Automated Phone Counseling Helps Parents of Overweight Children Model and Encourage Appropriate Behaviors, Leading to Meaningful Reduction in Body Mass Index

Problem Addressed

• Rising rates of childhood obesity: National surveys show that childhood obesity increased dramatically between 1976 and 1980 and 2003 and 2006, from 5 to 12.4 percent among children aged 2 to 5 years, from 6.5 to 17 percent among children aged 6 to 11 years, and from 5 to 17.6 percent in those aged 12 to 19 years.¹ The latest available statistics show that 16.3 percent of children and adolescents between the age of 2 and 19 years are obese.²
• Leading to increased health risks: Obese children face a higher risk of health problems, such as high blood pressure, high cholesterol, and type 2 diabetes and are more likely to remain obese as adults. 
• Parental struggles in helping children lose weight: Parents play a critical role in determining their children’s diet and physical activity. Yet, many parents struggle to develop effective strategies to encourage weight loss.
• Lack of provider support: Many clinicians have little or no interest in helping obese and overweight children lose weight.³ Weight management is often viewed as a lifestyle issue and an individual responsibility, with providers frequently blaming parents for their children's obesity. In addition, providers receive few rewards for addressing weight issues with parents and children and have access to few proven strategies for promoting healthier lifestyles in their young patients.³

Description of the Innovative Activity

• Recruiting families: Kaiser Permanente Colorado used its electronic medical record system to identify children between the ages of 8 and 12 years who have body mass index (BMI) at or above the 85th percentile for their age. Pediatricians were asked to exclude patients if children or their parents were not good candidates for the intervention. The health system sent letters, signed by the family’s pediatrician, inviting parents to participate, and also contacted parents by phone.
• Screening families: Roughly 38 percent of contacted parents agreed to participate, primarily those with children at or above the 95th percentile for BMI. Participants attended a group assessment session where their children had their BMI measured; physical activity level assessed (using Youth Behavioral Risk Survey questions); fruit, vegetable, and sugared drink consumption documented (using the Block Kids Questionnaire); and any eating disorder symptoms identified (using the Kids’ Eating Disorders Survey). (This screening was performed for the purposes of the evaluation research study, and would not necessarily be required in a non-research setting.)
• Weight loss interventions: The interventions focused on supporting parents as the key implementers of healthier, more active lifestyles for the entire family. They included a workbook, two small-group discussion sessions, and up to 10 interactive, recorded phone messages. (During the trial, three different groups were set up—one receiving just the workbook, one receiving the workbook and attending the group sessions, and a third receiving all three interventions.)
  • Family Connections workbook: This 61-page workbook promotes increased physical activity and consumption of fruits and vegetables while discouraging intake of sugared drinks, watching television, and playing on the computer. The workbook includes two sections to be completed over a 1-week period, with homework assignments designed to encourage lasting changes in family lifestyle.
  • Discussion groups: Participants attended two 2-hour small-group sessions (held 1 week apart) at a local clinic. Led by a dietitian for a group of 10 to 15 parents, the sessions used the workgroup to promote parents' behavioral health skills; enhance their knowledge of weight, nutrition, and physical activity; and improve essential parenting skills, such as setting limits, communicating effectively, and role modeling. The sessions concluded with role-playing, problem-solving, and the development of action plans.
  • Automated phone calls: The 10 automated telephone calls began 1 week after the second group session.
    • Logistics: Parents either called the automated phone system themselves or waited for the system to call them at a time they designated as being convenient (generally between 7:00 and 9:00 p.m. on weekdays). During the first call, they entered their medical record number and recorded their names, making it easy for them to identify future calls (and not mistake them for telemarketing calls). The first four calls occurred weekly, the next four were biweekly, and the last two were monthly. Calls generally lasted between 5 and 10 minutes.
    • Topics covered: Each call focused on a different concept for strengthening parenting skills and promoting healthier living. Topics included the importance of consistency, praise, and communication; healthy eating habits (including the need to have the parents set an example in this area); using contingencies to reach desired outcomes; setting goals; and preventing relapses in unhealthy eating. 
    • Customized guidance: During each call, the parent responded to questions using numbers on the phone's keypad. Depending on the answers given, the automated system provided information and advice on specific topics relevant to the caller's situation.
    • Goal setting: At the end of each call, the parent selected a goal to implement during the following week. At the beginning of the following call, the parent heard the goal selected during the previous week and rated his or her success in meeting it on a 3-point scale (1 for excellent, 2 for mediocre, and 3 for failure). Depending on the response, the parent was given the option of hearing tips relating to that topic before moving on to a new subject area. During the sixth call and for all subsequent calls, parents received  instructions on how to set family-wide goals related to healthy eating and physical activity. The calls encouraged parents to assess behavior and motivation and instructed them on how to reach collaborative agreements on goals and to identify and overcome barriers to achieving them. These later calls reinforced the basic skill-building activities and information provided in the workbook, meetings, and earlier calls.

References/Related Articles

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Results

• Lower BMI: The 38 children in the group receiving all three interventions and attending at least six automated counseling calls achieved the greatest reduction in BMI z-score,* from 2.03 at baseline to 1.9 at 12 months. By contrast, for the 20 children whose parents received all three interventions but attended five or fewer automated calls, BMI z-score rose slightly, from 2.08 at baseline to 2.09 after 12 months. The 82 children whose parents received only the workbook and/or attended the two discussion groups experienced a very modest decline in BMI z-score, from 2.04 at baseline to 2.00 after 12 months.
• Slight decline in consumption of sugary drinks, but no other lifestyle changes: Children in all three groups reported only slight declines in the number of sugary drinks they consumed, but no significant changes in their levels of physical activity or consumption of fruits and vegetables. Researchers did not objectively track the children's diets or measure their physical activity, and were dependent on the children's own memory when responding to those questions at 6- and 12-month follow up screenings.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Creating workbook and curriculum: Kaiser Permanente Colorado’s Weight Management Program and research staff developed the workbook and the curriculum for the two classes.
• Designing automated phone system: Kaiser staff scripted the phone calls, while outside contractors developed the automated system. (See the Story section for a sample script.) They designed the system to identify whether a call had been answered by a live person or an answering machine, or whether there had been no answer. For unsuccessful calls (i.e., those not answered or picked up by a machine), the system was designed to attempt up to three calls per day to each parent; when an answering machine picks up, the system leaves a message explaining that Kaiser tried to contact them and will try again later. Programmers designed the system to track the number of unsuccessful calls and to minimize the need to listen to multiple voice prompts by allowing those who answer the call to key-ahead prior to the completion of a voice message. 
• Training: Those responsible for maintaining and tracking the outbound call schedule received training on the phone system. 
• Introducing program to clinicians: Kaiser introduced the program to clinicians through practice-wide meetings. During these sessions, physicians were encouraged to screen candidates and to grant permission to use their names on recruitment letters sent to parents.

Resources Used and Skills Needed

• Staffing: As noted, Kaiser used internal staff, some of whom worked on other weight loss programs, to design the trial, create the workbook’s content, and script the automated phone calls. A project manager oversaw the program, including communications with providers and patients, while a Kaiser dietitian led the small group sessions. Outside programmers and technical contractors designed and created the interactive phone system.
• Costs: Kaiser paid roughly $25,000 for the design of the phone system and received $250,000 to conduct the study over a 2-year period.

Funding Sources

Garfield Memorial Fund

Tools and Other Resources

• National Guideline Clearinghouse. Primary prevention of childhood obesity. Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=7092&string
• National Guideline Clearinghouse. Management of obesity in children and young people. A national clinical guideline. Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3735&string=
• Barlow S and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007 Dec;120:S164. Available at: http://pediatrics.aappublications.org/cgi/content/full/120/Supplement_4/S164

Getting Started with This Innovation

• Assess screening capability: Determine whether the organization’s medical record system can be searched electronically to easily identify overweight and at-risk children who might benefit from the intervention. If not, customize screening protocols to accommodate each medical practice’s patient record technology.
• Customize educational materials: Consider the Kaiser Permanente Colorado workbook as a potential starting point, and then customize the material to the target population, taking into consideration ethnicity and the community's recreational resources.
• Assess automated phone system: Determine whether the program can be integrated into the organization’s existing phone system or an independent system must be created. If necessary, contract with a programming company to develop the system.
• Encourage physician participation: Introduce the program to physicians, highlighting any evidence to support its effectiveness. Solicit physician input on the program design, including the appropriate process for screening patients and identifying those who may not be good candidates. 
• Create a monitoring and evaluation system: Identify staff (nurses or dieticians) to conduct periodic assessments of participants' progress, and establish how frequently such assessments should occur. Create a system to document parent involvement, including how many automated phone calls they complete.  

Sustaining This Innovation

Additional Considerations and Lessons