Primary Care Practice Addressing Child Overweight and Obesity: A Survey of Primary Care Physicians at Four Clinics in Southern Appalachia

Objective: The prevalence of childhood overweight and obesity in southern Appalachia is among the highest in the United States (US). Primary care providers are in a unique position to address the problem; however, little is known about attitudes and practices in these settings. Methods: A 61-item healthcare provider questionnaire assessing current practices, attitudes, perceived barriers, and skill levels in managing childhood overweight and obesity was distributed to physicians in four primary care clinics. Questionnaires were obtained from 36 physicians. Results: Physicians\u27 practices to address childhood overweight and obesity were limited, despite the fact that most physicians shared the attitude that childhood overweight and obesity need attention. While 71% of physicians reported talking about eating and physical activity habits with parents of overweight or obese children, only 19% reported giving these parents the tools they needed to make changes. Approximately 42% determined the parents\u27 readiness to make small changes for their overweight or obese children. Physicians\u27 self-perceived skill level in managing childhood overweight and obesity was found to be a key factor for childhood overweight- and obesity- related practices. Conclusion: Primary care physicians in southern Appalachia currently play a limited role in the prevention or intervention of childhood overweight and obesity. Training physicians to improve their skills in managing childhood overweight and obesity may lead to an improvement in practice

Parent-Led Activity and Nutrition (plan) for Healthy Living: Design and Methods

Child obesity has become an important public health concern, especially in rural areas. Primary care providers are well positioned to intervene with children and their parents, but encounter many barriers to addressing child overweight and obesity. This paper describes the design and methods of a cluster-randomized controlled trial to evaluate a parent-mediated approach utilizing physician\u27s brief motivational interviewing and parent group sessions to treat child (ages 5–11 years) overweight and obesity in the primary care setting in Southern Appalachia. Specific aims of this pilot project will be 1) to establish a primary care based and parent-mediated childhood overweight intervention program in the primary care setting, 2) to explore the efficacy of this intervention in promoting healthier weight status and health behaviors of children, and 3) to examine the acceptability and feasibility of the approach among parents and primary care providers. If proven to be effective, this approach may be an exportable model to other primary care practices

Depression Screening Patterns for Women in Rural Health Clinics

Context: Rates and types of screening for depression in rural primary care practices are unknown. Purpose: To identify rates of depression screening among rural women in a sample of rural health clinics (RHCs). Methods: A chart review of 759 women\u27s charts in 19 randomly selected RHCs across the nation. Data were collected from charts of female patients of rural primary care providers, using trained data collectors (inter-rater reliability.88 to.93). The Women\u27s Primary Care Screening Form, designed by the authors, was used to collect demographic, health, and screening data. Data describing the characteristics of the clinics were collected using the National Rural Health Clinic Survey. Data regarding formal screening (validated instrument used) or informal (documentation of specific questions and answers regarding depression) in the previous 5 years were recorded. Findings: Characteristics of participating clinics and demographics of the women were similar to published data. Formal screening was documented in 2.4% of patients\u27 charts. Informal screening was documented in 33.2% of charts. Patients with a history of anxiety were more likely to be screened (P \u3c.001), and younger women were more likely to be screened than older women (P \u3c.001). Conclusions: Primary care providers in RHCs use more informal than formal depression screening with their female patients. Providers are more likely to screen younger patients or patients with a diagnosis of anxiety

Joint Effects of Child Temperament and Maternal Sensitivity on the Development of Childhood Obesity

The interplay between child characteristics and parenting is increasingly implicated as crucial to child health outcomes. This study assessed the joint effects of children’s temperamental characteristics and maternal sensitivity on children’s weight status. Data from the National Institute of Child Health and Human Development’s Study of Early Child Care and Youth Development were utilized. Infant temperament, assessed at child’s age of 6 months by maternal report, was categorized into three types: easy, average, and difficult. Maternal sensitivity, assessed at child’s age of 6 months by observing maternal behaviors during mother-child semi-structured interaction, was categorized into two groups: sensitive and insensitive. Children’s height and weight were measured longitudinally from age 2 years to Grade 6, and body mass index (BMI) was calculated. BMI percentile was obtained based on the Centers for Disease Control and Prevention’s BMI charts. Children, who had a BMI ≥ the 85th percentile, were defined as overweight-or-obese. Generalized estimating equations were used to analyze the data. The proportions of children overweight-or-obese increased with age, 15.58% at 2 years old to 34.34% by Grade 6. The joint effects of children’s temperament and maternal sensitivity on a child’s body mass status depended on the child’s age. For instance, children with difficult temperament and insensitive mothers had significantly higher risks for being overweight-or-obese during the school age phase but not during early childhood. Specific combinations of child temperament and maternal sensitivity were associated with the development of obesity during childhood. Findings may hold implications for childhood obesity prevention/intervention programs targeting parents

Parent and Provider Perceptions of Use of the NIH We Can! Curriculum for Group Visits In Primary Care to Treat Child Overweight and Obesity

As part of a cluster randomized controlled trial of a parent-mediated approach to treating overweight and obese children ages 5-11 years in Southern Appalachia, feedback on use of the NIH We Can! curriculum for parent group visit sessions in primary care was obtained from parents and providers in two intervention clinics. Parents/caregivers of 28 children in two primary care clinics were randomized to the intervention group to participate in four on-site 1.5 hour group sessions held every other week during an 8-10 week period. Five primary care providers (PCPs) in the two clinics were trained to lead the group sessions using the NIH We Can! online training and an additional 1-hour face-to-face training conducted by the project team. The Project Coordinator and one project team clinician (Pediatrician, Pediatric Psychologist, or Registered Dietician (RD)) was present during each group visit to answer any questions about the study protocol, behavior (Pediatric Psychologist) or nutrition/eating (RD). The Project Coordinator or RD called each parent during the week following each group visit to discuss the family’s progress and answer questions. Written feedback surveys were completed by parents and focus groups were conducted with providers following the last group session. Provider focus groups were recorded and later transcribed and coded to indentify themes. Among 22 (79%) parents/caregivers who completed group sessions and a feedback survey, 91% agreed/strongly agreed that “this program was very useful to me as a parent.” In addition, 95% said that they would “recommend We Can! to a friend” citing benefiting from information received from healthcare providers and parents as well as the opportunity for “fellowship” with other parents. All five PCPs led at least 1 or 2 group sessions and participated in focus groups. Most PCPs agreed that the We Can! leader’s guide and training prepared them to lead the group sessions. All providers reported that preparation time to lead a session (15-90 minutes) was reasonable. On average, providers perceived the group sessions to be moderately effective in promoting healthier eating, physical activity, and reducing screen time in their patients. Some providers were interested in continuing to offer a monthly group session for long-term support. These findings suggest parent and healthcare provider acceptability of using NIH We Can! parent group sessions to treat child overweight in primary care

Provider Perceptions on Parent-Led Activity and Nutrition (PLAN) for Healthy Living Study Targeting Child Overweight and Obesity

Childhood overweight and obesity rates have grown immensely in recent years in the United States, especially in rural areas. The current study evaluated health care providers’ perceptions of training and implementation of a cluster-randomized clinical trial, Parent-Led Activity and Nutrition (PLAN) for Healthy Living, for treatment of overweight and obesity in children 5-11 years of age. Five physicians (3 in a pediatric clinic and 2 in a family medicine clinic) were trained in (1) brief motivational interviewing techniques for individual visits with parents, and (2) the National Institutes of Health (NIH) We Can! (Ways to Enhance Children’s Activity and Nutrition) Curricula to lead group sessions with these same parents aimed at providing them with the tools necessary to aid in changing their family’s eating and physical activity behaviors. Upon completion of the 10-week intervention, physicians (N = 4) participated in focus groups with research staff to discuss their experiences with the study. Based on the individual visit training in brief motivational interviewing, the principle of supporting self-efficacy was used by all providers during individual visits and was determined to be of most help. One physician commented that individual sessions would likely be more effective with families that are well-known by the provider, and several physicians believed that longer-term follow-up visits conducted by a registered dietician or nurse are feasible. Findings revealed that physician preparation time for a group session with parents was within the range of 15-90 minutes, with all providers believing this time was well-spent. The provider ratings of group session effectiveness were very high, approximately a 6 on a 7 point scale. Several providers felt the group visits were more effective than the individual visits. Additionally, some providers suggested continuing the group sessions on a monthly basis for long-term support. The collective data suggests that physicians view PLAN as an acceptable and feasible approach to the treatment of child overweight and obesity

Joint Effects of Child Temperament and Maternal Sensitivity on the Development of Childhood Obesity

The interplay between child characteristics and parenting is increasingly implicated as crucial to child health outcomes. Based on data from a national birth cohort, this study assessed the joint effects of children\u27s temperamental characteristics and maternal sensitivity on the development of childhood obesity. Infant temperament, assessed by maternal report, was categorized into three types: easy, average, and difficult. Maternal sensitivity, assessed by observing maternal behaviors during mother-child semi-structured interaction, was categorized into two groups: sensitive and insensitive. Child\u27s weight and height were measured longitudinally from age two years to Grade 6 and body mass index (BMI) was calculated. Obese (≥ the 95th percentile) and overweight-or-obese (≥ the 85th percentile) were defined based on sex and age specific BMI percentiles. Generalized estimating equations were used to analyze data. The proportions of children who were obese and overweight-or-obese increased as they got older, 5.47% and 15.58% at 2 years of age, to 18.78% and 34.34% at Grade 6. Children with easy temperament and under the care of a sensitive mother were at the lowest risks of obesity and overweight-or-obesity over childhood. The joint effects of children\u27s temperament and maternal sensitivity on overweight-or-obesity largely depended on childhood phases. For instance, children with difficult temperament and under the care of an insensitive mother had much higher risks during school age but not during early childhood. In conclusion, parents may need to tailor their parenting strategies to particular child temperamental characteristics in order to prevent and control the development of childhood obesity

Home Food Environment, Dietary Intake, and Weight among Overweight and Obese Children in Southern Appalachia

Objectives: This study examined the relation of multiple aspects of the home food environment to dietary intake and body weight among overweight and obese children in southern Appalachia. Methods: The study used baseline data from a cluster-randomized controlled trial, Parent-Led Activity and Nutrition for Healthy Living, evaluating a parent-mediated approach to treating child overweight and obesity in the primary care setting in southern Appalachia. Sixty-seven children ages 5 to 11 years were recruited from four primary care clinics. Multiple linear regression was used to estimate the relation between multiple aspects of the home food environment to dietary intake (fruit and vegetable intake, fat and sweets intake), and standardized body mass index (zBMI), adjusted for baseline family characteristics (education, smoking status during the past month, BMI) and child characteristics (sex, age, Medicaid/TennCare). Results: Findings showed greater parental restriction and pressure in feeding were associated with greater fruit and vegetable intake in children (β = 0.33, β = 0.30, respectively; both P \u3c 0.05). The availability of chips and sweets in a child’s home and parental inappropriate modeling of eating were associated with an increased risk for consumption of fats and sweets by children (β = 0.47, β = 0.54, respectively; both P \u3c 0.01). Parental monitoring of the child’s eating was associated with a reduced risk for fat and sweets intake (β = −0.24; P \u3c 0.01). Finally, parental responsibility for feeding the child was associated with lower zBMI (β = −0.20; P \u3c 0.05). Conclusions: The home food environment, including food availability and parenting behaviors, was associated with overweight and obese children’s dietary intake and weight. This study adds to evidence suggesting that programs aimed at improving overweight and obese children’s eating patterns may target both aspects of the physical home environment and parental behaviors surrounding eating