On his own initiative, Dr. Rowland went further. He attended many of the sessions, sitting in with the kids and keeping his own food and activity logs.
“I don't have any weight issues, and I am physically fit, but I really wanted to learn what these kids were thinking. And I started thinking, maybe I could also do better. I realized what a huge issue these lifestyle changes are,” Dr. Rowland said. “That's why the whole family has to be on board—one member can't make [the] change if other members aren't trying, too.”
Of 73 families who enrolled in the program, 37 completed it. (Families were “completers” if they attended six of the eight group sessions and one of the three follow-up sessions.)
In addition to the mean drop in weight and BMI, the 37 children decreased their consumption of high-fat, low-nutrient foods by half or more. Twenty-one of these children who used pedometers throughout the intervention period also saw a 50% increase in steps per day. (All children started the intervention using pedometers, but many discontinued using the pedometers after the first few weeks.)
Interviews with parents showed that the physicians used what they'd been taught, said Linda Ewing, Ph.D., a codirector of the project who presented some of the findings at the annual meeting of the Pediatric Academic Societies.
Twenty-seven randomly selected parents were interviewed before and after the program. Prior to the training, 37% reported that their child's doctor had discussed physical activity during their well-child visit; after training, this jumped to 89%.
The percentage of parents who reported that the doctor had discussed their child's eating habits jumped from 37% before training to 82% afterward, she said.
“We've shown that it's feasible—that pediatricians will [adopt new skills] and address issues of weight more confidently, and that parents will come to an evidence-based intervention in the office,” said Dr. Ewing of the University of Pittsburgh. “It's the first step, but by no means the last.”
Clinical Growth Charts 'To Go'
If your practice is already working on weight management or getting ready to work with the upcoming clinical guidelines on weight management, the Centers for Disease Control and Prevention's National Center for Health Statistics can help with the record keeping. Copyright-free, customizable PowerPoint charts for tracking boys' and girls' stature-for-age, weight-for-age, and BMI-for-age are available online (
www.cdc.gov/nchs/about/major/nhanes/growthcharts/Powerpt.htm
From Weigh-Ins to Group Sessions: What Behavioral Treatment Entails
Children who attended the behavioral treatment program at Dr. Rowland's practice started each of the eight weekly sessions with a “weigh-in” and an individual family “coaching” session.
The children then met in a group with a clinical psychologist from outside the practice while the parents met primarily with the pediatric office's nurse-practitioner, M. Kathleen Kelly.
“The kids are very honest, and they're encouraged by small changes,” said Dr. Rowland, who attended many of the children's group sessions. “They would readily answer to 'What was difficult for you?' and 'What can you do for next week?'”
Sessions for both parents and children focused on self-monitoring of diet and activity, stimulus control, goal setting, positive reinforcement, social assertion, and relapse prevention.
The goals were to decrease intake of high-fat, low-nutrient foods; to increase intake of low-fat, high-nutrient foods; to decrease sedentary behaviors; and to increase activity and exercise.
Many of the children already had received a small BMI chart color-coded into red, yellow, and green zones to indicate overweight, at-risk, and healthy ranges of BMI. The colors correspond to the red, yellow, and green categories of food in the “stop-light diet”—a concept that the project directors incorporated into the nutritional counseling element of the project. They had the chart designed as an educational tool.
Of 73 children who enrolled, only 4 had a BMI between the 85th and 94th percentiles; the rest of the children were heavier.
Each run of the program in each of the two participating practices—Pittsburgh Pediatric Associates, Dr. Rowland's practice, and Children's Community Care, a rural practice right outside Pittsburgh—consisted of fairly even numbers of boys and girls, with a mean age of 10 years.