utility with SBMIS when the report included parent education and whether parental intent to modify obesity risk factors would vary with report type or child weight. METHODS: A cluster-controlled trial was conducted with 31 elementary schools randomized to distribute a standard SBMIS report or the standard report plus education (SBMIS+). A random subsample of parents completed a mailed survey (731 SBMIS, 738 SBMIS+). Using a two-stage cluster sampling design, logistic regression models with school-level random effect were used to assess differences between conditions and by weight category. RESULTS: Parents in the SBMIS+ condition vs. the standard condition were more likely to indicate that the report provided useful information (not significant) and an intent to help their child get enough sleep (p < 0.001). Parents of children who were overweight or obese were less likely than parents of children who were not to indicate that the report provided useful information about their child's weight status (p < 0.001) or access to resources (p < 0.05). However, these parents were more likely to plan a visit to healthcare provider (p < 0.001) and to intend to limit sugar-sweetened beverages (p < 0.05). CONCLUSIONS: Parental education can enhance the utility of the SBMIS report and parental intention to modify at least one obesity risk factor. SBMIS reports prompted parents of children with overweight and obesity to seek clinical care and limit sugar-sweetened drinks.

Bariatric Surgery Patients and Their Families: Health, Physical Activity, and Social Support.

BACKGROUND: This study evaluated the social environment of bariatric surgery patients in the preoperative period. METHODS: Forty bariatric surgery patients (mean = 46.2 ± 11.2 years), 35 adult cohabitating family members (mean = 45.2 ± 12.7 years), and 15 cohabitating children (mean = 11.5 ± 3.6 years) were recruited from a large rural medical center. Adult participants (patients and family members) completed height, weight, body composition, blood draws, and physical activity assessments (accelerometry), as well as eating behavior and social support inventories before the patient underwent bariatric surgery. Child participants completed demographic, height, and weight assessment only. RESULTS: Over 90 % of adult family members were overweight or obese (body mass index (BMI) ≥ 25 kg/m2, as were 50 % of children (BMI percentile ≥ 85 %). More than one third (37.1 %) of family members met the criteria for moderate to severe insulin resistance. Physical activity measured by accelerometry was moderately correlated between the patient and adult family members (r = 0.46, p = 0.023). Bariatric surgery patients reported high levels of social support from their family members on multiple social support measures. CONCLUSIONS: Many family members of bariatric surgery patients also lived with obesity and related comorbidities, and demonstrate high sedentary behavior. However, patients reported high levels of support from family members, including support in following a healthy diet and engaging in physical activity. Engaging families in behavior change may help bariatric surgery patients and their families to become healthier.

Collateral weight loss in children living with adult bariatric surgery patients: a case control study.

OBJECTIVE: To evaluate the impact of adult bariatric surgery on the body mass index (BMI) of children living in the same household. METHODS: A retrospective case-control study. Case dyads (n = 128) were composed of one adult who had bariatric surgery and one child at the same address. Control dyads (n = 384) were composed of an adult with obesity but no bariatric surgery and a child at the same address. Two-sample t-test was used to determine whether the differences between actual and expected BMI at follow-up (post-surgery) differed between children in the case and control dyads. RESULTS: Among boys who were overweight, boys who lived with a surgery patient had a lower than expected BMI post-surgery, while boys who did not live with a surgery patient had a higher than expected BMI at follow-up (P = 0.045). Differences between actual and expected BMIs of children were not significantly different between cases and controls in girls or in children in other weight classes. CONCLUSIONS: Overweight boys who lived with an adult bariatric surgery patient had a lower than expected BMI after surgery as compared to controls. Future studies may be warranted to determine the mechanisms by which these children experience collateral weight loss.

The protective effects of parent-college student communication on dietary and physical activity behaviors.

PURPOSE: Recent studies suggest that parents maintain influence as their adolescents transition into college. Advances in communication technology make frequent communication between parents and college students easy and affordable. This study examines the protective effect of parent-college student communication on student eating and physical activity behaviors. METHODS: Participants were 746 first-year, first-time, full-time students at a large university in the United States who completed a baseline and 14 daily web-based surveys. RESULTS: On days when students communicated with their parents for 30 minutes or more, they consumed fruits and vegetables, an additional 14%, more times and were 50% more likely to engage in 30 minutes or more of physical activity, consistent with a protective within-person effect. CONCLUSIONS: Encouraging parents to communicate with their college-aged children could improve these students' daily eating and physical activity behaviors and should be explored as a relatively easy and affordable component of a student preventive intervention.

Changes in eating and physical activity behaviors across seven semesters of college: living on or off campus matters.

The transition from adolescence to adulthood is an important period for establishing behavioral patterns that affect long-term health and chronic disease risk. Nelson and colleagues speculated that developmental changes and changes in living situation may play an important role in the nutrition and physical activity behaviors of college students. Data from the University Life Study, a longitudinal study of college students that includes web-based surveys administered 14 consecutive days each semester, were used to examine fruit, vegetable, and sugared soda consumption, physical activity, and sedentary activity behaviors across seven semesters. Estimates for each semester were calculated to determine the frequency with which students consumed fruits, vegetables, and sugared soda, engaged in moderate to vigorous physical activity, and engaged in sedentary activities. Four models, estimated with HLM 6.04, were used to predict changes in these behaviors across the seven semesters. Living on or off campus was included to determine if this explained additional variance. Results indicated that few college students consumed fruits and vegetables or exercised at optimal levels during the seven semesters surveyed. Daily fruit and vegetable consumption and daily physical activity declined significantly from the first to the seventh semester. For both of these findings, living off campus exacerbated the problem. Average number of hours of sedentary behaviors declined over time, as did number of days on which at least one sugared soda was consumed. Living location did not explain additional variance in these positive trends. Implications for policy, practice, and future research are discussed.

Obesity disparities among elementary-aged children: data from school-based BMI surveillance.

OBJECTIVES: To examine 3-year trends and spatial clustering in the prevalence of obesity among elementary-aged children in Pennsylvania. METHODS: Height and weight were measured for ~980 000 children between ages 5 and 12 years, corresponding to kindergarten through grade 6 in 3 consecutive school years (2006-2007, 2007-2008, 2008-2009). These data were obtained at the school district level and reported to the Pennsylvania Department of Health in response to a state mandate requiring public schools to conduct annual surveillance of student growth. Analyses at the school district level (n = 501) regarding obesity prevalence (BMI ≥ 95th percentile) according to age and gender were conducted to examine associations over time and in relation to population density, geographic boundaries, and a calculated family distress index. RESULTS: The mean prevalence of obesity remained stable over 3 years at ~17.6% of elementary-aged children. However, within the state, significant differences in the prevalence of obesity were identified. Schools in the most rural areas had adjusted obesity prevalence over 2 percentage points higher than urban schools. Consistent with secular findings for the nation in general, students with families living in socioeconomic distress exhibited upward trends in obesity risk. CONCLUSIONS: School-based surveillance elucidates the disparate risk of obesity for younger students living in the most rural areas, a key finding for primarily rural states. Preventive interventions are needed to reach the most rural children with an emphasis on families where parents are single, are unemployed, have a lower income, and lower educational attainment.