As Paul L. Rowland III, M.D., now sees it, physicians can talk to parents and their overweight children about diet and physical activity, or they can really counsel—that is, ask, listen, listen some more, and talk.
It's only through real counseling, he said, that doctors can hope to prevent and treat obesity and overweight—and all the morbidities that accompany it. “I've learned how to approach this in a positive way, how not to alienate [the families].”
Dr. Rowland is 1 of 20 pediatricians in the Pittsburgh area who participated in a two-pronged practice-based pilot project in which they changed and intensified their counseling—and implemented behavioral treatment programs in their two practices for overweight 8- to 12-year-old children and their families.
The short-term results have encouraged Dr. Rowland and his colleagues to continue. Thirty-seven children who were counseled during well-child visits and subsequently completed the 5-month-long intervention had a mean weight loss of 4 pounds. Seventeen of these children, who were followed for 6 months or more, had a mean decrease in BMI of 2 absolute units, or approximately 7% of their baseline BMI.
Perhaps more importantly, the children made dietary changes and changes in their activity levels that Dr. Rowland and his colleagues believe will have a long-lasting impact.
“We didn't see great weight loss. But these children are at an age where they're expected to gain weight and height, so any weight loss is fabulous,” said Ellen Wald, M.D., who codirected the project.
The call for physicians to incorporate weight management into their practices is intensifying. Numerous bodies have recommended that childhood obesity be prevented and treated in the primary care setting, and both the American Academy of Pediatrics (AAP) and the American Medical Association soon plan to issue clinical guidelines for weight management in children.
Surveys have repeatedly revealed what holds back primary care physicians: a lack of training and perceived competence, a lack of time, parent unwillingness to become involved, few available treatment options, and a lack of third-party reimbursement.
Dr. Rowland said he “didn't need any prompting” when asked to participate in the project almost 2 years ago. He and the five other full-time pediatricians in his ethnically and economically diverse practice, Pittsburgh Pediatric Associates, had only recently begun measuring BMI in some patients. Still, he said, overweight “was a concern that [had been] weighing on our minds for a long time.”
Dr. Rowland also is a member of a 3-year-old practice-based research network—Pediatric PitNet—comprising physicians in practices that are partially owned by Children's Hospital of Pittsburgh. The network had been awarded a $125,000 grant through the Robert Wood Johnson Foundation's “Prescription for Health” program—an initiative that funds practice-based pilot projects aimed at combating unhealthy behaviors in primary care.
For their part, he and the other physician participants completed a 60-minute self-study packet that included 7-year-old recommendations on obesity management from the federal Maternal and Child Health Bureau, the AAP's 2003 policy statement on pediatric overweight and obesity, and reports by Leonard H. Epstein, Ph.D., on his successes with behavioral family-based treatment.
(In 1994, Dr. Epstein and his colleagues reported 10-year outcomes showing that significant numbers of children who lost weight through family-based behavioral treatment maintained that weight loss, or lost more, through adolescence and into adulthood.)
They then attended a 90-minute session—led by health psychologists from the Western Psychiatric Institute and Clinic—in which they revamped their approach to talking during well-child visits about weight and BMI, nutrition, and physical activity.
“The important thing is not to come off sounding judgmental, but to solicit and tease out their concerns a little bit better,” said Dr. Rowland. “I learned to see where the family's coming from—to ask open-ended questions and restate what they're saying—before I start sharing my opinions.”
He said he was surprised by how many parents are concerned about their child's excess weight, but just need to be prompted to talk about it. When parents don't voluntarily express concern, “I show them the [BMI] curve and see how they respond. I might ask, are you concerned? Many will say 'Yes, I didn't bring it up before, but yes.'”
“We almost always end up talking about activity or snacking. Parents will sometimes say, 'He's eating a lot of healthy foods' but when I restated their thoughts, they'd start talking about portion size, how 'He eats seconds or thirds.'”
Per the study protocol, Dr. Rowland encouraged children with a BMI at the 85th percentile or higher, whenever possible, to participate with their parents in a behavioral treatment program. Each run of the program consisted of eight weekly group sessions and three individual follow-up sessions held right in his practice. (See box below at right.)