# Presentation: 875492

##  Obesity Risks and Parental Motivations to Make Changes*Research in progressRecruitment issues in primary care obesity studies

*Ardis  L.Olson MD, *
*Cecelia Gaffney MEd, Pam Lee PhD, Pam Starr MS, *
*Carolyn Mohr BA, Zsolt Nagykaldi PhD*
*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

## Promoting Healthy Families Study Design

**Promoting Healthy Families Study Design**

## Healthy Families Project Thus far...

- 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) obesity related health risks,
- 2) each parent’s motivation to change for nutrition and activity,
- 3) counseling prompts for motivational interviewing
- Enrollment of parents of children with obesity risks and BMI >85% completed and cohort now between 3 and 6 months after enrollment

## What Clinician knows at start the visit 

**What Clinician knows at start the visit **
**using the PDA**

- •

## Clinician Counseling cues if ready to change

## Nutrition risks by weight category

**Nutrition risks by weight category**

- •

**Notes:**
 Children eat fruits, but few vegetables per day. 
 Compared to normal children, obese children eat fewer fruit servings, while drinking more sodas/sweet/juice drinks.

## Physical activity risks by weight category

**Physical activity risks by weight category**

- •

**Notes:**
Obese children spend more time with TV, video games, and on the 
   computer
 Almost 30% of obese children spend less than 1 hour per day in active play. 

## 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 

- •

**Parental interest and confidence **
**to make nutrition changes**** **

**Notes:**
Take Home Message:  
 Families of young children are less engaged in making changes in their child’s physical activity than nutrition.  This is shown by low perceived importance and interest in starting to make changes. 
 When interested, nearly half of all families lack confidence they can make changes for their child to be more active.
 Among overweight children, most parents think that changing their child’s eating is very important, yet less than half of these parents of overweight children have confidence that they can make changes for their child to eat healthier.

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

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

- •

**Notes:**
Take Home Message:  
 Families of young children are less engaged in making changes in their child’s physical activity than nutrition.  This is shown by low perceived importance and interest in starting to make changes. 
 When interested, nearly half of all families lack confidence they can make changes for their child to be more active.
 Among overweight children, most parents think that changing their child’s eating is very important, yet less than half of these parents of overweight children have confidence that they can make changes for their child to eat healthier.

## Importance and Confidence Reflect 

**10**

**Importance**

**Confidence**

**10**

**0**

**High**

**High**

**Low**

**Success**

**Importance and Confidence Reflect **
**Commitment to Change**

**Frustrated**

**Skeptical**

**Unaware or Cynical**

**Moving: **
**  ****helping**

**Notes:**
As noted earlier, the grid shows how Conviction and Confidence interact to reflect the likelihood of taking action and changing behavior. 

Both high conviction and confidence are needed before a patient can finally achieve success.

Let’s say both conviction and confidence are low,  a very common situation, especially when patients are in the precontemplator stage. Would you start with trying to increase conviction or confidence? [Elicit ideas from the participants.....asking then to elaborate on their reasoning. Almost always someone will say start with conviction.]

As some have said, it is usually best to focus on increasing conviction firs. Enhancing confidence to begin an exercise regimen is not likely to lead to change if the person is not convinced that it is valuable or important.

## If interested in making a change,

**If interested in making a change,**
**Who is ready to take action? **

- •

- Nutrition

- Physical
- Activity

- Confidence

- Importance

- Importance

**Children with BMI **_***>***_** 95%**

**Notes:**
Take Home Message:  
 Families of young children are less engaged in making changes in their child’s physical activity than nutrition.  This is shown by low perceived importance and interest in starting to make changes. 
 When interested, nearly half of all families lack confidence they can make changes for their child to be more active.
 Among overweight children, most parents think that changing their child’s eating is very important, yet less than half of these parents of overweight children have confidence that they can make changes for their child to eat healthier.

## Parental concerns by child weight category

**Parental concerns by child weight category**

- •

**Notes:**
	Take Home Message: 
Above concerns assessed before questions about nutrition and activity risk behaviors.

Parents of obese children on average have twice the number of concerns 
      as parents of normal weight children. Since parents of obese children have multiple concerns, 
      obesity concerns may not get enough attention in a short office visit.

## Recruitment Challenges in Childhood Obesity 

- Determining eligible subjects
- BMI calculated along with % BMI for age
- 	  electronic medical record
-      chart review
- • How to determine parental risk factors if are also used to determine eligibility
- 	   Maternal weight status, FH of risk factors

**Notes:**
Is BMI used clinically
6000 charts reviewed manually

Need to ask parents at recruitment

## Do they think the juice is worth the squeeze?

**Family**
-     Family view of the child’s weight and need to participate
- 	Do they think the child is overweight or likely to persist
-     Do they think child’s weight is an issue that they need to address by participating in an intervention study

**Clinicians**
-    Clinical benefits of participating in delivering the intervention
-          Not enough time to do extra activities in the visit
-          Don’t feel effective in their counseling
-    Problem if enrollment process time consumin
-   Additional burdens for office staff

**Notes:**
 Parents not ready to take action re child’s weight not likely to enroll

## Healthy Families ProjectReaching the subjects 

- 302 families in our study eligible and interested in participating
-     168  could be contacted by phone
-         157 enrolled of these families contacted
- 	     		Average of 8 calls per family
- 			No time of day or day of the week better
-                 Family designated time to call also not helpful

**Notes:**
 Challenge of gearing up staffing to match calling with enrollment peaks and delays due to multiple calls- lost 50 early families

## Lessons from other pediatric obesity research studies

- • Need to have realistic intervention that engages both the patients and providers
- 	Large study relying on paying clinicians to work an extra hour per week to perform follow up unable to recruit clinician
- • Anticipate recruitment difficulties if clinicians recruit
-     Only 90 families recruited by 14 pediatricians over 6 months
- • Include engagement of families and anticipate considerable drop off when intervention has multiple steps in enrollment or multiple follow up visits
-     50% drop out after first visit with family weight loss intervention
- • Need to use culturally appropriate methods for families
- 	     Use of a Spanish radio station for community engagement and support of   program and recruitment.

## Conclusions

- Obesity risk factors are 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 are key to the counseling and also subject recruitment process
- New approaches that use technology to determine eligibility and reduce recruitment burden are important to use
- Thorough feasibility piloting is key to have appropriate interventions, time,  and staffing
- This is a major clinical and public health problem that is important for practice based research networks to develop creative, practical studies