In our study, we were able to show that important short term dietary and physical activity behavior changes were reported by parents of children ages 4–12 following a relatively easy-to-implement intervention in a single pediatrics continuity clinic. Confirming prior research,7,11,12
many parents of children in this age group whose BMI’s are ≥85% perceive their children as at a healthy weight. Our intervention resulted in an improvement in the rate of parents correctly identifying their child’s weight status. Though not as simple as weight alone, BMI flags risk for overweight and obesity better than traditional growth charting;16
and our findings confirm previous research that simple modifications like color-coding the BMI chart may facilitate documentation, discussion, and understanding of BMI.26,29,30
However, based on published literature, ours may be the first intervention to change parental recognition of overweight through a simple clinic-based intervention.
Providers who use BMI may be more likely to recognize mild overweight at an earlier age, when treatment may require less significant behavior change. These providers may also more likely to provide nutrition and activity counseling for overweight children. Also, we know from prior study that parents perceive doctors’ nonchalance about overweight at early ages as a barrier to changing health habits.31
Importantly, in our study which focused on communicating BMI status and providing targeted behavior counseling, there were significant short-term (three-month) improvements in reported dietary and physical activity behaviors. Our study suggests that the clinical setting can be an effective site to address at least short term behavior changes to improve obesity and echoes recent research demonstrating that physicians’ assessment of parental confidence and readiness to change is associated with parental confidence to make changes.32
One of the most important strengths of our study is that it was a real-life, brief, and user-friendly intervention that could be implemented in most pediatrics clinics, especially ones that had electronic medical records and a system for handing out questionnaires in the waiting room. The population was also heterogeneous, suggesting that diverse populations could similarly benefit. While studies have shown that brief interventions similar to ours in pediatric providers’ offices have demonstrated feasibility30,33
and improved parental confidence, and others show chart evidence of provider improvements in counseling rates, documentation of overweight,29,33,34
there are few reports that assess parent perception or child behavior outcomes.
Two important studies that did assess behavior outcomes showed that a primary care intervention did not produce any significant differences in child behavior.22,35
One possible reason we were able to demonstrate improvements in behaviors was our focus on recognition of weight status by parents. We do not know specifically if improved parental accuracy of weight status translates into greater understanding of the need to follow behavioral prescriptions with respect to nutrition and physical activity or weight trajectories, and our sample was too small to assess this association. However, this area deserves further research as a possible mechanism for improving the effectiveness of clinic-based obesity interventions.
Our study had several limitations. The changes reported are only short term, and our sample size was relatively small, derived from the willing English-speaking families at just one clinic, so generalizability is limited. However, our clinic is diverse; and this was reflected in the demographics of our sample as well. Small sample size also limited the ability to fully assess the relationship between improved weight status understanding and behavior change. This small sample size is mostly attributed to the relatively infrequent occurrence of parents scheduling and bringing their four to 12 year olds to clinic for well-child visits in this population. Attrition (particularly from one month to three month follow up) also limits our interpretability. However, the limitation of attrition is mitigated by the fact that demographics were similar between groups that did and did not complete the study; and the only differences in behaviors were at the one month follow up. Interestingly, these differences reflected the fact that busier families likely followed up less often as they were more likely to report fewer than two days of family activity per week and more likely to report eating out more than once per week. Another limitation is that our STC instrument has not been previously validated, though the questions are based on previous research. Importantly, the changes seen in reported behaviors could easily be the result of social desirability or reporting bias; and we do not have objective measures of diet or physical activity before and after implementation of the tool. Also, parent report of discussions of weight or BMI with the physician may not accurately reflect whether or not they occurred. Our results were only assessed at one and three months following the intervention, so we can not attest to sustainability. Longer follow-up periods would also allow for greater tracking of changes in children’s weight status and how behavior changes affect weight trajectories long-term. Finally, the lack of a control group definitely limits the ability to assess whether changes seen were related to the intervention, and thus causality can not be determined. This should be remedied in future research.
Treatment plans cannot address unidentified problems. Whether BMI screening and communication to parents of young children and changed understanding of children’s weight status helps parents adopt recommended behavior changes or changes pediatricians’ management has not been adequately investigated and is an area ripe for future research. For families who do not change behaviors with such a simple intervention, more intensive counseling may be necessary, such as a motivational interviewing approach that has shown promise.21
Also, more research might be needed to find out which parent and practitioner characteristics are associated with lack of change in order to improve dynamic communication.
Still, ours is one of the first studies to report short-term healthy weight behavior adoption following brief provider counseling. Given the evidence that television reduction is associated with body mass index reduction36,37
and the importance of sweetened beverages toward total daily energy intake,38
it is encouraging that parents in our study reported improvement in these areas. Our finding of improved reports of discussion of BMI following use of color-coded BMI charts adds to the growing body of research on this potentially important tool. Future research is needed to determine whether tools like this and our “Starting the Conversation” assessment and counseling instrument might impact sustainable and important behavior change and weight status for children in our increasingly “obesogenic” world.