SEARCH

SEARCH BY CITATION

Keywords:

  • Child and adolescent obesity;
  • Chronic Care Model;
  • primary care provider training

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References

The purpose of this systematic review was to examine 15 studies which evaluated interventions aimed at improving primary care providers' identification, assessment, prevention and/or management of obesity in children and adolescents. Interventions were evaluated in terms of length, components addressing nutrition, physical activity and behavioural counselling consistent with expert recommendations, and inclusion of components of the Chronic Care Model. Overall, training interventions were delivered face to face or in a combination of lecture, assigned readings, preceptorship with experienced providers, and critiqued evaluations of interactions of the provider with the patient and family. Many studies incorporated training of providers as an initial step prior to delivering an obesity intervention for children and adolescents measuring weight loss and behaviour change as outcomes. Each study was evaluated for components of the Chronic Care Model. The interventions most frequently utilized the elements of self-management support (69%), decision support (100%), delivery system support (77%) and clinical information systems (23%). Although science in this area is emerging, results suggest that intervention programmes that included more components of the Chronic Care Model were more effective.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References

The assessment and management of paediatric overweight and obesity have become major daily concerns for primary healthcare providers. Data from the National Health and Nutrition Examination Surveys (NHANES) suggest that for the years from 2003 to 2006, 11.3% of children and adolescents between the ages of 2 and 19 years were at or above the 97th percentile (morbidly obese). Over 16% of children and adolescents were measured at or above the 95th percentile (obese) and 31.9% were at or above the 85th percentile (overweight) (1). Ogden et al. have found, overall, 17.1% of youth in the USA between the ages of 6 and 19 years have a body mass index (BMI) ≥95% (2). In addition, data from NHANES show that another 16.5% of children and adolescents between the ages of 2 and 19 years have BMIs from the 85th to the 95th percentiles (3). This dramatic increase in overweight and obese youth has led to the emergence of associated chronic co-morbidities such as dyslipidemia, hypertension, type 2 diabetes, musculoskeletal disorders, respiratory conditions and mental health problems (4–10).

Obesity prevention guidelines

Recognizing the need for practical guidance for providers in the area of paediatric obesity, professional organizations convened experts to review the evidence and develop guidelines and recommendations aimed at the prevention, assessment, and treatment of overweight and obesity in children (11). Considerable research on paediatric obesity had been conducted since the 1998 Expert Panel Recommendations (12), indicating that the traditional primary care prescriptive approach was not working to treat this epidemic. Experts now wanted to include a developmental, family-centred approach that encouraged the use of motivational interviewing (MI) to guide practitioners in promoting healthy weight in youth (13,14).

The National Association of Pediatric Nurse Practitioners (NAPNAP) convened a panel of clinical experts who conducted a comprehensive literature review of current evidence on obesity prevention for the paediatric population. This panel drafted obesity prevention recommendations in six areas: early identification of overweight, developmental considerations, parent/child communication, nutrition essentials, feeding and eating behaviours, and physical activity (11). The criteria established by the American Academy of Pediatrics were used to rate the level of evidence available in the literature (15). Evidence-based, culturally sensitive, age-specific guidelines were released for NAPNAP's 6000+ members in spring 2006. The guidelines are relationship-focused, encouraging the use of MI to help the providers collaborate and support families in adopting healthier nutrition and activity habits. The family-centred approach recognizes that children and families have strengths that will facilitate their acquiring healthier behaviours. The family collaborates with the clinician on a plan that will be most effective for them in the context of their family and community.

In addition, the American Medical Association (AMA) in partnership with Health Resources and Services Administration and the Centers for Disease Control convened an Expert Committee and appointed scientists and clinicians from medicine, nutrition, nursing, psychology, and epidemiology to review the literature and recommend approaches to prevention, assessment, and treatment of youth overweight and obesity. The ‘Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity’ were published in a special supplement of Pediatrics in December 2007 (16).

Purpose

Current recommendations for the prevention, assessment and treatment of child and adolescent overweight and obesity call for primary care providers to be at the centre of a nationwide effort to address obesity in the primary care setting (16). Evaluation of interventions that focus on changing provider behaviour and health systems to improve providers' use of current recommendations regarding the identification, assessment and management of childhood overweight and obesity are needed to address this chronic health problem. We therefore conducted a synthesis of the literature on the efficacy of interventions to train paediatric primary care providers on the identification, assessment and treatment of childhood overweight and obesity.

Provider lack of adherence to guidelines

In the primary care setting, comprehensive care for overweight and obese youth should be initiated and delivered immediately upon the assessment of this chronic health condition (17). Current recommendations suggest that providers calculate, document and track the child's BMI at well-child care visits. BMI is an indirect measure of adiposity utilizing body weight adjusted for height but is a feasible assessment in clinical practice to evaluate a child's overall health status and risk for health problems. Importantly, general practitioners and paediatricians have been found to have inaccurate assessments of paediatric overweight and obesity when utilizing visual cues alone (18).

Clinicians may be overlooking a large number of youth with overweight and obesity during routine office visits. Despite the publication of recommendations from a variety of professional organizations, translating these recommendations into practice remains a challenge as research suggests there is limited adoption of guidelines and recommendations (19–21). As few as 25% of paediatricians, paediatric nurse practitioners and registered dieticians have been found to include all elements of the recommended evaluations for overweight or obese youth (22). Mabry et al. reported that BMI was documented in only 5% of initial visits for children diagnosed with obesity during a routine well-child visit in a general paediatric practice (23). More recently, a chart audit of well-child visits revealed less than 1% (0.93%) of visits documented a diagnosis of obesity (24). In a recent survey, Dilley et al. found similar results in 13 diverse paediatric practices where only 28% of obese children (n = 248) and 5% of overweight children (n = 186) were identified as such on their medical records (25). Likewise, a chart audit of 191 paediatric visits (20% of population) conducted at a school-based health centre revealed that 98% had a weight and height documented but only 20% had a BMI documented, and only 17% had a BMI percentile based upon age (11).

Beno et al. suggest that training the entire healthcare team is advantageous for the adoption of new tools and practices for the management of paediatric overweight (26). This assessment, treatment and management of paediatric overweight and obesity is entrusted to the paediatric primary care provider and must be initiated starting early in childhood (27). Unfortunately, despite the recognition that paediatric obesity is a significant health problem, paediatric residency programmes offer little training in the area of obesity prevention and management (28).

Theoretical framework: Chronic Care Model for Childhood Obesity

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References

A framework that incorporates healthcare system change to promote evidence-based health care is the Chronic Care Model for Childhood Obesity (see Fig. 1) (11). The Chronic Care Model (CCM), originally described by Wagner, is a synthesis of evidence-based system changes that organizations might use to guide quality improvement and disease management activities (29). Glasgow et al. suggest that the changes needed to improve the delivery of effective preventive care are fundamentally the same as those recommended in the CCM of effective chronic disease management (30). The CCM provides a framework of organizing principles for practice change (i.e. evidence- and population-based and patient centred) in which improvement strategies can be tailored to local conditions (16). The National Initiative on Child Health Quality agreed that adapting the CCM to guide acute, chronic and preventive care for children and their families would be effective and proposed the Care Model for Child Health (31).

image

Figure 1. Chronic Care Model for Childhood Obesity. BMI, body mass index; BP, blood pressure; CIS, clinical information systems.

Download figure to PowerPoint

The primary care clinic functions within the environment of the community's resources and health policies. The model (Fig. 1) depicts how improved practice changes provide the provider and patient/family with (i) self-management support using relationship-focused methods such as MI, family education and monitoring to increase child and family skills and confidence; (ii) decision support for providers, including utilization of evidence-based guidelines; (iii) delivery-system redesign to promote better care and follow-up of identified patients; and (iv) clinical information systems (CIS) to provide data to evaluate the progress the practice is making in meeting its goals and track patient progress with reminder prompts and generated reports. The resultant improvements in healthcare delivery positively influences both patient and provider outcomes (i.e. patient confidence, BMI, lipid profile; provider counselling, tracking and referral).

Dietz et al. emphasize that patient self-management is the core determinant in the obesity CCM (32). Providers of primary care, within an effective healthcare system, help families recognize the health consequences of their child's weight, assist the family in developing healthy lifestyle goals and support the family's decisions to make healthy changes. Indirect evidence from the National Health Disparities Collaborative on Asthma, Diabetes, and Depression suggests that improved patient outcomes also will result with the use of the practice-based changes made at the system level based on the CCM (33–39).

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References

Search strategy

A systematic search of Pubmed, MedLine, CINAHL, Cochrane, PsychINFO and professional meeting abstracts of the English language literature from the years 1998 (year that Expert Committee Recommendations were first published) (12) to December 2009 was performed. Articles included in this review describe interventions that focus on improving primary care providers' obesity care for children and adolescents. Careful examination excluded articles that reported only on the outcomes of interventions for overweight youth (i.e. weight loss) rather than also focusing on primary care providers and the interventions that sought to improve the provider's assessment, management and treatment of paediatric obesity.

The retrieved articles were saved in RefWorks® and duplicate titles removed. The search terms included: child and adolescent obesity, overweight prevention and treatment, clinician counselling, practice behaviour, primary health care, continuing education, and medical training. The review of reference lists in retrieved articles and hand searches also yielded studies to be included for review.

Identification of relevant studies

Two reviewers independently assessed the retrieved titles and abstracts. English articles with full-text of those studies that met inclusion criteria were obtained. Relevant articles were tabled and reviewed by the authors. Other collaborative projects initiated with paediatric primary care providers and major health insurers throughout the USA were also evaluated (40). Unfortunately, no published evaluations of these programmes are available to the general public.

This review critically analyses 15 studies which evaluated interventions aimed at improving provider's identification, assessment, prevention and/or management of obesity in children and adolescents. Table 1 details, in chronological order, critical information about each reviewed study.

Table 1.  Intervention studies targeting provider knowledge, assessment and management of paediatric overweight and obesity
Author and locationDesign/methodNo. of subjectsSampleComponents of the intervention and outcome measuresFindingsStrengths and limitations
Beno et al. (2005) (26). Design and implementation of training to improve management of paediatric overweight. Kaiser Permanente of Georgia.Pre-test/post-test (baseline and 3 months). Questionnaire. Focus groups. Descriptive statistics with results reported in percentages.n = 76 paediatric healthcare team members. 75% participation rate. Training group size ranged from 3–18 participants.23 physicians. 6 PAs and nurse practitioners. 18 registered nurses. 33 licensed practical nurses and medical assistants.Two 60-min interactive continuing medical education seminars. Interventions delivered by one trained physician and either one registered dietitian or behavioural health professional. Sessions contained: education, assessment or counselling tools overview and interactive exercises.At 3 months: More than 40% of providers reported that all of the tools were useful. Concerns were raised about addressing all of the history information in one counselling session. Clinician motivation and attitudes were found to hinder acceptance of the tools in practice.Strengths: Tools included self-history form, Rx Pad and counselling guide. Based on motivational interviewing (MI). Training of entire staff. Limitations: Lack of diversity in practitioners. Too many tools introduced at one time to staff. Results would have been strengthened with use of t-tests.
Hinchman et al. (2005) (44). Evaluation of a training to improve management of paediatric overweight. Kaiser Permanente of Georgia.Pre-test/post-test. Chart abstractions at baseline, 3 and 6 months. Delayed-controlled design: start times for the two groups were 4 months apart. Descriptive statistics, χ2.Nine paediatric clinics stratified into two groups: Group 1: four clinics and 33 nursing staff and 19 clinicians. Group 2: five clinics and 31 nursing staff and 18 clinicians.n = 220 charts (110 in each group) were abstracted at each time point as a random sample of paediatric patients ages 5–18 years. Charts: 65% normal weight; 17% overweight and 17% obese; 51% female; 33% preteen.Paediatric healthcare team members received training by professionals stated above in the Beno et al. (2005) study (26). Intervention: Session 1: education about obesity trends, assessment. Session 2: counselling model and tools for counselling techniques, patient motivation and clinician time.No charted body mass index (BMI) or BMI% at baseline. Group 1: BMI recorded 40.7% at 3 months and 35.2% at 6 months; BMI% 12% at 3 months and 16.2% at 6 months. Values represent significant increases over baseline. Group 2: BMI 43.0% at 3 months and 38.3% BMI%. Both with significantly increased reporting. All tools except the Rx pad with statistically increased use over baseline. Overweight patients had significantly more completed.Strengths: Brief in-service training for both staff and providers. Limitations: Attendance at both training sessions was 42% for group 1 and 29% for group 2. Total of 36% of eligible participants attend both training sessions. No discussion of why adherence to training continued to be so low after the intervention.
McCallum et al. (2005) (50). Can Australian general practitioners (GPs) tackle childhood overweight/obesity? Methods and processes from the LEAP (Live, Eat and Play) randomized controlled trial (RCT). Australia.Pre-test/post test. Design for GP knowledge, skills and attitudes to childhood obesity embedded within a feasibility and efficacy RCT intervention trial. Cross-sectional BMI survey recruited eligible overweight/obese children.General practitioners (n = 34) from 598 GPs contacted by letter. General practitioners attended at least two of three training sessions (75%) (2.5 h each) on management of childhood overweight. 28 (82%) of GPs completed baseline and follow-up questionnaires.29 family medical practices. Survey of 5- to 9-year-old BMIs. Overweight/obese children attending these practices (n = 163) which represents 40% of eligible children. 82 (50%) randomized to intervention group and 81 (50%) to control group.Intervention focused on achievable goals in nutrition, physical activity and sedentary behaviour. Education sessions based on the Stage of Change Model. Intervention was delivered in four consultations over 12 weeks to both child and parent.All 34 GPs recruited were retained throughout the study period. 27 (79%) expressed competence in managing obesity after training compared with 12 (35%) before training. No significant BMI differences between groups post intervention.Strengths: Medical practices represented a broad socioeconomic status demographic. Trained office staff. Theory-based. Limitations: Not all GPs attended all of the training sessions. Unknown how many children each GP intervened with.
Gee et al. (2006) (42). Overweight children: a comprehensive approach to address the epidemic. Kaiser Permanente Northern California.Presumed pre-test/post-test but not explicitly stated. Utilized comprehensive health questionnaire that included nutrition and physical activity questions.Children (7–15 years) and parents. n = 138 for 1–4 low intensity intervention sessions. n = 81 for 6–8 moderate intensity 9-week intervention sessions. n = 26 for 6–8 moderate intensity 6-week intervention sessions. n = 73 for 20 high intensity sessions over a 6-month period.Physician and staff on site training at 38 Kaiser Permanente facilities.Practice Guidelines for Kaiser: Physician Training Options: 1. Basic training: BMI, assessment, advice, treatment; 2. Communication skills: brief negotiation, cognitive behaviour skills; 3. Health professional advocacy. Outcomes: Physical assessment, goals, lab tests, focused advice, follow-up, MI.Child outcomes: Low intensity: reported significant change in dietary, physical activity and TV/video behaviours. Moderate intensity (9 weeks): significant decrease in mean daily servings of high-fat foods, high-sugar foods, servings of soda and TV viewing. Moderate intensity (6 weeks): significant improvement in fruits and vegetable intake, drinking soda and physical activity. High intensity: significant decrease in mean BMI.Strengths: Interventions targeted nutrition, education, exercise and behaviour change. Health system support for physicians participating in community advocacy. High family completion rate. High level of parent and child satisfaction. Limitations: Study design not published. Little information concerning provider outcomes or intervention training length.
Gonzalez & Gilmer (2006) (46). Obesity prevention in paediatrics: a pilot paediatric resident curriculum intervention on nutrition and obesity education and counselling. Texas, USA.Quasi-experimental design. Attitudinal and knowledge questionnaires, examinations, and a checklist of desired provider skills and behaviours. Questionnaires were also administered when the second-year residents completed their third-year residency. Paired t-tests. Sign and Wilcoxon signed rank tests.n = 6 second-year residents received new curriculum. n = 3 third-year residents served as control. Unknown number of first-year residents also surveyed for baseline data on attitudes and knowledge.Postgraduate second-year residents participating in an ‘Obesity Prevention in Pediatrics’ curriculum during a 1-month out-patient community rotation.Intervention consisted of (i) 20 min written lecture on obesity; (ii) pre-lecture review of curriculum goals, objectives, instructional strategies and evaluation methods; (iii) assigned readings on paediatric obesity; (iv) obesity clinic experience with paediatric nutritionist; (v) 1-h small group discussion of cases with nutritionist; and (vi) Resident observed and evaluated during clinic interaction.Control residents' knowledge and counselling skills on obesity prevention and management were well below expectation. Following participation, second-year residents' knowledge (per cent correct on examination) and comfort in counselling overweight and obese patients improved. Mean attitudinal scores also increased by 45%.Strengths: Intervention targeted both prevention and treatment strategies. Curriculum included counselling skills in nutrition and physical activity. Limitations: Small sample size because of residency cohort size. No data reported on first-year residents.
Dunlop et al. (2007) (59). Improving Provider's Assessment and Management of Childhood Overweight: Results of an Intervention Emory University School of Medicine.Pre-test/post-test medical record abstraction of all records of well-child visits for patients 2–17 years of age. Compared provider training alone or in conjunction with office-based tool dissemination. Data obtained 3 months prior to training, 1–3 months after the training and 4–6 months after the distribution of the tools. χ2. Logistic regression.n = 38 of 44 primary care providers (86%). 6 community-based primary care clinics affiliated with an academic medical centre. 466 medical abstractions at baseline. 538 abstractions at 1–3 months. 344 abstractions at 4–6 months.17 family medicine physicians and paediatric physicians. 19 family medicine residents and paediatric physicians. 2 nurse practitioners and staff (receptionists, medical assistants, nurses).Two 1-h training sessions delivered by a physician. Utilized: Expert Committee Recommendations; Use of assessment tools; Advise, identify, motivate counselling model; and Prescription pads. 3 months later tools were distributed to clinics and placed in every patient's chart at well visits. Outcomes: Documentation of BMI%, nutrition-activity history; nutrition-activity counselling.Non-significant increases in documentation in all outcomes at 1–3 months. Significant increases in all three outcomes at 4–6 months after the introduction of office-based tools in each chart. Baseline and post-training rates were lower for residents. Odds of provider documentation of all three outcomes increased with patient BMI.Strengths: Office-based tools provided for clinic use. Intervention based on the advise-identify-motivate counselling model. Staff training. Limitations: Relied on ‘checked box’ on medical record to indicate that nutritional or activity counselling took place at baseline. No changes noted until tools added to protocol 3 months after initial training.
Schwartz et al. (2007) (45). Office-based MI to prevent childhood obesity. Private paediatric offices belonging to the American Academy of Pediatrics, Pediatric Research in Office Settings group.Non-randomized clinical trial. Feasibility study to determine if physicians and registered dietitians can implement an office-based MI intervention. anova, paired t-testsn = 15 paediatricians (0.7%) from separate private paediatric practices. n = 5 registered dietitians. n = 5 practices non-randomly assigned to each arm recruited 10 patients each.Paediatricians chosen to represent diversity of patients and provide geographical dispersion. Child (3 to 7 years of age) participants were assigned within clinics to: (i) control; (ii) minimal intervention (10- to 15-min MI session with paediatrician only); or (iii) intensive intervention (10- to 15-min MI session with paediatrician and 45- to 50-min MI session with registered dietitian).Intervention: paediatricians and registered dietitians attended a study orientation and completed a 2-day MI training session. Another 2-d training session occurred 1 year later because of delay in start of recruitment. Control paediatricians and registered dietitians received anthropometry training via telephone. Outcomes: BMI, nutrition, physical activity.Enhanced motivational and counselling skills for obesity management occurred with both the paediatricians and the dietitians. Parents were highly satisfied with the MI counselling session(s). No significant BMI differences between groups. Significant decrease in dining out in intensive group. Significant decrease in snacking in minimal intervention group.Strengths: Feasibility pilot study enabled researchers to obtain suggestions from participants in order to plan for a larger full-scale trial of the intervention. Limitations: No practice recruited required number of study child participants. Large number of families dropped out of the study before the 6-month follow-up, especially in the intensive intervention group.
Dennison et al. (2008) (43). Training healthcare professionals to manage overweight adolescents: Experience in rural Georgia communities. Georgia, USA.Post-test medical chart abstraction to assess practitioner compliance after training. Descriptive statistics.n = 58 providers (nurses, nurse practitioners, physicians).10 rural paediatric clinics. 97% of providers had not previously utilized BMI or BMI% to assess overweight patients. 85 overweight or obese adolescents, 13–18 years of age, were assessed. 49 (57%) adolescents completed the scheduled 16-week follow-up visit.Intervention: 90-min adolescent overweight assessment and management training session. Utilized Beno et al. (2005) and Hinchman et al. (2005) paediatric training protocol (26,44). Included Centers for Disease Control (CDC) interactive case studies in growth chart training modules.Practitioners complied with protocol and discovered risk factors in many overweight patients that had not been previously diagnosed. After training, all but one chart had recorded BMI, and appropriate lab work ordered.Strengths: Targeted training to providers in a rural area with high incidence of obesity. Limitations: Compliance of adolescents/families to recommended management was not high despite reminder phone calls and monetary incentive. This may be a reflection of the lack of MI in the training content. No direct measure of provider knowledge and assessment skills post intervention.
Kopp & Hornberger (2008) (60). Proper Exercise and Nutrition Kit: Use of Obesity Screening and Assessment Tools with Underserved Populations. KAN Be Healthy (KBH) registered nurse training programme. Kansas, USA.Pre-test/post-test. Pre-survey concerning current practice, knowledge screening and assessment skills of nurses. Proper Exercise and Nutrition (PEN) tool kits to incorporate revised curriculum of KBH. Telephone interview utilized as a follow-up to the survey.n = 500 public health, school and clinic-based paediatric nurses were mailed surveys with 32% return (n = 159).Public Health Nurses performing KBH health assessments in 77 counties in Kansas. Initial 46% pass rate on pre-survey KBH questionnaire.Intervention: 4-h expanded training curriculum on growth, nutrition, obesity (BMI), client education, anticipatory guidance, and counselling and assessment tools. Each nurse was mailed the PEN tool kit. Outcome measures: BMI chart wheel and educational materials use. Plotting on the CDC growth chart, CDC BMI chart, nutrition intake and physical appearance.Strong nurse support for this intervention (92%). Results indicated that of 10 000 KBH clients each year, 53% would benefit from the Pen tool kit. Results indicated increased identification of overweight and obesity and increased use of screening tools and referrals.Strengths: Comprehensive educational components for intervention. Significant sample size. Limitations: Convenience sample. Lack of educational materials in Spanish. Post-evaluation via telephone interview not chart abstraction.
Perrin et al. (2008) (49). Bolstering confidence in obesity prevention and treatment counselling for resident and community paediatricians. North Carolina, USA.Pre-test/post-test. Intervention to improve self-efficacy and frequency of obesity management and counselling. ‘Promoting Healthy Weight’ tools. Physician survey. Signed Rank Test for ordinal data and the McNemar's test for dichotomous data.n = 49 of 52 (94%) paediatric resident physicians. n = 18 of 27 (90%) of community physicians.80% female; 88% Caucasian. University of North Carolina at Chapel Hill Pediatrics Continuity Clinic and four rural community practice sites. Residents used the tools with an average of five patients each. Community physicians used the tools with an average of 23 patients.1-hour training included: assessment, communication, and counselling to improve diet and activity, follow-up, and use of screening and management tools. Resident physicians used tools a total of 9 months. Community physicians used tools 2–4 months. Residents used tools longer because of shorter scheduled clinic time. Outcomes: confidence and use of tools.Confidence improved significantly in both the resident and community physician groups after training. Ease and frequency of counselling about healthy eating, physical activity and healthy weight significantly increased. More than 50% of respondents reported that the tool utilization increased the length of the well visit.Strengths: Utilized social cognitive theory, transtheoretical model and MI. Developed confidence (self-efficacy) questionnaire with Cronbach's alpha of 0.86. Limitations: Number of encounters and duration of the intervention varied between types of sites. Small convenience sample. No control group.
Ewing et al. (2009) (51). Translating an evidence-based intervention for paediatric overweight to a primary care setting. Kids Striving to Improve Diet and Exercise (KidSTRIDE) University of Pittsburgh.Pre-test/post-test. Descriptive statistics and anova.10 paediatricians and a paediatric nurse practitioner at each participating site (n = 22). Eligible 8- to 12-year-old children were referred to an 11 session group behavioural intervention (KidSTRIDE) which was adapted from Epstein et al. (1994) (61) and delivered by trained office nurses and nurse practitioners.One participating paediatric practice located in an urban setting. One paediatric practice located in a rural county.Provider training included a 30-min self-study packet and 2, 1-h face-to-face skills training session with one of the investigators as the trainer. Counselling skills included Stages of Change approach to behaviour change and MI. Follow-up occurred 1 month later to reinforce skills and provide practice and discussion of materials.Primary care providers increased skills and confidence in assessing and communicating with overweight/obese children and their families. Sustainability of intervention promoted with training of office nurses to deliver the intervention.Strengths: Combined training of healthcare providers with staff. Included MI. Limitations: No descriptive information given about providers. Unknown how many contacts providers had with identified and referred children as intervention was delivered by office nurses. No data presented to document provider increase in knowledge and skills.
Gance-Cleveland et al. (2009) (62). Changes in nurse practitioners knowledge and behaviours following brief training on the Healthy Eating and Activity Together (HEAT) guidelines. National Association of Pediatric Nurse Practitioners (NAPNAP) Annual Conference 2006.Pre-test/post-test. One group design. Programme to improve primary care providers' behaviour and efficacy in preventing paediatric overweight and obesity. 17-question questionnaire to tap knowledge, practice behaviours and identify barriers to success. Descriptive statistics; t-tests; χ2.n = 35 nurse practitioners attending the NAPNAP 2006 Annual Conference.89% (n = 31) of participants worked in paediatrics; and one participant in each of the following specialties: family practice, endocrinology, ear/nose/throat, and paediatric and adolescent diabetes. 85% (n = 30) had been in practice >5 years; 9% (n = 3) were in practice 3–5 years; 3% (n = 1) and 3% (n = 1) had been in practice 1–3 years and 1 year of less respectively.Intervention: Intensive 4-h HEAT Clinical Practice Guideline training session (see NAPNAP, 2006).Significant improvements in practitioner assessment skills, knowledge, intent to follow guidelines using MI and behaviour modification techniques and to engage the family in the discussion of healthy practices. Proficiency and confidence in their ability to address child and family barriers to healthier lifestyles did not reach significance.Strengths: Nationally representative sample. Provided training in an intensive 4-h intervention. Limitations: Limited evidence to equate increased knowledge to change in practice with use of guidelines to identify and manage overweight and obesity. Small sample size. Survey data without follow-up.
Nicholas et al. (2009) (48). Randomized controlled trial of a mailed toolkit to increase use of BMI percentiles to screen for childhood obesity. New York State.Randomized controlled trial. Pre-test/post-test. Mailed self-report survey at baseline and 5 months after toolkit introduction. χ2 for categorical variables; non-parametric Wilcoxon rank-sum tests for ordered variables; t-tests for continuous variables; multivariate logistic regression models for differences in paediatric age groups.n = 402 physicians returned baseline surveys (40%). n = 211 physicians returned follow-up surveys (21%).Control and intervention group physicians did not differ on any measured variables. Similar exposure to public and private education on childhood obesity during the study in both groups.Intervention group: Toolkit promoted use of BMI percentiles to screen youths aged 2–20 years of age. Included BMI calculator, growth charts, instructions for calculating BMI, printed recommendations from the AAP, links to CDC training modules, links to Bright Futures in Practice, patient and family questionnaires on nutrition. Control group: attention control.Recently trained physicians (post-1998 guideline publication) reported increased BMI screening at baseline. Urban physicians utilized BMI screening more frequently than those in rural or suburban settings. Intervention group increased use of BMI percentiles across the three age groups significantly in children aged 2–5 years. 72% found the toolkit helpful and 67% found that it influenced practice.Strengths: Simple, inexpensive intervention demonstrating modest effect. Limitation: Self-report data may measure intention to change practice. No information available on non-responders. Low response rate. Office staff involvement to varying degrees within practices.
Polacsek et al. (2009) (47). Impact of a primary care intervention on physician practice and patient and family behaviour: Keep ME Healthy The Maine Youth Overweight Collaborative Maine, USA.Quasi-experimental design. Pre-test/post-test provider surveys. Logistic regression. t-tests.Paediatric residency programme (n = 1). Family practice residency programme (n = 1). Primary care paediatric practices (n = 9). Family practice (n = 1).12 practice teams made up of clinical experts, primary care practices and community partners.Intervention targeted specific changes in office practice: Healthcare system support; Self-management support; Healthcare system redesign. Intervention length = 3 1.5-day learning sessions for each 3-member team. Followed in the next 18 months with two additional learning sessions, bimonthly conference calls, site visits and information emails. Outcomes: provider counselling, BMI utilization.Teams showed improved knowledge of BMI and efficacy in addressing lifestyle issues. Improvement in providers' knowledge of community resources. Patients and families heard more messages about nutrition, television, physical activity and sweetened beverages. Chart reviews demonstrated more use in BMI, BMI percentiles for age and gender. Providers also demonstrated more diverse goal setting with patients in chart reviews. Increased follow-up appointments made. Office systems improved significantly.Strengths: Based on the Chronic Care Model (CCM). Comprehensive intervention. Limitations: No comparison data. Instruments modified by researchers in this study without extensive pilot testing.
Pomietto et al. (2009) (52). Small steps to health: Building sustainable partnerships in paediatric obesity care. Steps to Health King County programme. Seattle Children's Hospital in Seattle, Washington partnering with Public Health and King County.One group pre-test/post-test design. Chart reviews: ∼20/month. Descriptive statistics.Pilot phase 1: n = 3 participating practices. Pilot phase 2: n = 5 Medicaid managed care plans and n = 20 medical practices of which eight clinics worked on improving care for paediatric obesity. Phase 3: no number of healthcare providers or number of clinic participating reported. Stated as statewide involvement.Within all three phases of the collaborative, collaboration occurred with numerous (n = 75) community partners representing schools, health plans, hospitals, healthcare providers, health departments and universities.Components of the intervention: 1-year-long collaborative. Three 8-h learning sessions, monthly conference calls, site visits, coaching and support as needed. Establishment of a registry and clinical assessment of basic processes of care. Intervention content responsive to community assessed needs. Focused on cultural competency in content.Outcome measures by chart review: per cent of overweight and obese patients, per cent of BMI measured, per cent receiving healthy lifestyle messages; assessment of readiness to change and/or self-management goals discussed, documented race and ethnicity and planned follow-up. Specific statistics not reported.Strengths: Two prior pilot studies to test the intervention. Content based on the Socioecological Model of health. Collaboration process based on the CCM which increased the programme's sustainability. Limitations: Inherent flexibility of implementing community specific interventions hampers ability to evaluate outcomes for efficacy.

Review of the evidence

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References

The consideration of levels of evidence generated by studies is important when evaluating the strength and relevance of research for healthcare decisions (41). Evidence from this review primarily consists of results from descriptive pre-experimental designs (i.e. level VI evidence). Nine of the 15 studies (60%) reported a pre-test/post-test design. It was presumed that the study design utilized by Gee et al. also was a pre-test/post-test design but this was not explicitly stated in the description of the study (42). One study reported healthcare provider compliance with training parameters by utilizing medical chart abstraction at a scheduled patient follow-up appointment which occurred 16 weeks after the training (43). One study utilized a delayed-controlled design with participating clinics stratified according to clinic size, geographical diversity and number of patients (44). In order to achieve geographical dispersion, ethnic and racial diversity of patients, and an urban–rural balance, Schwartz et al. provided MI training to a convenience sample of paediatricians and registered dieticians in a non-randomized controlled study where young overweight children were identified in clinics providing either standard care (control group), minimal intervention (physician only) or intensive intervention (physician and registered dietician) (45). An attention control group of first-year paediatric residents was utilized to compare the results of the intervention that was delivered to second-year residents in the study by Gonzalez and Gilmer (46). Polacsek et al. designed a quasi-experimental study in which control primary care sites were compared with sites where providers were trained in counselling of a specific intervention programme called the Maine Youth Overweight Collaborative (47). Finally, a randomized controlled trial of the efficacy of a mailed toolkit that contained items to increase the use of BMI percentile screening was utilized in one study measuring physician self-reported practice (48).

Intervention length to train healthcare staff and/or physicians and nurse practitioners in assessing and managing paediatric overweight and obesity varied from 1 h (49) to an intensive 4.5 days with additional follow-up utilizing site visits and emails with attached educational materials (47). Overall, training interventions were delivered face to face or in a combination of lecture, assigned readings, preceptorship with experienced providers (i.e. nutritionists), mailed toolkits and critiqued evaluations of interactions of the provider with the patient and family.

A number of studies incorporated, as an initial phase, the training of healthcare providers and, then as a second phase, delivered an intervention designed to positively impact overweight and obese youth. Primarily, these studies (40%) focused the dissemination of their findings on the outcomes of the overweight and obese children and adolescents who received the intervention delivered by the trained healthcare providers (42,43,45,47,50,51). Unfortunately, the authors often omitted from the published report much of the statistical analyses concerning the participating providers and the effectiveness of the training on the providers' subsequent skills and behaviour. In addition, an improvement in the children and adolescents' weight or nutrition and physical activity behaviours, for example, were utilized as indicators of training intervention effectiveness in a number of studies.

Consistent with the AMA recommendations, we also critiqued the interventions based upon the components of the Chronic Care Model for Childhood Obesity (11). In this way, each intervention was evaluated as to the use of the components of the CCM in the delivery of obesity care within a specific community. Each study was evaluated for four of six CCM components: self-management, decision support, delivery system design and CIS (35). Two studies designed and included study materials incorporating components of the CCM (47,52). With careful review, the remainder of the reviewed studies contained at least one of the four critical elements of the model (see Table 2). The interventions most frequently utilized the elements of self-management support (67%), educational materials and educational enhancement for providers (decision support) (100%) and the use of multidisciplinary teams to initiate new procedures within the office (delivery system design) (73%). Reminder systems and feedback to track provider performance and patient outcomes (CIS) were present in four studies (27%) (42,47,49,52). The same four studies documented the presence of all four critical components of the Chronic Care Model for Childhood Obesity (42,47,49,52).

Table 2.  Presence of critical components of the Chronic Care Model for Childhood Obesity in reviewed studies
 Self-management supportDecision support for providersDelivery system redesignClinical information systems
Beno et al. 2005 (26) 
Hinchman et al. 2005 (44) 
McCallum et al. 2005 (50) 
Gee et al. 2006 (42)
Gonzalez & Gilmer 2006 (46)  
Dunlop et al. 2007(59) 
Schwartz et al. 2007 (45) 
Dennison et al. 2008 (43)  
Kopp & Hornberger 2008 (60)  
Perrin et al. 2008 (49)
Ewing et al. 2009 (51)  
Gance-Cleveland et al. 2009 (62)   
Nicholas et al. 2009 (48)   
Polacsek et al. 2009 (47)
Pomietto et al. 2009 (52)

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References

In order to meet the healthcare needs of children and adolescents, paediatric primary care providers must attain knowledge and skills in the assessment, prevention, treatment and management of overweight and obesity. Likewise, the primary care clinic system must be responsive to patients who have this chronic health condition. Children and adolescents with obesity and their families require intensive education and support so that they can increase their self-management skills and adopt healthy lifestyle behaviours.

The methods used to increase provider adoption of the Expert Committee Recommendations in these studies varied from providing education alone in a brief educational intervention or providing education in an individual technique (i.e. MI) to incorporating provider training and an educational intervention into a practice setting to directly impact patient outcomes. The inclusion of office-based assessment and counselling tools (i.e. BMI charts, nutrition and physical activity history forms, and documentation of MI and family/patient goal setting) was a successful visible reminder on the patients' medical record, which improved performance and adherence to recommendations. Overall, brief staff and provider interventions are a feasible and cost-effective way in order to improve the assessment and management of overweight and obese children and adolescents. Interestingly, in most studies that combined provider training with a specific intervention programme for children or adolescents, the utilization of assessment tools and provider counselling was greater with the most obese patients demonstrating that primary care providers may need to be encouraged to use the materials with every child or adolescent in order to promote healthy lifestyles and prevent obesity.

Overweight and obesity assessment and management in the primary care setting must first begin with a paradigm change that acknowledges that paediatric obesity is a chronic condition that can be prevented and managed. With the exception of the studies by Polacsek et al. (47) and Pomietto et al. (52), this review demonstrates how paediatric obesity intervention research utilizing the critical components of the Chronic Care Model for Childhood Obesity is in its early stages. Coleman et al., in a systematic review, found that when elements of the CCM were implemented, there were significant improvements in quality care for adults with chronic illnesses (53). The more developed studies in this review not only impacted decision support for providers but also initiated delivery system redesign. Targeting both of these critical elements positively increased the efficacy of patient outcomes (self-management support).

It is important to ensure that training intervention programmes that target overweight and obese youth contain components that have shown efficacy in clinical trials. The most successful approaches in clinical specialty and school settings have included not only physical activity and nutrition education and counselling, but also parent involvement, and behaviour modification and or cognitive behavioural skill building techniques (54). Few studies have been conducted to test the feasibility and acceptability of overweight and obesity intervention programmes within the paediatric primary care setting (43,47,55–58). Precipitously launching paediatric primary care interventions that attempt to target the problem with emphasis only on cost, brevity and expediency within the primary care setting may be detrimental to the overall goal of assessing and managing this chronic health condition. The goal is to assess every child and adolescent for overweight and obesity and, once identified, to intervene with intervention programmes within the primary care setting that are evidence-based.

The number of training sessions and duration of the training for the providers varied in each study. We are not able to make conclusions about the most effective length of the training interventions based upon this review. It is recommended that any future overweight and obesity intervention study for children and adolescents begin with a systematic training programme, based upon the Chronic Care Model for Childhood Obesity, for the healthcare providers and staff within the primary care setting. When the providers demonstrate improvement in their knowledge and confidence in their abilities to assess and manage these patients, then specific intervention programmes can be tested in the primary care setting.

Limitations

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References

It is unclear from the reviewed studies if permanent changes to the delivery of obesity care were sustained. Healthcare providers voiced that the increased assessment paperwork (i.e. tools) was a barrier to engaging in counselling with children and families because of the time it took to complete and evaluate the forms. No mention was made in any study of provider training including aspects of coding for insurance reimbursement. Sustainability of any intervention programme must address and incorporate this aspect of delivering care in order to compensate the provider for the additional time that is required to deliver quality obesity counselling.

Non-controlled study designs and small, non-diverse provider sample sizes utilized in the reviewed studies limit the generalizability of the results to other paediatric primary care providers and healthcare educational settings. Provider education and increased confidence and ability to follow Expert Committee Recommendations, implementation of assessment tools and educational reminders, and office system redesign were utilized in combination in most of the reviewed studies which demonstrated significant results. Future studies will be needed in order to decipher which of the elements of the Chronic Care Model for Childhood Obesity are most effective in eliciting patient self-management behaviour change.

Conclusion

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References

The results of this review demonstrate emerging evidence regarding methods to improve healthcare providers' assessment and management of paediatric overweight and obesity in the office setting. Adequate training of primary healthcare providers in paediatric obesity care will ensure that youth receive the necessary support to lead a healthy life now and in the future. Increasing the providers' knowledge, skills and confidence in delivering care to overweight and obese youth requires a commitment to address obesity not only in healthcare provider training programmes but also as part of continuing education programmes.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Theoretical framework: Chronic Care Model for Childhood Obesity
  5. Methods
  6. Review of the evidence
  7. Discussion
  8. Limitations
  9. Conclusion
  10. Conflict of Interest Statement
  11. References
  • 1
    Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003–2006. JAMA 2008; 299: 24012405.
  • 2
    Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006; 295: 15491555.
  • 3
    American Heart Association. Overweight and obesity: statistics. [WWW document]. URL http://www.americanheart.org (updated 2008, accessed 30 November 2009).
  • 4
    Beebe DW, Lewin D, Zeller M, McCabe M, MacLeod K, Daniels S, Amin R. Sleep in overweight adolescents: shorter sleep, poorer sleep quality, sleepiness, and sleep-disordered breathing. J Pediatr Psychol 2007; 32: 6979.
  • 5
    Chen AK, Roberts CK, Barnard RJ. Effect of a short-term diet and exercise intervention on metabolic syndrome in overweight children. Metabolism 2006; 55: 871878.
  • 6
    Freedman D, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr 2007; 150: 1217.
  • 7
    Hannon T, Rao G, Arslanian S. Childhood obesity and type 2 diabetes mellitus. Pediatrics 2005; 116: 473480.
  • 8
    Janssen I, Katzmarzyk P, Srinivasan SR, Chen W, Malina R, Bouchard C, Berenson G. Combined influence of body mass index and waist circumference on coronary artery disease risk factors among children and adolescents. Pediatrics 2005; 115: 16231630.
  • 9
    Janicke DM, Harman JS, Kelleher KJ, Zhang J. The association of psychiatric diagnoses, health service use, and expenditures in children with obesity-related health conditions. J Pediatr Psychol 2009; 34: 7988.
  • 10
    Wearing S, Hennig E, Byrne N, Steele J, Hills A. The impact of childhood obesity on musculoskeletal form. Obes Rev 2006; 7: 209218.
  • 11
    Gance-Cleveland B, Gilbert LH, Kopanos T, Gilbert KC. Evaluation of technology to identify and assess overweight children and adolescents. J Spec Pediatr Nurs 2010; 15: 7283.
  • 12
    Barlow SE, Dietz W. Obesity evaluation and treatment: Expert Committee recommendations. Pediatrics 1998; 102: e29.
  • 13
    National Association of Neonatal and Pediatric Nurse Practitioners. Identifying and preventing overweight in childhood clinical practice guideline part I. J Pediatr Health Care 2006; 20(Suppl. 1): 132.
  • 14
    National Initiative for Children's Healthcare Quality. Expert Committee recommendations on the assessment, prevention and treatment of child and adolescent overweight and obesity – 2007: an implementation guide from the Childhood Obesity Action Network. [WWW document]. URL http://leah.mchtraining.net/images/stories/tc_materials/070920/ar_coan_implement_guide_62607.pdf (updated 2007, accessed 16 February 2010).
  • 15
    American Academy of Pediatrics Steering Committee on Quality Improvement & Management. Classifying recommendations for CPGs. Pediatrics 2004; 114: 874877.
  • 16
    Barlow SE, the Expert Committee. Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007; 120: S164S192.
  • 17
    Spear BA, Barlow SE, Ervin C, Ludwig D, Saelens B, Schetzina K, Taveras E. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 2007; 120(Suppl. 4): S254S288.
  • 18
    Spurrier N, Magarey A, Wong C. Recognition and management of childhood overweight and obesity in children. J Paediatr Child Health 2006; 42: 411418.
  • 19
    Anderson PM, Butcher KE. Childhood obesity: trends and potential causes. Future Child 2006; 16: 1945.
  • 20
    Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge F, Barlow S. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics 2002; 110: 210.
  • 21
    Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PC, Rubin HR. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 14581465.
  • 22
    Barlow SE, Dietz WH, Klish WJ, Trowbridge FL. Medical evaluation of overweight children and adolescents: reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics 2002; 110(1 Pt 2):222228.
  • 23
    Mabry IR, Clark SJ, Kemper A, Fraser K, Kileny S, Cabana MD. Variation in establishing a diagnosis of obesity in children. Clin Pediatr (Phila) 2005; 44: 221227.
  • 24
    Cook S. Screening and counseling associated with obesity diagnosis in a national survey of ambulatory pediatric visits. Pediatrics 2005; 116: 112116.
  • 25
    Dilley KJ, Martin LA, Sullivan C, Seshadri R, Binns HJ, Pediatric Practice Research G. Identification of overweight status is associated with higher rates of screening for comorbidities of overweight in pediatric primary care practice. Pediatrics 2007; 119: e148e155.
  • 26
    Beno L, Hinchman J, Kibbe D, Trowbridge F. Design and implementation of training to improve management of pediatric overweight. J Contin Educ Health Prof 2005; 25: 248258.
  • 27
    Perrin EM, Finkle JP, Benjamin JT. Obesity prevention and the primary care pediatrician's office. Curr Opin Pediatr 2007; 19: 354361.
  • 28
    Goff SL, Holmboe ES, Curry L. Barriers to obesity training for pediatric residents: a qualitative exploration of residency director perspectives. Teach Learn Med 2006; 18: 348355.
  • 29
    Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998; 1: 24.
  • 30
    Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q 2001; 79: 579612.
  • 31
    National Initiative on Child Health Quality. Child Care Model. [WWW document]. URL http://www.nichq.org (accessed 25 October 2006).
  • 32
    Dietz W, Lee J, Wechsler H, Malepati S, Sherry B. Health plans' role in preventing overweight in children and adolescents. Health Aff 2007; 26: 430440.
  • 33
    Benin AL, Vitkauskas G, Thornquist E, Shapiro ED, Concato J, Aslan M, Krumholz HM. Validity of using an electronic medical record for assessing quality of care in an outpatient setting. Med Care 2005; 43: 691698.
  • 34
    Bodenheimer T. Interventions to improve chronic illness care: evaluating their effectiveness. Dis Manag 2003; 6: 6371.
  • 35
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002a; 288: 17751779.
  • 36
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic care illness: the chronic care model. JAMA 2002b; 288: 19091914.
  • 37
    Bray P, Roupe M, Young S, Harrell J, Cummings DM, Whetstone LM. Feasibility and effectiveness of system redesign for diabetes care management in rural areas: the eastern North Carolina experience. Diabetes Educ 2005; 31: 712718.
  • 38
    Hupke C, Camp AW, Chaufournier R, Langley GJ, Little K. Transforming diabetes care: Part 1. Changing practice. Diabetes Spectr 2004; 17: 102106.
  • 39
    Norris SL, Olson DE. Implementing evidence-based diabetes care in geriatric populations: the chronic care model. Geriatrics 2004; 59: 3539.
  • 40
    Blue Cross Blue Shield of Massachusetts. Healthy Care for Healthy Kids: a pediatric learning collaborative. Jump Up Go Newsletter 2005; 1: 18.
  • 41
    Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare : A Guide to Best Practice. Lippincott Williams & Wilkins: Philadelphia, PA, 2005.
  • 42
    Gee S, Howell A, Mirkin RE. Overweight children: a comprehensive approach to address the epidemic. [WWW document]. URL http://www.nichq.org/ConferencesAndTraining/2006 (updated 2006, accessed 16 September 2008).
  • 43
    Dennison D, Yin Z, Kibbe D, Burns S, Trowbridge F. Training health care professionals to manage overweight adolescents: experience in rural Georgia communities. J Rural Health 2008; 24: 5559.
  • 44
    Hinchman J, Beno L, Dennison D, Trowbridge F. Evaluation of a training to improve management of pediatric overweight. J Contin Educ Health Prof 2005; 25: 259267.
  • 45
    Schwartz RP, Hamre R, Dietz WH, Wasserman RC, Slora EJ, Myers EF, Sullivan S, Rockett H, Toma KA, Dumitru G, Resnicow KA. Office-based motivational interviewing to prevent childhood obesity: a feasibility study. Arch Pediatr Adolesc Med 2007; 161: 495501.
  • 46
    Gonzalez JL, Gilmer L. Obesity prevention in pediatrics: a pilot pediatric resident curriculum intervention on nutrition and obesity education and counseling. J Natl Med Assoc 2006; 98: 14831488.
  • 47
    Polacsek M, Orr J, Letourneau L, Rogers V, Homberg R, O'Rourke K, Hannon C, Lombard KA, Gortmaker SL. Impact of a primary care intervention on physician practice and patient and family behavior: keep ME healthy – the Maine youth overweight collaborative. Pediatrics 2009; 123(Suppl. 5): S258S266.
  • 48
    Nicholas J, Dennison B, de Long R, Prokorym M, Brissette I. Randomized controlled trial of a mailed toolkit to increase use of body mass index percentiles to screen for childhood obesity. Prev Chronic Dis 2009; 6: 111.
  • 49
    Perrin EM, Jacobson Vann JC, Lazorick S, Ammerman A, Teplin S, Flower K, Wegner S, Benjamin J. Bolstering confidence in obesity prevention and treatment counseling for resident and community pediatricians. Patient Educ Couns 2008; 73: 179185.
  • 50
    McCallum Z, Wake M, Gerner B, Harris C, Gibbons K, Gunn J, Waters E, Baur LA. Can Australian general practitioners tackle childhood overweight/obesity? Methods and processes from the LEAP (Live, Eat and Play) randomized controlled trial. J Paediatr Child Health 2005; 41: 488494.
  • 51
    Ewing LJ, Cluss P, Goldstrohm S, Ulrich R, Colborn K, Cipriani L, Wald E. Translating an evidence-based intervention for pediatric overweight to a primary care setting. Clin Pediatr (Phila) 2009; 48: 397403.
  • 52
    Pomietto M, Docter AD, Van Borkulo N, Alfonsi L, Krieger J, Liu LL. Small steps to health: building sustainable partnerships in pediatric obesity care. Pediatrics 2009; 123(Suppl. 5): S308S316.
  • 53
    Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009; 28: 7585.
  • 54
    Snethen J, Broome ME, Cashin S. Effective weight loss for overweight children: a meta-analysis of intervention studies. J Pediatr Nurs 2006; 21: 4556.
  • 55
    Cotton B, Smith A, Hansen I, Davis C, Doyle A, Walsh A. Physician-directed primary care intervention to reduce risk factors for Type 2 diabetes in high-risk youth. Am J Med Sci 2006; 332: 108111.
  • 56
    Young PC. Efficacy of a weight management program in overweight children. JAMA 2007; 298: 1860.
  • 57
    Jacobson D. A Primary Care School Age Healthy Choices Intervention Program. [PhD]. Arizona State University, Arizona, USA; 2009.
  • 58
    McCallum Z, Wake M, Gerner B, Baur LA, Gibbons K, Gold L, Gunn J, Harris C, Naughton G, Riess C, Sanci L, Sheehan J, Ukoumunne OC, Waters E. Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight/mild obesity. Int J Obes 2007; 31: 630636.
  • 59
    Dunlop AL, Leroy Z, Trowbridge FL, Kibbe DL. Improving provider's assessment and management of childhood overweight: results of an intervention. Ambul Pediatr 2007; 7: 453457.
  • 60
    Kopp MK, Hornberger C. Proper exercise and nutrition kit: use of obesity screening and assessment tools with underserved populations. J Pediatr Nurs 2008; 23: 5864.
  • 61
    Epstein LH, Valoski A, Wing R, McCurley J. Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol 1994; 13: 383.
  • 62
    Gance-Cleveland B, Sidora-Arcoleo K, Keesing H, Gottlesman MM, Brady M. Changes in nurse practitioners' knowledge and behaviors following brief training on the Healthy Eating and Activity Together (HEAT) guidelines. J Pediatr Health Care 2009; 23: 222230.