# Presentation: 875490

##  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.

**Notes:**
This generation of children will potentially live shorter life spans than their parents due to Obesity morbities.

## Promoting Healthy Families Study Design

**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 

**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

**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.

## 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
- •

**Notes:**
Can fell like nagging to the parent and frustrating to c linnician who over times gives up/they don’t change anyway

## 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
- •

**Notes:**
 Asking about  nutrition issues may prime parents
38% were concerned/ at beginning of PDA 55% interested in making change in nutrition later

## 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