Pediatric Obesity Treatment in a Safety Net Clinic: Piloting the Step by Step Program
Condition: Pediatric Obesity; Overweight and Obesity
MeSH terms: Obesity; Overweight; Pediatric Obesity
Study type: Interventional

Summary: 
      Obesity treatment interventions have been studied in pediatric primary care offices and are
      often conducted in low-income and minority populations, and pediatric obesity clinics. Key
      components of programs that have been shown to be effective include parent engagement
      providing physical activity, nutrition and behavior education and at least 26 hours of total
      contact time. However, there is little guidance in the literature describing translation of
      successful programs into sustainable, real-world practice for uninsured children and
      families. To the investigator's knowledge no studies in the United States have evaluated the
      feasibility of implementing a fitness and nutrition program in safety net clinics where
      uninsured parents and their children receive health care. The objectives of this project were
      to design an evidence-based, family-centered fitness and nutrition program and evaluate the
      feasibility and acceptability of implementing this program in a Volunteer in Medicine Clinic,
      discussing successes, challenges and lessons learned.
    

Detailed description: 
      The objectives of this project were to design an evidence-based, family-centered fitness and
      nutrition program and evaluate the feasibility and acceptability of implementing this program
      in a Volunteer in Medicine Clinic, discussing successes, challenges and lessons learned.

      This prospective pilot study was conducted within a Volunteers in Medicine (VIM) model clinic
      in Southeastern Pennsylvania from July - December 2012. The VIM Model focuses on providing
      primary care to children, adolescents and adults that are uninsured. This model is guided by
      the principles of inclusion, service and community involvement, with volunteers providing the
      vast majority of health care and support services.

      Community Volunteers in Medicine (CVIM) provides primary care and dental care to uninsured
      adults and children who live or work in Chester County with incomes less than 300% of the
      federal poverty level. In 2016, Chester County's residents were 7% Hispanic, 24% obese, 9%
      uninsured and 10% of children living in families with incomes below the poverty level. Most
      pediatric patients served by CVIM are of Hispanic/Latino descent and have a high prevalence
      of overweight and obesity (54%), which is higher than the county prevalence of 25% in
      school-aged children.

      After a quality improvement project identified the high prevalence of childhood obesity in
      children served by CVIM, the authors proposed developing a family-centered obesity treatment
      program. CVIM's Executive Board committed support to the program. Temple University School of
      Medicine's Institutional Review Board approved the project. Consent materials were available
      in English and Spanish.

      The program name Step by Step (Paso a Paso) was chosen by consensus, logo designed by a local
      graphic artist, and T-shirts provided to staff, volunteers and participants. Behavior change
      theory and goal-setting principles informed the program design. A literature review
      identified evidence-based best practices. Thirteen 1.5 hour weekday educational sessions,
      five 1-hour weekday fitness classes and seventeen 1 hour weekend activities were scheduled
      over 22 weeks. The planned total contact time was 41.5 hours, above the minimum effective
      amount recommended by the USPSTF. Children participated in all activities. Weekly text
      messages with motivational messages and reminders were planned. A Manual of Operations
      detailed the volunteer orientation, session outlines, and handouts. Sessions had bilingual
      staff and handouts were available in English and in Spanish. Clinic staff, volunteers and
      family members were encouraged to participate in fitness and nutrition activities.

      Staff and Volunteer Recruitment and Training Providers recruited from clinic volunteers and
      staff conducted enrollment histories and physical examinations. The clinic's nutrition
      education specialist organized cooking classes with assistance from volunteers. Volunteers
      recruited from an Accelerated Pre-Medicine Post Bachelor's Program at a local college
      completed a background check, CVIM volunteer orientation and Step by Step program
      orientation. Volunteers provided child supervision, assistance with physical activity and
      cooking classes and language support. A physician (KS) was present for every session.

      Participant Recruitment and Enrollment Enrollment goal was 10 families. Chart review
      identified eligible families; they were contacted by phone and invited to attend the
      enrollment meeting with a standard script.

      At enrollment, parents signed informed consent and children assented; parents gave permission
      for photography and physical activity participation. Parents and children completed baseline
      questionnaires on fitness and nutrition knowledge and practices. Participant histories and
      physicals were completed using the Pennsylvania Sports Physical Standard form. Families gave
      permission to receive text reminders and were given a schedule for activities and educational
      sessions.
    

Intervention name(s): Step by Step: A Family-Centered Healthy Lifestyle Intervention
Intervention type(s): Behavioral
Intervention model: Single Group Assignment
Intervention model description: Pilot Program to Implement a Family Centered Pediatric Obesity Treatment Program in a Safety Net Clinic using Goal Setting Principles and Behavior Change Theory
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: pediatric obesity; safety net clinic; patient centered; nutrition therapy; body weight