Report: Obesity interventions falling short

There is precious little pediatricians do or are encouraged to do during clinical visits for young children to help lower the risk of obesity, a pediatric researcher told an Academy of Medicine panel in October.

For one thing, there is little research on what to do, said Ian Paul, MD, Chief of the Division of Academic General Pediatrics, Pennsylvania State College of Medicine. From pregnancy to age 2 years there are few interventions shown to be effective or even researched. There are almost none on preventive efforts alone for the 2 to 5-year age group, he said. 

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Paul’s presentation was part of a day-long October workshop sponsored by the Academy’s Roundtable on Obesity Solutions.

He cited as a positive step American Academy of Pediatrics (AAP’s) recent report, “The Role of the Pediatrician in Primary Prevention of Obesity,” that calls for pediatricians to take proactive steps including identifying children at risk, using growth charts, looking at behavioral risk factors, screening for knowledge about diet and activity, and educating. That education, Paul said, can include encouraging self-monitoring, pointing out resources like Women, Infant, and Children (WIC) and Supplemental Nutrition Assistance Program and online resources including MyPlate.gov with examples of good food plates.

Although pediatricians are key in the fight against obesity, he acknowledged there are “a ton of barriers.” There are always time constraints and many other priorities. Physician care is expensive.

“Pediatricians don’t always feel equipped to handle these questions or issues about obesity prevention or even obesity treatment,” Paul said, and reimbursement has not been good for obesity-related care.

In a child’s first 5 years, he noted, it’s often hard to convince families there is a problem.

Guidelines for clinic visits don’t focus on obesity, he pointed out. Within the recommendations in AAP’s “Bright Futures,” he said, “None of the visits for 2 through 4 years list diet or nutrition as a priority,” and the questions and forms for parents and physicians have little on the subject.

He does note that limiting television viewing and the promotion of physical activities are in the priority list.

Paul bemoaned the fact that over the last 10 to 15 years studies have shown pediatricians are not using body mass index (BMI) growth charts, although that may now be changing.

“However, I can assure you that the weight-for-length chart for children under 2 is almost never being used by pediatricians,” he asserted.

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There is hope of the future, he said. For one thing, the push for quality improvement, defined as “systematic and continuous actions that lead to measurable improvement” in healthcare, has initially been used in inpatient settings and is moving to outpatient settings also.

Electronic health records, he said, could be leveraged to improve quality. For example, “alarm values” could show up on the electronic record when a child has a high weight-for-length or BMI. Or automatically uploaded data from pre-visit or waiting room surveys could alert the doctor to obesogenic behaviors, including early introduction of solids, prolonged bottle use, consumption of fruit juices or sugar sweetened beverages, a lack of fruits and vegetables, and too much TV.

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New models of care might help, he said. For example, the “centering care” model typically has group visits with 6 to 7 parents with their babies. In 8 to 9 sessions of an hour and a half to 2 hours, the groups get assessment, education, and support.

“It has been shown to have high patient satisfaction. And the families form a support network,” said Paul.

An adaption of that model is being tested at New York University study, in which groups are led by a nutritionist-child development specialist, he said.

There are other communities pediatricians can partner with, he pointed. For instance, he pointed out, “There is very little communication between primary care and WIC even though it is used by so many families in our country.”

Dieticians can be a partner for early intervention, and pediatricians can point families to community resources including farmers’ markets.

In most institutions, he said, communication between obstetricians and pediatricians has been pretty poor. And that could be an avenue for promoting discussion of things like breastfeeding, smoking during pregnancy, and appropriate gestational weight gain.

Also, he said, pediatrician communication with childcare providers is almost never happening, and there could be some education there, for example, on beverages and snacks.

The influential Academy of Medicine, which held the workshop, was until this year called the Institute of Medicine. It’s part of the National Academy of Sciences, a private institution chartered by Congress.

The videos and presentations from the October 6 workshop are available under “Events” on www.iom.edu.