This pleases Dr. Paul. “Pediatricians only have a limited amount of time for each visit, and an office setting is not very conducive to get in as in-depth a conversation as you would like, especially in well-child care. By meeting with several families at once, instead of delivering the same information five times, it can be done once in 100 minutes where everyone can be in on the discussion,” he said in an interview.
Partnering with others in the community not only adds another layer of support, it also takes the burden off the physician to do it all.
The NET-Works study (Now Everybody Together for Amazing and Healthful Kids), currently underway at the University of Minnesota, on the Twin Cities campus, includes the families of 500 preschoolers, followed for 3 years after being randomly assigned to standard care or an integrated model that features nutritional counseling, both at the primary care and community level, as well as a home-based intervention, and support from neighborhood and community resources to promote optimal healthful lifestyle habits, including diet and physical activity, and screen time limits. Results from the study are due in 2017.
“What I like about this study is that the pediatrician has a supporting, rather than leading, role in a community-wide effort to prevent and treat childhood obesity,” said Dr. Paul. “I think that’s the answer.”
Another model of community-based care, promoted by the CDC, leverages the time more than 60% of U.S. children spend in early education and care centers by linking various community resources with these early learning facilities to ensure that children learn to consume healthful foods and exercise.
Dr. Dianne Ward, professor of nutrition at the University of North Carolina, Chapel Hill, and a panelist at the IOM roundtable, noted that one hitch is that often the child care providers themselves are often unhealthy. “A number of studies show these women often have poor diets, stress, inactivity, and smoke, yet these are the same women we ask to be role models for our children and lead the healthy eating educational programs. It’s unclear whether their health status has a negative effect on the children.”
Dr. Paul’s own work with others such as Dr. Leann Birch, the William P. “Bill” Flatt Childhood Obesity Professor at the University of Georgia, Athens, focuses on home-based interventions delivered by nurses. By training parents and caregivers in what they call “responsive feeding,” their SLIM-Time study addresses how and why parents feed their children, rather than what they feed them, with the essential byproduct being greater capacity in both parents and children to self-soothe and exert self-control.
Similar to Dr. Messito’s work, SLIM-Time (Sleeping and Intake Methods Taught to Infants and Mothers Early in Life) “teaches people how to respond appropriately to a baby’s cues earlier in life. If you take a baby and give it a bottle, it will stop crying, whether or not [the baby is] hungry. Food should be used for hunger,” Dr. Paul said. “We teach parents to use food for hunger, not comfort.”
The results of the randomly controlled SLIM-Time study of 110 mother-infant dyads, published online in 2010, were that by teaching parents soothing and sleep strategies other than bottle feeding, and helping them to recognize satiety cues, as well as educating them on the appropriate time to introduce solid foods, study babies were encouraged to finish their bottles only half as often as were controls. At 1 year, study babies were in the 35th percentile for weight-for-length compared with 50% of controls. Babies in the test group also required fewer nighttime feedings than did controls at weeks 3, 4, 8, and 16 (P = .003) (Obesity. 2011 Feb; 19[2]: 353-61).
The results led Dr. Paul and his colleagues to create the similarly structured INSIGHT Study (Preventing Obesity Through Interventions During Infancy), the results of which are still in preparation, but preliminarily seem to reinforce SLIM-Time’s results, with 15% of controls being in the 95th or higher weight-per-length percentiles at 1 year compared with 5% of intervention group babies being in that range.
Dr. Birch stated during the IOM round table that the effects in each study group were similar, regardless of whether a child was fed formula or breast milk. “We still have a lot of data to analyze, but at this point, it looks like the effects aren’t limited to intense breastfeeding.” Breastfeeding has been found protective against obesity (Am J Epidemiol. 2005 Sept 1;162[5]:397-403. Epub 2005 Aug 2; Int J Obes Relat Metab Disord. 2004 Oct;28[10]:1247-56.)