Family-Based Behavioral Treatment for Childhood Obesity Implemented in Pediatric Primary Care: A Randomized Clinical Trial.

Importance: Intensive behavioral interventions for childhood overweight and obesity are recommended by national guidelines, but are currently offered primarily in specialty clinics. Evidence is lacking on their effectiveness in pediatric primary care settings. Objective: To evaluate the effects of family-based treatment for overweight or obesity implemented in pediatric primary care on children and their parents and siblings. Design, Setting, and Participants: This randomized clinical trial in 4 US settings enrolled 452 children aged 6 to 12 years with overweight or obesity, their parents, and 106 siblings. Participants were assigned to undergo family-based treatment or usual care and were followed up for 24 months. The trial was conducted from November 2017 through August 2021. Interventions: Family-based treatment used a variety of behavioral techniques to develop healthy eating, physical activity, and parenting behaviors within families. The treatment goal was 26 sessions over a 24-month period with a coach trained in behavior change methods; the number of sessions was individualized based on family progress. Main Outcomes and Measures: The primary outcome was the child's change from baseline to 24 months in the percentage above the median body mass index (BMI) in the general US population normalized for age and sex. Secondary outcomes were the changes in this measure for siblings and in BMI for parents. Results: Among 452 enrolled child-parent dyads, 226 were randomized to undergo family-based treatment and 226 to undergo usual care (child mean [SD] age, 9.8 [1.9] years; 53% female; mean percentage above median BMI, 59.4% [n = 27.0]; 153 [27.2%] were Black and 258 [57.1%] were White); 106 siblings were included. At 24 months, children receiving family-based treatment had better weight outcomes than those receiving usual care based on the difference in change in percentage above median BMI (-6.21% [95% CI, -10.14% to -2.29%]). Longitudinal growth models found that children, parents, and siblings undergoing family-based treatment all had outcomes superior to usual care that were evident at 6 months and maintained through 24 months (0- to 24-month changes in percentage above median BMI for family-based treatment and usual care were 0.00% [95% CI, -2.20% to 2.20%] vs 6.48% [95% CI, 4.35%-8.61%] for children; -1.05% [95% CI, -3.79% to 1.69%] vs 2.92% [95% CI, 0.58%-5.26%] for parents; and 0.03% [95% CI, -3.03% to 3.10%] vs 5.35% [95% CI, 2.70%-8.00%] for siblings). Conclusions and Relevance: Family-based treatment for childhood overweight and obesity was successfully implemented in pediatric primary care settings and led to improved weight outcomes over 24 months for children and parents. Siblings who were not directly treated also had improved weight outcomes, suggesting that this treatment may offer a novel approach for families with multiple children. Trial Registration: ClinicalTrials.gov Identifier: NCT02873715.

Association of Early Antibiotic Exposure With Childhood Body Mass Index Trajectory Milestones.

Importance: Past studies have showed associations between antibiotic exposure and child weight outcomes. Few, however, have documented alterations to body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) trajectory milestone patterns during childhood after early-life antibiotic exposure. Objective: To examine the association of antibiotic use during the first 48 months of life with BMI trajectory milestones during childhood in a large cohort of children. Design, Setting, and Participants: This retrospective cohort study used electronic health record data from 26 institutions participating in the National Patient-Centered Clinical Research Network from January 1, 2009, to December 31, 2016. Participant inclusion required at least 1 valid set of same-day height and weight measurements at each of the following age periods: 0 to 5, 6 to 11, 12 to 23, 24 to 59, and 60 to 131 months (183 444 children). Data were analyzed from June 1, 2019, to June 30, 2020. Exposures: Antibiotic use at 0 to 5, 6 to 11, 12 to 23, 24 to 35, and 36 to 47 months of age. Main Outcomes and Measures: Age and magnitude of BMI peak and BMI rebound. Results: Of 183 444 children in the study (mean age, 3.3 years [range, 0-10.9 years]; 95 228 [51.9%] were boys; 80 043 [43.6%] were White individuals), 78.1% received any antibiotic, 51.0% had at least 1 episode of broad-spectrum antibiotic exposure, and 65.0% had at least 1 episode of narrow-spectrum antibiotic exposure at any time before 48 months of age. Exposure to any antibiotics at 0 to 5 months of age (vs no exposure) was associated with later age (ß coefficient, 0.05 months [95% CI, 0.02-0.08 months]) and higher BMI (ß coefficient, 0.09 [95% CI, 0.07-0.11]) at peak. Exposure to any antibiotics at 0 to 47 months of age (vs no exposure) was associated with an earlier age (-0.60 months [95% CI, -0.81 to -0.39 months]) and higher BMI at rebound (ß coefficient, 0.02 [95% CI, 0.01-0.03]). These associations were strongest for children with at least 4 episodes of antibiotic exposure. Effect estimates for associations with age at BMI rebound were larger for those exposed to antibiotics at 24 to 35 months of age (ß coefficient, -0.63 [95% CI, -0.83 to -0.43] months) or 36 to 47 (ß coefficient, -0.52 [95% CI, -0.72 to -0.31] months) than for those exposed at 0 to 5 months of age (ß coefficient, 0.26 [95% CI, 0.01-0.51] months) or 6 to 11 (ß coefficient, 0.00 [95% CI, -0.20 to 0.20] months). Conclusions and Relevance: In this cohort study, antibiotic exposure was associated with statistically significant, but small, differences in BMI trajectory milestones in infancy and early childhood. The small risk of an altered BMI trajectory milestone pattern associated with early-life antibiotic exposure is unlikely to be a key factor during prescription decisions for children.

Characteristics of Children 2 to 5 Years of Age With Severe Obesity.

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.

The Primary Care Obesity Network: Translating Expert Committee Guidelines on Childhood Obesity Into Practice.

Childhood obesity remains a serious public health threat. There is an urgent need for innovative, effective, and sustainable interventions for childhood obesity that are multisector, integrated, and pragmatic. Using the 2007 Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity as a guide, a tertiary care obesity program at a children's hospital established the Primary Care Obesity Network (PCON). This article describes the structure, implementation, resources, and outcome measures of the PCON, a network of primary care practices and a tertiary care obesity center established to prevent and treat childhood obesity in Central Ohio. This program offers an opportunity to assess how and whether the expert committee guidelines can be translated into practice. As Accountable Care Organizations strive to provide services through the lens of improving population health, the PCON can serve as an example for addressing childhood obesity.

Characteristics of Youth Presenting for Weight Management: Retrospective National Data from the POWER Study Group.

BACKGROUND: There are no existing multisite national data on obese youth presenting for pediatric weight management. The primary aim was to describe BMI status and comorbidities among youth with obesity presenting for pediatric weight management (PWM) at programs within the Pediatric Obesity Weight Evaluation Registry (POWER). METHODS: Data were collected from 2009-2010 among 6737 obese patients ages 2-17. Patients were classified in three groups by BMI (kg/m(2)) cutoffs and percent of the 95th percentile for BMI: (1) obesity; (2) severe obesity class 2; and (3) severe obesity class 3. Weighted percentages are presented for baseline laboratory tests, blood pressure, and demographics. Generalized logistic regression with clustering was used to examine the relationships between BMI status and comorbidities. RESULTS: Study youth were 11.6 ± 3.4 years of age, 56% female, 31% black, 17% Hispanic, and 53% publicly insured. Twenty-five percent of patients had obesity (n = 1674), 34% (2337) had severe obesity class 2, and 41% (2726) had severe obesity class 3. Logistic regression revealed that males (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.0), blacks (OR, 1.7; 95% CI, 1.5-2.0), age <6 years (OR, 2.0; 95% CI, 1.5-2.6), and public insurance (OR, 1.8; 95% CI, 1.5-2.0) had a higher odds of severe obesity class 3. Severe obesity class 3 was associated with higher odds of laboratory abnormalities for hemoglobin A1c (OR, 1.7; 95% CI, 1.3-2.2), alanine aminotransferase ≥40 U/L (OR, 1.9; 95% CI, 1.3-2.6), and elevated systolic blood pressure (OR, 2.5; 95% CI, 2.0-3.0). CONCLUSIONS: Youth with obesity need earlier access to PWM given that they are presenting when they have severe obesity with significant comorbidities.

An Integrated Framework For The Prevention And Treatment Of Obesity And Its Related Chronic Diseases.

Improved patient experience, population health, and reduced cost of care for patients with obesity and other chronic diseases will not be achieved by clinical interventions alone. We offer here a new iteration of the Chronic Care Model that integrates clinical and community systems to address chronic diseases. Obesity contributes substantially to cardiovascular disease, type 2 diabetes mellitus, and cancer. Dietary and physical activity interventions will prevent, mitigate, and treat obesity and its related diseases. Challenges with the implementation of this model include provider training, the need to provide incentives for health systems to move beyond clinical care to link with community systems, and addressing the multiple elements necessary for integration within clinical care and with social systems. The Affordable Care Act, with its emphasis on prevention and new systems for care delivery, provides support for innovative strategies such as those proposed here.

Maternal intuitive eating as a moderator of the association between concern about child weight and restrictive child feeding.

Mothers who are concerned about their young child's weight are more likely to use restrictive feeding, which has been associated with increased food seeking behaviors, emotional eating, and overeating in young children across multiple prospective and experimental studies. In the present study, we examined whether mothers' intuitive eating behaviors would moderate the association between their concern about their child's weight and their use of restrictive feeding. In a sample of 180 mothers of young children, two maternal intuitive eating behaviors (i.e., eating for physical reasons, trust in hunger and satiety cues) moderated this association after controlling for maternal age, body mass index, years of education, race/ethnicity, awareness of hunger and satiety cues and perceptions of child weight. More specifically, concern about child weight was unrelated to restrictive feeding for mothers with higher levels of eating for physical reasons and trust in hunger and satiety cues. However, concern about child weight was positively related to restrictive feeding among mothers with lower or average levels of eating for physical reasons and trust in hunger and satiety cues. These findings indicate that it may be important address maternal intuitive eating within interventions designed to improve self-regulated eating in children, as mothers who attend these interventions tend to be highly concerned about their child's weight and, if also low in intuitive eating, may be at risk for using restrictive feeding behaviors that interfere with children's self-regulated eating.

Targeting Feeding and Eating Behaviors: Development of the Feeding Dynamic Intervention for Caregivers of 2- to 5-Year-Old Children.

Targeting feeding dynamics, a concept centered on the roles and interaction of the caregiver and child in a feeding relationship, may have significant potential for obesity intervention. The aim of this paper is to describe the 3-phase development of the Feeding Dynamics Intervention (FDI), an acceptability and feasibility study on implementing the feeding dynamic roles (Study 1), development of the FDI content (Study 2), and a pilot study on use of the 6-lesson FDI to promote behaviors consistent with a feeding dynamic approach (Study 3). Sample population was mothers with young children, 2-5 years old. An effect size (Hedges' g) greater than 0.20 was seen in more than half (57%) of maternal feeding behaviors, with the largest effect sizes (Hedges' g ≥ 0.8) occurring with behaviors that represent the mother adopting her roles of determining what food is served, not using food as a reward, and not controlling her child's intake. There was a significant decline in Pressure to Eat behaviors (2.9 versus 2.2, p < 0.01) and Monitoring (4.1 versus 3.5, p < 0.001). The FDI emerged as an acceptable and implementable intervention. Future studies need to investigate effects of the FDI on the child's eating behaviors, self-regulation of energy intake, and anthropometrics.

Rationale and design of the Feeding Dynamic Intervention (FDI) study for self-regulation of energy intake in preschoolers.

In 2011, the Institute of Medicine Early Childhood Prevention Policies Report identified feeding dynamics as an important focus area for childhood obesity prevention and treatment. Feeding dynamics includes two central components: (1) caregiver feeding practices (i.e., determining how, when, where, and what they feed their children) and (2) child eating behaviors (i.e., determining how much and what to eat from what food caregivers have provided). Although there has been great interest in overweight and obesity prevention and treatment in young children, they have not focused comprehensively on feeding dynamics. Interventions on feeding dynamics that reduce caregivers' excessive controlling and restrictive feeding practices and encourage the development of children's self-regulation of energy intake may hold promise for tackling childhood obesity especially in the young child but currently lack an evidence base. This manuscript describes the rationale and design for a randomized controlled trial designed to compare a group of mothers and their 3-to 5-year old children who received an intervention focused primarily on feeding dynamics called the Feeding Dynamic Intervention (FDI) with a Wait-list Control Group (WLC). The primary aim of the study will be to investigate the efficacy of the FDI for decreasing Eating in the Absence of Hunger (EAH) and improving energy compensation (COMPX). The secondary aim will be to examine the effect of the FDI in comparison to the WLC on maternal self-reported feeding practices and child satiety responsiveness.

Instituting a sugar-sweetened beverage ban: experience from a children's hospital.

Sugar-sweetened beverage (SSB) consumption is linked to increased weight and obesity in children and remains the major source of added sugar in the typical US diet across all age groups. In an effort to improve the nutritional offerings for patients and employees within our institution, Nationwide Children's Hospital in Columbus, Ohio, implemented an SSB ban in 2011 in all food establishments within the hospital. In this report, we describe how the ban was implemented. We found that an institutional SSB ban altered beverage sales without revenue loss at nonvending food locations. From a process perspective, we found that successful implementation requires excellent communication and bold leadership at several levels throughout the hospital environment.

Identification and counseling for obesity among children on psychotropic medications in ambulatory settings.

OBJECTIVE: To examine identification and counseling for obesity at pediatric office visits associated with psychotropic medications. DESIGN AND METHODS: Analysis of ambulatory care visits by children 2-17 years in the National Ambulatory Medical Care Surveys and outpatient component of the National Hospital Ambulatory Medical Care Surveys from 2005 to 2008. Physician identification of obesity was determined using ICD-9 CM diagnostic codes. RESULTS: In 2005-2008, there were 38,539 pediatric ambulatory care visits weighted to represent 600 million pediatric visits nationally. Psychotropic medications were associated with 5.2% of visits. The prevalence of overweight/obesity (BMI ≥ 85th%tile) was 15.9% for visits without psychotropic medication, 19.4% and 16.8% for visits associated with nonobesogenic and obesogenic psychotropic medications, respectively. Controlling for age, gender, and BMI, obesity was more likely to be identified at visits associated with psychotropic medications (OR 5.2, 95% CI 3-8.8), among females (OR 1.6, 95% CI 1.1-2.3) and non-Hispanics (OR 1.5, 95% CI 1.0-2.4). At visits with psychotropic medications, dietary counseling was provided at 11.4%, while blood pressure and cholesterol screening were obtained at 6.9% and 6.8% of these visits, respectively. CONCLUSIONS: Our results indicate suboptimal identification and counseling for obesity children who are prescribed psychotropic medications, despite their increased risk for weight gain.

Which adaptive maternal eating behaviors predict child feeding practices? An examination with mothers of 2- to 5-year-old children.

Researchers have started to explore the detrimental impact of maladaptive maternal eating behaviors on child feeding practices. However, identifying which adaptive maternal eating behaviors contribute to lower use of negative and higher use of positive child feeding practices remains unexamined. The present study explored this link with 180 mothers of 2- to 5-year-old children. Hierarchical regression analyses (controlling for recruitment venue and maternal demographic characteristics, i.e., age, education, ethnicity, and body mass index) examined mothers' intuitive eating and eating competence as predictors of four feeding practices (restriction, monitoring, pressure to eat, and dividing feeding responsibilities with their child). Mothers who gave themselves unconditional permission to eat were less likely to restrict their child's food intake. Mothers who ate for physical (rather than emotional) reasons and had eating-related contextual skills (e.g., mindfulness when eating, planning regular and nutritious eating opportunities for themselves) were more likely to monitor their child's food intake. Mothers who had eating-related contextual skills were more likely to divide feeding responsibilities with their child. No maternal eating behavior predicted pressure to eat. Interventions to help mothers develop their eating-related contextual skills and eat intuitively, in particular, may translate into a more positive feeding environment for their young children.

Lifestyle behaviors of obese children following parental weight loss surgery.

BACKGROUND: Following weight loss surgery (WLS), patients are expected to make diet and lifestyle changes which may lead to children mimicking the changing behaviors of their parents. The purpose of the study was to identify the differences in diet and lifestyle behaviors between obese children with and without a parent who received WLS. METHODS: Medical records of 45 children whose parents had undergone WLS and 90 age- and gender-matched control children were reviewed from a weight loss program in a large Midwest children's hospital. Differences in dietary choices and behaviors, perceived barriers, and sedentary behaviors were examined between both groups. RESULTS: The mean age for the sample was 12.8 years. Children in the parental weight loss surgery (PWLS) group were more likely to eat two or more helpings of food at each sitting (p = 0.02) and less likely to play outdoors for more than an hour each day (p = 0.01). Compared to the control group, the PWLS group more frequently reported eating fast food on most days (45.2 vs. 27.0 %), soda consumption several times a week (48.6 vs. 29.4 %), and no vegetable intake (9.5 vs. 1.1 %). The top three barriers to exercise for both groups were lack of self-discipline, lack of interest, and lack of energy. CONCLUSIONS: Obese children who live with a parent that had undergone WLS reported several unhealthy lifestyle behaviors, in some cases worse than the children who live with parents who had not had WLS. Being cognizant of these findings will help obesity providers focus their counseling and expectations appropriately.

Parents as health promoters: a theory of planned behavior perspective on the prevention of childhood obesity.

Childhood obesity is a significant problem in the United States. A number of communication campaigns and interventions have been conducted to combat the problem, with parents being recognized as an important target audience. A critical aspect of involving parents in such campaigns is formative research on parents' perceptions of their role in preventing childhood obesity. To facilitate this process, a study was conducted in which parents (N = 201) responded to Theory of Planned Behavior (TPB) survey items as they relate to providing healthy foods and limiting unhealthy foods for their children. Results indicated support for TPB predictions. Additionally, the degree to which parents viewed providing healthy foods and limiting unhealthy foods as effective in preventing obesity (response efficacy) was predictive of parent tracking of children's unhealthy eating behavior. Finally, parent TV viewing behavior was related to perceived response efficacy of limiting children's TV viewing hours. Practical implications for communication practitioners are discussed.

Adequacy of two ambulatory care surveillance systems for tracking childhood obesity practice patterns.

BACKGROUND: The National Ambulatory Medical Care Surveys (NAMCS) and National Hospital Ambulatory Medical Care Surveys (NHAMCS) are surveillance systems in the USA that track provider practice patterns at ambulatory care visits. This study investigated the adequacy of the NAMCS/NHAMCS for surveillance of childhood obesity practice patterns. METHODS: The frequency of obesity visits in the 1997-2000 NAMCS/NHAMCS (outpatient component) was compared with obesity prevalence among children who reported a physician visit in the preceding 12 months in the National Health and Nutrition Examination Survey (NHANES) 1999-2000. Obesity was identified using the International Classification of Diseases 9th revision clinical modification code ICD-9-278.0 in the NAMCS/NHAMCS. For the NHANES, age- and gender-specific body mass index >95th percentile was used. RESULTS: Between 1997 and 2000, obesity was identified in 4.1 million (0.8%) of 516 million ambulatory care visits. With an obesity prevalence of 14.2% from the NHANES survey, NAMCS/NHAMCS only identified 5.6% of all children aged 2-17 years >95th percentile. Of those identified, the rate of obesity visits in the NAMCS/NHAMCS was lowest for non-Hispanic Whites (3.9%) compared with non-Hispanic Blacks (6.9%) and Hispanics (10.2%). CONCLUSION: The very infrequent reporting of obesity in the NAMCS/NHAMCS suggests that these surveillance systems do not reflect how healthcare providers identify and care for overweight children. Collecting weight and height measures would improve their utility in tracking identification and management of overweight children.

Parental preferences on addressing weight-related issues in children.

Little is known about parental preferences on how providers should approach or manage weight-related concerns. A cross-sectional survey was conducted of 292 parents in a pediatric primary care faculty group practice. Of the 292 respondents, 90% were women, 45% had a child on Medicaid, and 53% had a body mass index of 25 or more. Only 12.1% of parents reported they had an overweight child. The term "gaining too much weight" was preferred 2:1 to "overweight" (51.1% versus 25.9%, P < .001). Most respondents (62.3%) thought the physician's office was the best place to manage an overweight child. Parents who reported they had an overweight child were more likely to prefer individual than group sessions compared with those without an overweight child (odds ratio, 2.1; 95% confidence interval, 1.2-3.7). Further research is needed to investigate the reasons underlying these preferences and how they positively or negatively impact program satisfaction, attrition rates, and behavior change outcomes.

Patterns of psychotropic medication use in very young children with attention-deficit hyperactivity disorder.

Psychotropic medications are increasingly used for very young children. Patterns of use in a well-described group of children 3 years and younger with a diagnostic label of attention-deficit hyperactivity disorder (ADHD) reveal both reasons to use such medications and concerns about how these medications are used. Of 223 children with ADHD, more than half (n = 127) received psychotropic medications in an idiosyncratic manner, both in the specific medication and in use over time. Almost half of the children who were medicated did not have opportunities for monitoring as often as every 3 months, despite the fact that more than half received psychotropic medications for 6 months or longer. Children with comorbid mental health conditions and chronic health conditions were at greater risk for receiving psychotropic medications. These patterns of use demonstrate a compelling need for guidance in psychopharmacological treatment of very young children.