A new study co-authored by University of Rochester Medical Center (URMC) faculty provides evidence for a straightforward solution to addressing the rise of pediatric obesity: collaboration between families and their local pediatrician’s office.
The study, published in the Journal of the American Medical Association, was conducted in three states with children ages 6-12. Masters-level specialists with backgrounds in social work and behavioral health were recruited to work in pediatricians’ offices and lead family-based treatment programs for obesity, which focused on getting the whole family—not just the child—to participate in lifestyle changes.
The program improved weight-loss outcomes for the treated child and parent, and even extended to untreated siblings.
“It’s no surprise that the family therapy approach benefits many patients, because if it’s in the family it will likely model sustained behaviors,” said Stephen Cook, MD, MPH, associate professor of Pediatrics at URMC and a provider at UR Medicine’s Golisano Children’s Hospital. “If you get buy-in and commitment from the family you’ll see success, and this has been verified repeatedly in research.”
The randomized clinical trial enrolled 452 children with one parent in primary care practices in Buffalo and Rochester, New York, Columbus, Ohio and St. Louis, Missouri. Half of the children were randomly assigned to family-based treatment and the other half received standard care; 27.2% of the children were Black, 8.8% were Latino, and 57.1% were white.
The study found that three times as many children in the treatment group (27%) as in the usual care group (9%) had a clinically meaningful reduction in body mass index (BMI), which was associated with improved cardiometabolic outcomes, such as lower blood pressure and lipid levels and increased glucose regulation.
Children enrolled in family-based treatment lowered their BMI by an average of 6.48% more versus the control group, while their parents had a reduction of 3.97 percent and their untreated siblings who were overweight had a reduction of 5.38 percent compared to controls. The reductions among family members were related, meaning that positive changes for the child also were more likely to happen for siblings and parents in the same family.
Rochester-area practices that participated were Elmwood Pediatrics, Genesis Pediatrics, Golisano Children’s Hospital Pediatric Practice, Long Pond Pediatrics, Panorama Pediatrics, and Rochester General Pediatric Associates.
Embedded Specialists Make a Difference
The employment of masters-level specialists in pediatric practices—with backgrounds in behavioral health related fields—helped to produce these positive outcomes, according to Cook.
“We trained people who had never done this type of obesity work before and embedded them to work within the primary care practice. Having that type of integration with primary care, with specialists trained to identify both behavioral health issues and socio-economic barriers, helped us find solutions that benefitted the whole family,” he said. “I’m not aware of any published studies that show the same ripple or halo effect when you only target and treat an adult.”
Meghan Dahlman, MA, MS, interventionist and consultant for the Developmental and Behavioral Pediatrics department at URMC, served as one of these specialists and worked in several Rochester-area practices for the study. Previously a special education teacher in Victor, NY, Dahlman found that her educational and professional background helped her transition to the family-based treatment program.
“I had been using behavioral strategies in my teaching to get kids working on their daily life skills, so it was a natural fit to adapt some of these methods for obesity consulting,” she said.
During the project, embedded specialists were provided BMI and weight criteria for inclusion in the program. Specialists preemptively flagged charts and informed doctors and nurses that a particular patient was eligible for enrollment. In addition, the program placed recruitment materials in pediatric practices and in communications from these practices to patients.
Setting expectations—and securing buy-in from families—were critical for results, according to Dahlman. “It was really important to get to know a family and brief them on all aspects of the program, then get consent from both the parents and children before we engaged in any activities,” she added.
Families who participated met weekly with the specialist, either on Zoom or in person. Specialists focused on getting families to increase physical activity, reduce screen time, and engage in realistic meal planning.
“Meal planning was huge, but we acknowledge some of the limitations families deal with,” said Dahlman. “We would create weekly plans. If we knew that there was going to be a conflict like a school event or sports activity and the family was likely to grab fast food in between those activities, then we would pull up the menu during our meal planning session and come up with ideas for the healthier choices on the menu.”
Among the families Dahlman worked with, enthusiastic child participation correlated with the best results.
“Children who were energetic about joining the program helped the whole family get on board and achieve goals,” said Dahlman. “In general, when both the child and family members were committed, we had success.”
Reforms Needed to Make Model Permanent
Follow-up studies will look to build on the evidence-based success of this program, but implementing this model permanently will require changes to insurance reimbursements, as well as staffing regulations, according to Cook.
“You can provide this treatment plan by having insurance cover the services and by allowing mental health providers and counselors to be co-located in pediatric practices,” he said. “This approach will lead to early and appropriate steps to change unhealthy behaviors in a safe and effective way. This system also integrates behavioral health and aligns with advanced pediatric primary care models that New York State Medicaid is moving toward with its next waiver.”
In addition, this model could help pediatricians identify behavioral health issues early. “It’s more efficient to have specialists trained in identifying and addressing a variety of behavioral health symptoms located in the primary care home. You can address many of these issues earlier and in the context of the family. We are less likely to see worse mental, behavioral or physical health issues later in adolescence and young adulthood,” said Cook.
Cook hopes the program can also expand to include more after-hours options for families and telemedicine services to be more accommodating. “It’s an intensive program, and it’s not for every child or family; we present that upfront so families understand the time and effort it will take. By co-locating in the pediatric office and using telemedicine we can build on the progress we’ve made by making it even more convenient for families, because we’ve seen strong evidence that family commitment will help model sustained behaviors,” he said.