September 2010

Grant Results

SUMMARY

In two related projects, researchers at the University of Rochester School of Medicine and Dentistry carried out research to find the best ways to encourage primary care physicians to screen and treat childhood obesity in their practices and their communities.

First, they conducted surveys of pediatricians and family practice physicians, asking them about how they manage obesity in their practices. Then, through a series of follow-up activities, the researchers worked with the American Academy of Pediatrics to develop and implement ways to encourage physicians to address childhood obesity.

Key Findings
Findings on their survey of pediatricians appear in a paper slated for publication in Pediatrics in 2010, entitled "Adoption of BMI Guidelines for Screening and Counseling in Pediatric Practice."

Findings of their survey of family practitioners appear in an unpublished paper entitled "Screening and Counseling for Childhood Obesity: Results of a National Survey."

  • Nearly all pediatricians (99 percent) surveyed routinely measured children's height and weight, but only about half (52 percent) used this information to calculate children's body mass index (BMI)—a measure used to diagnose obesity.
  • Some 45 percent of family practice physicians plotted BMI at all or most visits with children ages 2 and older.
  • Most physicians—67 percent of pediatricians and 61 percent of family practice physicians—said they did not have enough time during office visits to counsel patients on weight management.

Key Results

  • The researchers retooled the obesity Web site of the American Academy of Pediatrics to make it easier for front-line caregivers, parents and others to navigate the site. The updated site includes information on policies and projects in local communities and links to other Web sites.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project from October 2005 through October 2008 with two grants totaling $416,460.

 See Grant Detail & Contact Information
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The Problem

The proportion of young people who are obese has grown rapidly since the mid-1970s, according to the Centers for Disease Control and Prevention (CDC). The percentage of children ages 2 to 5 who are obese rose from 5 percent to 12.4 percent from 1976 to 2006, from 6.5 percent to 17 percent for children ages 6 to 11 and from 5 percent to 17.6 percent for children ages 12 to 19.

Carrying excess weight is unhealthy. Obese children are more likely to develop chronic health problems, such as diabetes and heart disease, according to the CDC.

To combat obesity, the American Academy of Pediatrics recommends that physicians track the body mass index (BMI)—a measure of body fat calculated from weight and height—of all children, beginning at age 2. Specifically, BMI is a measure of weight in kilograms divided by height in meters squared. A BMI less than 20 is considered too thin; a BMI from about 21 to 25 is considered normal. A BMI between 25 and 29 is considered overweight, and a BMI higher than 30 is considered obese.

The academy also urges members to use changes in BMI to identify children who need a referral to a dietician or other follow-up care. However, only 11 percent of pediatricians routinely use BMI to track the body fat of their patients, according to a 2002 study published in the April 2004 Journal of Pediatrics. This is the case even though inexpensive plastic calculators are widely available to convert height, weight, age and gender data into BMI scores in about 30 seconds. In addition, many Web sites do a calculation in seconds.

Why don't physicians use BMI? In 2004, researchers at the University of Rochester School of Medicine and Dentistry set out to answer that question. With funding from RWJF, they conducted a literature review and held 13 focus groups with a total of 107 participants. (See Grant Results.) The focus group attendees cited a number of reasons why they did not use BMI in their practices, including:

  • Time constraints faced by staff.
  • Difficulties in changing office practices.
  • Feelings of helplessness in addressing obesity.

The researchers conducted the literature review and focus group sessions in order to gather background information for a national survey of physicians about their office processes to track and treat obesity.

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RWJF Strategy

RWJF seeks to reverse the upward trend in childhood obesity by 2015. RWJF has developed three integrated strategies to reverse the childhood obesity epidemic: evidence, action and advocacy.

  • Evidence. Investments in building the evidence base will help ensure that the most promising efforts are replicated throughout the nation.
  • Action. RWJF's action strategy for communities and schools focuses on engaging partners at the local level, building coalitions and promoting the most promising approaches.
  • Advocacy. As RWJF staff learns from the evidence and action strategies, it shares results by educating leaders and investing in advocacy, building a broad national constituency for childhood obesity prevention.

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The Project

In two related projects, researchers at the University of Rochester School of Medicine and Dentistry worked to find out the best ways to encourage primary care physicians to screen and treat childhood obesity in their practices and their communities.

In the first stage, researchers surveyed pediatricians and family practice physicians, asking how they manage obesity in their practices.

In a series of follow-up activities, the researchers worked with the American Academy of Pediatrics to develop and implement ways to encourage physicians to address childhood obesity in their practices and communities.

The Surveys

The researchers fielded two surveys: one sent to pediatricians and a second sent to physicians in family practice.

For the pediatricians, the researchers sent surveys via mail to 1,622 pediatricians; 1,013 were returned for a response rate of 62 percent. A total of 336 surveys were not used because the physicians did not regularly supervise the health of children. (See Findings and Conclusions for details on survey results.)

For the survey of family practitioners, the researchers sent out 1,800 surveys; 729 were returned for a response rate of 41 percent. A total of 284 surveys were not used because the physicians did not regularly supervise the health of children. (See Findings and Conclusions for details of survey results.)

The researchers developed the first survey in collaboration with the American Academy of Pediatrics, which included the questions as part of a periodic survey of its members. The researchers were unable to reach a similar arrangement with the American Academy of Family Physicians and developed the second survey in collaboration with a team at the Department of Family Medicine at the University of Medicine and Dentistry of New Jersey.

Follow-up Activities

Through a one-year transition grant from RWJF, the researchers worked with the Academy of Pediatrics, using the research findings to develop ways to encourage pediatricians to address childhood obesity in their practices and communities.

The project was based on the idea that front-line caregivers are good advocates for change because they are in contact with patients daily and also are respected sources of medical expertise in their communities.

The project team held meetings with leaders of American Academy of Pediatrics chapters, sponsored webinars and awarded grants to physicians with obesity projects targeted at underserved populations. They also retooled the academy's Web site on childhood obesity.

Communications

The researchers presented findings from the two surveys at a number of professional meetings, including:

  • Summit on childhood obesity sponsored by RWJF and the National Initiative for Children's Healthcare Quality in September 2006 in Washington.
  • New York State Childhood Obesity Invitational Summit in November 2006 in Albany.
  • Pediatric Academic Societies' Annual Meeting in May 2007 in Toronto, Canada.
  • American Academy of Family Physicians' Scientific Assembly in October 2007 in Chicago.

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Findings

The researchers reported their findings on their survey of pediatricians in a paper slated for publication in Pediatrics in 2010, entitled "Adoption of BMI Guidelines for Screening and Counseling in Pediatric Practice." They reported their findings on their survey of family practitioners in an unpublished paper, entitled "Screening and Counseling for Childhood Obesity: Results of a National Survey."

  • Nearly all pediatricians (99 percent) who responded to the survey routinely measure children's height and weight, but only about half (52 percent) use this information to calculate children's body mass index (BMI)—a measure used to diagnose obesity.
  • Some 45 percent of family practice physicians who responded to the survey plot BMI at all or most visits with children ages 2 and older.
  • Pediatricians surveyed discuss healthy lifestyles during well visits. For example:
    • Eighty-nine percent discuss the five-a-day recommendation on fruit and vegetables.
    • Eighty-six percent discuss physical activity.
    • Seventy-six percent discuss limiting television, computer and video game time.
    • Sixty-five percent discuss limits on sugar-sweetened beverages.
    • Fifty-five percent discuss snacks.
    • Forty-four percent discuss fast food.
    • Thirty-one percent discuss the food pyramid.
  • Most physicians surveyed—67 percent of pediatricians and 61 percent of family practice physicians—said that there is not enough time during office visits to counsel patients on weight management adequately.
  • Surveyed pediatricians believe that the lack of insurance reimbursement inhibits treatment options: Only 15 percent can bill for obesity counseling separate from well child visits. More than half say insurance does not cover dietician services, and 69 percent say insurance does not cover weight management programs.
  • A total of 47 percent of family practice physicians surveyed believe that reimbursement is insufficient for counseling and treatment of obese patients.
  • Some 60 percent of surveyed pediatricians who had received training about treating childhood obesity were familiar with national treatment guidelines, compared with 40 percent of those who had not received training.

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Results

The project director noted the following results in reports submitted to RWJF:

  • Retooled the obesity Web site of the American Academy of Pediatrics to make it easier for front-line caregivers, parents and others to navigate the site. It includes information on policies and projects in local communities and links to other Web sites.
  • Supported five obesity-related projects targeted at underserved communities with grants of up to $2,000. The Council on Community Pediatrics within the American Academy of Pediatrics awarded the grants. (For a complete list, see the Appendix.) The projects included:
    • A comprehensive prevention and treatment program for children from birth to age 5 who have a BMI of 35 or greater. The program is targeted at patients of the Cherokee Indian Hospital in Cherokee, N.C.
    • A conference on breastfeeding targeted at physicians in Northeast Tennessee. The Northeast Tennessee Regional Breastfeeding Coalition designed the conference to encourage local physicians to refer their patients to community-based resources available to help mothers breastfeed their babies. According to the CDC, accumulating evidence suggests that infants who are breastfed may be at lesser risk for becoming overweight during childhood.
  • As a result of meetings, webinars and other activities, more than 20 state chapters of the American Academy of Pediatrics launched ongoing projects to address childhood obesity, which the national office tracks and summarizes on its obesity Web site. The projects included:
    • A program called "Walking Works," in which obese children ages 9 to 12 get vouchers for local Kentucky YMCAs as well as sessions with a nutritionist. The Kentucky chapter sponsors the program, which operates in Louisville, Lexington and Northern Kentucky.

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Conclusions

The researchers concluded that:

  • Physicians who are familiar with national guidelines for managing obesity are more likely to follow them. Therefore, educational offerings and toolkits are very important.
  • Changes in reimbursement policies are needed to fuel prevention and treatment of childhood obesity in primary care.

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Lessons Learned

  1. Involve local, clinical leaders in advocacy efforts whenever possible. Clinical leaders of local- and state-based professional groups will educate other front-line caregivers about an important issue, who, in turn, will educate their patients. (Project Director/Klein)
  2. When you conduct survey research without an endorsement from a key group or individual, pay extra attention to the basic tenets of getting good response rates, including simple and succinct survey design and repeated follow-up. For example, the researchers created an easy-to-follow, 41-question, multiple-choice survey for physicians in family medicine. To encourage physicians to complete the survey, researchers mailed it five times. (Project Director/Klein)

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After the Grant

The Alliance for a Healthier Generation—a nonprofit organization created by the American Heart Association and the William J. Clinton Foundation—launched a project in February 2009 to test models of insurance benefits for children in need of follow-up care to treat obesity. The American Academy of Pediatrics, the American Dietetic Association and four insurance companies also participated in the project.

In June 2009, RWJF awarded a grant of $3.25 million to the National Initiative for Children's Healthcare Quality (ID# 065757) to provide training and technical support to help front-line caregivers become advocates for public policies to prevent childhood obesity. The American Academy of Pediatrics, the California Medical Association and the RWJF Center to Prevent Childhood Obesity also participated in the project.

In August 2009, Principal Investigator Jonathan Klein, M.D., M.P.H., became an associate executive director of the American Academy of Pediatrics.

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GRANT DETAILS & CONTACT INFORMATION

Project

Studying current physician screening and referral practices for childhood obesity and advancing environmental and policy interventions by physicians

Grantee

University of Rochester School of Medicine and Dentistry (Rochester,  NY)

  • National survey of current physician screening and referral practices for childhood obesity
    Amount: $ 324,242
    Dates: October 2005 to September 2008
    ID#:  053344

  • Advancing, disseminating and institutionalizing childhood obesity environmental and policy interventions
    Amount: $ 92,218
    Dates: November 2007 to April 2009
    ID#:  063356

Contact

Jonathan D. Klein, M.D., M.P.H.
(847) 434-4322
jklein@aap.org

Web Site

http://www.aap.org/obesity

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APPENDICES


Appendix 1

Preventing and Treating Obesity in Underserved Populations

The American Academy of Pediatrics awarded grants of up to $2,000 for five projects designed to prevent and treat obesity in underserved populations. The projects were:

  • A comprehensive prevention and treatment program for children from birth to age 5 who have a body mass index (BMI) of 35 or greater. The program is targeted at patients of the Cherokee Indian Hospital Authority in Cherokee, N.C.
  • A conference on breastfeeding targeted at physicians in Northeast Tennessee, which was held on April 18, 2009. During the conference, the Northeast Tennessee Regional Breastfeeding Coalition provided local physicians with information on community-based resources available to help mothers breastfeed their babies successfully.
  • A comprehensive clinic to treat obese Navaho children with services including pediatric medicine, physical therapy, mental health and nutrition guidance. The clinic is targeted at patients of the Fort Defiance Indian Hospital in Fort Defiance, Ariz.
  • A manual on nutrition and obesity prevention for home-based child-care providers in low-income communities in West Los Angeles County. The manual not only includes recommendations for preventing obesity—such as limiting screen time—but also recipes for healthy Mexican dishes in both English and Spanish. The project is the brainchild of Yvette Kimberly Wild, M.D., a pediatric resident. The manual is targeted at licensed home-care providers who are part of a network managed by the Westside Children's Center in Culver City, Calif.
  • An educational slide presentation and other tools to help pediatricians in Syracuse and Onondaga Counties in New York learn about the American Academy of Pediatrics' recommendations on preventing and treating childhood obesity. The New York Chapter 1, District II of the academy, which sponsored the project, targeted a racially and ethnically diverse group of physicians.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Klein JD, Sesselberg TS, Johnson MS, O'Connor KG, Cook S, Coon M, Homer C, Krebs N and Washington R. "Adoption of Body Mass Index Guidelines for Screening and Counseling in Pediatric Practice." Pediatrics, 125(2): 265–272, February 2010. Abstract available online.

Sesselberg TS, Klein JD, O'Connor KG and Johnson MS. "Screening and Counseling for Childhood Obesity: Results from a National Survey." Journal of the American Board of Family Medicine, 23(3): 334–342, May 2010. Available online.

World Wide Web Sites

www.aap.org/obesity. "Prevention and Treatment of Childhood Overweight and Obesity," on the American Academy of Pediatrics' Web site, contains information on what both patients and physicians can do to prevent and treat obesity as well as helpful links to other Web sites.

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Report prepared by: Linda Wilson
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans

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