Childhood Obesity Risks and Parental Motivations to Make Changes The Promoting Healthy Families Project Ardis L.Olson MD, Cecelia Gaffney MEd, Pam Lee PhD, Pam Starr MS Clinicians Enhancing Child Health (CECH) practice based research network Depts. of Pediatrics, & Community and Family Medicine, Dartmouth Medical School, Lebanon, NH Supported by NICHD funding

Background Childhood Obesity has been identified as a major public health problem where we are making little progress. During childhood the primary care office is the only setting that accesses both parent and child over time. Pediatric clinicians are urged to counsel to prevent and treat obesity but feel ineffective and frustrated. Restructuring the well visit is needed to discuss specific obesity risks while still addressing other topics.

Promoting Healthy Families Study Design

Healthy Families Project 4 community practices in rural New Hampshire with Pediatric and Family Medicine health providers (population 2,000 to 15,000) 1585 parents at well visits of their children ages 4 to 10 years have completed pre-visit screening utilizing a hand held computer (PDA) Clinicians training to use brief motivational interviewing techniques and provided via the PDA: 1) child’s BMI and BMI Percentile 2) obesity related health risks, 3) each parent’s motivation to change for nutrition and activity, 4) counseling prompts for motivational interviewing Enrollment of parents of children with obesity risks and BMI >85% is completed and now collecting follow up data on the cohort at 6 months after enrollment

What Clinician knows at start the visit using the PDA

Changes in the Visit with the PDA Parental data routinely gathered for major areas of well child visit are determined before the start of the visit for clinician review More obesity risk factors assessed than routine visits Clinician can expand on topics Can support good choices Prepares parent for discussion Concerns re common topics Clear than eating and activity important to clinician Readiness to make change for child’s eating and activity Efficient use of visit time Completed in 3-4 minutes Children often have hearing/vision screening in this age group and can complete then.

Clinician Counseling cues if ready to change

Nutrition risks by weight category

Physical activity risks by weight category

The Ingredients of Readiness to Change Importance (Why should I change?) Confidence Readiness (Can I do it?) Rollnick, Mason, & Butler, 2003

Parental interest and confidence to make nutrition changes

Parental interest and confidence to change their child’s physical activity

10 Importance Confidence High Low Success Importance and Confidence Reflect Commitment to Change Frustrated Skeptical Unaware or Cynical Moving: helping

If interested in making a change, Who is ready to take action? Nutrition Physical Activity Confidence Importance Children with BMI > 95%

Parental concerns by child weight category

Implications for clinical care Parental stage of motivation varies and needs to be addressed to more effectively engage parents in making family changes in nutrition and activity Few clinicians have received training in brief motivational interviewing approaches The common approach of giving information and handouts not likely to be effective for families who consider issue of low importance or lack confidence

Implications for clinical care Challenges: Multiple specific nutrition and activity risk factors need to addressed during obesity related counseling in all well visits Limited time in well visits and more concerns of parents of obese children are more likely to have other concerns as well Low cost technology assists by: Visit changed from majority of time on data gathering to discussion of issues Allow clinician to prioritize issues and plan counseling approach and understand which families may need another visit Parents have been prepared to discuss these issues Knowing if other psychosocial and developmental issues are playing a role

Conclusions Obesity risk factors are very common in children and primary care interventions are needed for both normal weight and overweight children Parental interest in taking action, as well as motivational factors, vary by weight status and differ for nutrition and activity New approaches that use low cost technology to efficiently gather data are feasible in busy primary care settings This is a major clinical and public health problem that is important for practice based research networks to study creative, practical approaches