June 06, 2017
Two packages of interventions that combined clinical care with parent empowerment and links with community services were both able to reduce body mass index (BMI) in obese children, according to findings published online June 5 in JAMA Pediatrics.
"At 1 year, we found that 9.3% of children in the enhanced primary (care) group and 11.6% of children in the enhanced primary care plus coaching group no longer had a BMI in the overweight or obese range," Elsie M Taveras, MD, chief of the division of general academic pediatrics at Massachusetts General Hospital for Children, Boston, and colleagues, write.
Dr Taveras told Medscape Medical News, "In both of the arms we had higher odds of children being in a lower BMI category than they were at baseline" — 18% higher for the enhanced primary care group and 23% higher for the enhanced-plus-coaching group.
Surprisingly Little Difference in Results Between Interventions
The intention-to-treat randomized and blinded trial called Connect 4 Health included 721 children ages 2 to 12.9 years with BMI in the 85th or greater percentile from six primary-care practices in Massachusetts.
The group included a mix of 35% non-Hispanic white children, 33% non-Hispanic black, 22% Hispanic, and 10% other races/ethnicities. Participants were randomized to one of two arms: enhanced primary care, which served as the control group, or enhanced primary care plus individualized, interactive coaching. The trial was conducted from June 2014 through March 2016.
In the enhanced primary care group, obese children were identified and physicians were alerted to their status through the electronic health record (EHR).
In addition to exposure to best practices in clinical care, the families got text messages once a month to encourage behavioral changes, such as links to the "Let's Move!" program, for example. Families also got a neighborhood resource guide listing places in their community that support healthy living.
The second group received those same interventions plus several additions, such as individualized health coaching tailored to each environment. Trained coaches contacted families every other month by phone, videoconferencing, or in person, depending on parent preference, for 15 to 20 minutes.
Families also got twice-weekly texts or emails and mailings after each session to support behavior-change goals. Coaches also offered families a 1-month free family membership to area YMCAs and invited the families to a program on healthy grocery shopping.
Dr Taveras said they were surprised to find that the improvements in the primary care-plus-coaching group were not statistically significant compared with the control group.
In the control group, the adjusted mean BMI z-score was 1.91 at baseline and 1.85 at 1 year, an improvement of -0.06 units. In the enhanced-plus-coaching group the adjusted mean BMI z-score was 1.87 at baseline and 1.79 at 1 year, an improvement of -0.09 units.
Outcomes were also not much different in parental empowerment levels or children's quality of life.
But that may be good news for primary-care practices that want to try this program but don't have the staff for intensive, personalized coaching, she said.
"I'm excited that we've created two packages that can be widely disseminated in practice." As long as doctor's offices have EHRs, they can easily adopt these protocols, she said. Big systems that might have more resources to add the personalized coaching may want to do so, but that "might not be necessary or cost-effective."
The study seems to show that any coaching helps, even if it is one-way and pushed out to families electronically, she stressed.
Families Helped Design Trial
Dr Taveras also noted that this trial was designed and conducted in collaboration with patients and their families who came to meetings and worked with them, an approach promoted by the funder, the Patient-Centered Outcomes Research Institute.
She said that likely helped with the high retention rates.
"We had over 90% contributing a BMI at 1 year out, and 88% of families completed a survey at follow-up. I think that says a lot about working to engage families with a certain condition in the full development of the study."
She says all three contributors worked together for success.
It starts with a physician "who won't let the topic go and knows what to do." Then, it's giving parents the resources so they are confident this is something they can tackle as a family. From there, it's providing information on a network of community resources that can help children and families work on their goals, she concluded.
The study was supported by the Patient-Centered Outcomes Research Institute, the National Institutes of Health, the Agency for Healthcare Research and Quality, and the National Institute of Diabetes and Digestive and Kidney Diseases. The authors report no relevant financial relationships.
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JAMA Pediatr. Published online June 5, 2017. Article