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Service Delivery Innovation Profile

Alternating Group and In-Home Sessions Help Obese Preschoolers and Overweight Parents Improve Eating Habits and Reduce Body Mass Index


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Snapshot

Summary

Behavioral health clinicians at Cincinnati Children's Hospital Medical Center lead a 24-week program for obese preschoolers and their overweight parent(s). Known as LAUNCH (Learning about Activity and Understanding Nutrition for Child Health), the program consists of alternating group-based sessions focused on improving behaviors related to diet and physical activity and in-home, one-on-one consultations designed to support, demonstrate, reinforce, and build on the concepts and strategies covered in the group sessions. The initial phase consists of 12 weekly sessions focused on dietary education, physical activity, and parenting skills, followed by a second phase of 6 biweekly sessions designed to help families continue to make and maintain positive changes. The program improved dietary (but not physical activity) habits among preschoolers, leading to less weight gain and reductions in body mass index as compared with a control group of preschoolers and parents receiving only an initial 45-minute counseling session led by a pediatrician. Parents of preschoolers participating in the program also achieved greater weight loss and lower body mass index than did parents in the control group.

Evidence Rating (What is this?)

Strong: The evidence consists primarily of an RCT that compared key metrics for 7 families (parent and preschooler) participating in the LAUNCH program and 10 families receiving "enhanced" usual care, which consisted of one 45-minute counseling session led by a pediatrician; metrics evaluated include changes in dietary habits (e.g., caloric intake, availability of high-calorie foods, fruits, and vegetables in the home), level of physical activity, weight, BMI z-score, and BMI percentile. Information provided in October 2013 indicates that another RCT is underway to test the treatment efficacy with a larger sample size (results pending).
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Developing Organizations

Cincinnati Children's Hospital Medical Center
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Date First Implemented

2007
A small feasibility test of this program with five families took place in 2007; a second, larger test began in February 2008 and ended in September 2009.begin ppxml

Patient Population

The program serves obese children between the ages of 2 and 5 years old with at least one overweight or obese parent (defined as a BMI greater than 25).Age > Preschooler (2-5 years)end pp

Problem Addressed

A significant and increasing number of preschoolers are obese. Obese children between the ages of 2 and 5 years old face an increased risk of developing high blood pressure, asthma, and behavioral problems, and of continuing to have weight problems during adolescence.

  • A significant, growing problem: In 2003–2004, 13.9 percent of children between the ages of 2 and 5 years old were obese, well above the 10.4 percent rate in 2000,1 and nearly triple the obesity rate among such children during the 1970s (5 percent).2
  • Increased risk of health and behavior-related problems: Obese preschoolers face an increased risk of developing high blood pressure,3 asthma by age 7,4 and behavioral problems when they enter kindergarten.5 Obese preschoolers are also 2 to 48 times more likely to be overweight at age 12 than nonobese preschoolers (with overweight being defined as a body mass index (BMI) above the 95th percentile).6

What They Did

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Description of the Innovative Activity

Behavioral health clinicians at Cincinnati Children's Hospital Medical Center lead a 24-week program for obese preschoolers and their overweight or obese parent(s). Known as LAUNCH (Learning about Activity and Understanding Nutrition for Child Health), the program consists of alternating group-based sessions focused on improving behaviors related to diet and physical activity and in-home, one-on-one consultations and support designed to demonstrate, reinforce, and build on concepts and strategies covered in group sessions. The initial phase consists of 12 weekly sessions focused on dietary education, physical activity, and parenting skills, followed by a second phase of 6 biweekly sessions designed to help families continue to make and maintain positive behavioral changes. Key elements of the program are described below:
  • Identifying and enrolling participants: Using a systematic chart review, the medical center identifies preschool-aged children with a BMI at or above the 95th percentile at their last well-child visit. During the initial trials, the program excluded morbidly obese children (defined as a BMI greater than twice the mean BMI for children), those with a disability or illness that would interfere with the ability to perform moderate physical activity, those taking medications or with a medical condition related to weight gain, those enrolled in another weight control program, and those who did not speak English or lived too far away (50 miles or more) from the medical center. The parents of eligible children receive a letter from their child's pediatrician introducing them to the program and inviting them to enroll. Those interested undergo a baseline assessment. During the most recent pilot study, interested families were randomized to the program or to an "enhanced care" control group that received a single 45-minute educational visit with a board-certified pediatrician based on dietary and physical activity recommendations laid out by the American Academy of Pediatrics7 as part of its "Prevention Plus" intervention.8
  • Intensive, initial phase focused on promoting and reinforcing healthy behaviors: The initial, intensive phase consists of 12 weekly sessions that alternate between group-based clinic sessions and in-home visits in which a therapist meets one-on-one with individual families. The group sessions focus on teaching strategies and skills for improving behaviors related to diet and physical activity for both parents and preschoolers, while the in-home sessions strive to provide practical assistance to help parents implement the general lessons and concepts discussed in the group sessions. Additional details on both types of sessions appear below:
    • Clinic-based group visits: These 90-minute sessions feature two concurrent groups—one for parents and one for preschoolers.
      • Sessions for parents: Led by a licensed clinical psychologist who follows a written manual, these six biweekly sessions focus on dietary education, physical activity, and parenting skills. Throughout the 12 weeks, parents learn about child behavior management skills related to implementing changes in diet and physical activity, including use of praise and attention, how to manage tantrums by ignoring them and using "timeouts," how to model desired behaviors, and how to use stimulus control strategies (e.g., eliminating high-calorie, low-nutrient foods and having fruits and vegetables in the home). Additional details on the dietary and physical activity components of these sessions appear below:
        • Dietary component: The dietary component, covered in the first three group sessions, feature separate sessions targeting snack and beverage intake, breakfast and lunch, and dinner. Throughout the 12 weeks, parents keep 7-day diet diaries covering food intake of both parent and child. The psychologist works with parents to set calorie goals for the child (1,000 to 1,200 a day depending on the child's age) and parent (with the goal set so as to bring BMI below 25). During each group session (including those sessions focused on physical activity, as described below), parents receive a 7-day supply of a vegetable rated as neutral by the child based on taste tests conducted in the preschooler group session (described below), along with instructions on how to use behavioral strategies to encourage the preschooler to engage in a daily taste test of the vegetable with the parent. These sessions also discuss practical strategies for improving diet, such as how to eat out less (particularly at fast-food restaurants), prevent "saboteurs" (such as grandparents) from giving children unhealthy foods, and make food a less important aspect of regular social activities.
        • Physical activity component: The next 3 group sessions focus on parenting strategies to reduce the child's screen time to 2 hours or less a day and increase levels of physical activity/play to 60 minutes or more a day. Both parents and children receive pedometers and walking goals (5,000 steps a day for children, 10,000 for parents); data from the pedometer and the dietary logs are used at subsequent sessions to provide feedback on the progress being made by both parent and child in reaching goals.
      • Sessions for preschoolers: While parents attend their group sessions, a pediatric psychology postdoctoral fellow, with support from a research assistant, leads the preschoolers in a separate group that features nutrition education through games and art activities, opportunities to sample new foods during a structured meal (including the vegetable taste test), and 15 minutes of moderate to vigorous physical activity.
    • In-home sessions: During weeks when group sessions do not meet, a home therapist (a psychology postdoctoral fellow) leads a 60- to 90-minute session in the home with the parent and child. These sessions serve to demonstrate, reinforce, and build on the themes and behavior management strategies taught in the group sessions, as described below.
      • Support related to diet: Each in-home session reinforces and supports adoption of the lessons and strategies related to diet covered in the group sessions. For example, the therapist might observe the vegetable taste test and provide feedback on and/or model use of child behavior management strategies, such as praise or use of a timeout. (The therapist also gives the family an additional 7-day supply to ensure the family has fresh vegetables that will last until the next group session.) During the visit following the group session on healthy snacks, the therapist brings a box to the home and goes through the family's food supply with the parent to identify unhealthful items and place them in the box. Rather than tell the parent to throw these items out or do so for them (as a traditional educational effort might do), the therapist goes through each item, discusses with the parent how and why the item does not support healthy eating habits, and jointly develops a plan with the parent for that item, which might include throwing it out, giving it away (e.g., to office mates at work), eating it less frequently, and/or agreeing not to purchase the item again once it has been consumed. For any item kept, the therapist and parent put a sticker on the item that delineates the agreed-upon plan, thus serving as a "real-time" (i.e., at-consumption) reminder to the parent. The therapist also shares practical strategies to address specific eating-related issues facing the family, such as advising them not to bring their wallet to the local swimming pool to avoid the temptation to buy something at the snack bar.
      • Support related to physical activity: Following the group sessions focused on physical activity, the therapist assists parents in setting up a safe place in the home for the child to engage in active play, and discusses realistic strategies for reducing screen time and getting the child to be more active, even if the parent is busy doing chores or other activities. Suggested strategies could include allowing the child to play with safe utensils on the kitchen floor and encouraging the child to "help" with chores (e.g., by tying a string to the laundry basket and having the child pull it along the floor). The goal is to encourage the parent to include the child in such activities rather than "parking" him or her in front of a screen.
  • Second phase focused on maintaining progress: The second 12-week period consists of six biweekly sessions that again alternate between clinic-based group visits and in-home, one-on-one sessions between therapist and family. This phase focuses on helping parents identify ongoing barriers to engaging in healthy behaviors, along with strategies for overcoming them, typically based on the material taught during the initial phase. To prepare the families for the end of the program, session leaders work with the parents to help them understand what they should ideally strive for with respect to their child's weight and BMI over the next year, along with dietary and physical activity goals (e.g., calorie consumption, amount of activity) designed to help achieve these goals. During this phase, parents fill out the dietary logs 3 days a week (2 weekdays and 1 weekend day) rather than every day, because filling them out daily often proves to be cumbersome and the lessons and insights to come out of the daily logs have largely been learned at this point. In addition, data from pedometers are no longer recorded, although parents and preschoolers are encouraged to continue wearing them.

Context of the Innovation

Cincinnati Children's Hospital Medical Center operates as a full-service, not-for-profit pediatric academic medical center with 523 registered beds, handling more than 30,000 inpatient admissions and 115,000 emergency department visits each year. The organization serves the comprehensive medical needs of infants, children, and adolescents, and also operates research and teaching programs. The LAUNCH program was spearheaded by Lori J. Stark, PhD, a clinical psychologist and researcher at the medical center who has substantial experience in working with parents and children on behavior-related issues, including diet and physical activity. Based on her work, Dr. Stark believed that much of the existing knowledge about how to work with preschoolers and parents on their dietary and physical activity behaviors had not previously been incorporated into existing support programs, with the result being that many parents lack the knowledge and treatments to work effectively with their children to change their (and their own) behaviors. Dr. Stark also has experience working with families to change the dietary behaviors of children with cystic fibrosis or CF (who generally need to gain weight to improve their health), and felt that lessons from this work could be applied to support parents in helping their children better control weight and BMI. Dr. Stark decided to focus her initial efforts on preschoolers and their parents, whose behaviors she believed might be easier to change than those of families with older children (although in hindsight this has not proven to be the case).

Did It Work?

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Results

The LAUNCH program improved dietary (but not physical activity) habits among preschoolers, leading to less weight gain and to reductions in BMI percentile, as compared with a control group of preschoolers and their parents receiving only an initial 45-minute counseling session. Parents of preschoolers participating in the program also achieved greater weight loss and lower BMI than did parents in the control group.
  • Improved dietary habits: In a randomized controlled trial (RCT) that included 17 families (7 participating in LAUNCH and 10 receiving "enhanced" usual care as described previously), LAUNCH preschoolers reduced daily caloric intake significantly more so than did those in the control group at both 6 and 12 months after baseline. These larger reductions were driven by a greater decline in availability of high-calorie foods and beverages (at both 6 and 12 months) and an increase in fruits and vegetables in the home (at 6 months only).9
  • No change in physical activity: In the RCT described above, the program did not have a significant impact on the amount of physical activity, with each group of preschoolers engaging in approximately 20 minutes of vigorous activity and 59 to 75 minutes of moderate activity each day.9 (Children in the study wore an Actigraph, a commonly used accelerometer that objectively measures physical activity.)
  • Lower BMI percentile and z-score among preschoolers: In the RCT described above, 6 of the 7 participating preschoolers reduced their BMI z-scores (an alternative, more accurate measure than BMI for children) between baseline and months 6 and 12, and 5 of the 7 children reduced their BMI percentile over the same time period. (The other two participants maintained the same percentile). By contrast, 5 of the 10 children in the control group increased their BMI z-score. After 12 months, 5 of the 10 children receiving usual care were at or above the 99th BMI percentile (indicating severe obesity), compared to just 1 of the 7 LAUNCH preschoolers. The differences in BMI z-scores came about due to differences in weight gain, with LAUNCH preschoolers gaining less weight than did those in the control group.9 (Most preschoolers would not be expected to lose weight; the goal in working with very young obese children is generally to decrease or at least stabilize the rate of weight gain.8,10) An earlier, smaller (five-family) feasibility test of the program yielded similar findings, with LAUNCH preschoolers reducing their BMI z-score while those not participating exhibited gains in BMI z-score.11
  • Greater weight loss, lower BMI among parents: In the aforementioned RCT, the parents participating in LAUNCH lost more weight and achieved a lower BMI than did the parents in the control group, with these differences being statistically significant at months 6 and 12.9

Evidence Rating (What is this?)

Strong: The evidence consists primarily of an RCT that compared key metrics for 7 families (parent and preschooler) participating in the LAUNCH program and 10 families receiving "enhanced" usual care, which consisted of one 45-minute counseling session led by a pediatrician; metrics evaluated include changes in dietary habits (e.g., caloric intake, availability of high-calorie foods, fruits, and vegetables in the home), level of physical activity, weight, BMI z-score, and BMI percentile. Information provided in October 2013 indicates that another RCT is underway to test the treatment efficacy with a larger sample size (results pending).

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Adapting program from work with CF patients: Beginning in the summer of 2006, Dr. Stark and several colleagues (also clinical psychologists with expertise in working with children and parents) began adapting the program for families with children who have CF—which consisted of 7 group-based sessions over a 9-week period—to serve families with obese preschoolers and at least one overweight parent. This process involved "reversing" the curriculum (but still relying on many of the same behavior management strategies) to focus on the need to control (rather than gain) weight through changes in diet and physical activity.
  • Developing program materials: The team of psychologists developed a curriculum for the group and home-based sessions, including a plan for each weekly session and a written manual to guide the group sessions with parents.
  • Conducting feasibility study, refining program: Beginning in the fall of 2007, the program was tested in a feasibility study that included five families. Based on lessons from this study, the team revised the program several times in an iterative process.
  • Launching RCT: As noted, 17 families completed the program as part of an RCT that began in February 2008 and ran through September 2009.
  • Planning for additional testing: Dr. Stark has applied for funding to conduct a full RCT of the program with 100 families; this test will evaluate the LAUNCH program as compared with a control group receiving an inperson meeting with a pediatrician who will use motivational interviewing techniques, followed by two home visits that will also incorporate motivational interviewing. Dr. Stark proposed this even more enhanced version of usual care in response to recommendations calling for use of motivational interviewing with families who have overweight/obese children.

Resources Used and Skills Needed

  • Staffing: During the RCT, a clinical psychologist with a doctorate degree led the parent groups, a pediatric psychology postdoctoral fellow led the preschooler groups with support from a research assistant, and a psychology postdoctoral fellow conducted the in-home sessions. Generally, the parent groups should be led by a clinical psychologist, potentially with support from a dietitian if the psychologist lacks such expertise. The group sessions with preschoolers could be led by a master's-level professional or a trained graduate student in psychology; the key is to use someone with training and experience in child behavioral management. The home sessions could be led by a trained graduate student or social worker.
  • Costs: During the initial RCT, the estimated cost of the intervention averaged $1,276 per participant, consisting of 10 group therapy sessions ($750, or $75 each) and 8 home visits ($526, or roughly $66 each).9
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Funding Sources

National Institutes of Health
The National Institutes of Health (NIH) and the National Center for Research Resources within NIH supported the initial feasibility study and the RCT. The program developer has applied for additional funding under an initiative being jointly sponsored by three NIH agencies—the National Heart, Lung, and Blood Institute; the National Institute of Child Health and Human Development; and the National Institute of Diabetes and Digestive and Kidney Diseases.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Seek funding: Because most payers will not cover weight-management programs (unless a patient has been diagnosed with a condition such as diabetes or high blood pressure where lifestyle changes are a formal part of the treatment), another source of funding—either internal or external—will likely be needed, at least initially.
  • Test and refine program based on family input: To ensure that the program meets the needs of participating families, conduct small trials with a few families, and then solicit their feedback and refine the program accordingly using an iterative process.
  • Use pediatrician to "sell" program to families: Many parents refuse to believe that their child is overweight or obese, and hence convincing families to participate can be quite difficult. In fact, only about a third of families invited to participate in the RCT of this program agreed to do so. To improve the likelihood that a family will agree to participate, introduce the program through a personal letter from the child's pediatrician that references previous office visits and conversations, and that clearly lays out the potential benefits for both parent and child. Even with this approach, however, participation rates may remain low.
  • Make it easy and convenient to participate: The program should be designed to make it easy for families to participate. For example, program developers decided to hold group sessions in the evenings (to facilitate attendance by working parents), to accommodate siblings by offering childcare services during the group sessions, and to provide a healthy meal during the group sessions to avoid the need for time-pressed families to eat at a fast-food restaurant before the session.

Sustaining This Innovation

  • Monitor outcomes and ongoing feedback, refine accordingly: Track the program's impact on key outcomes (e.g., BMI percentile or z-score, eating habits, physical activity levels) and regularly ask participating families what they do and do not like about the program. Using this information, refine the program on an ongoing basis to better meet family needs and improve effectiveness.
  • Regularly remind parents why they joined: To maintain parents' enthusiasm for the program, ask them why they signed up and what they hope to gain by participating, and then regularly remind them of these goals and their progress toward achieving them during the program.
  • Approach payers about covering program services: To secure ongoing funding for program services, share data on the program's benefits with payers, including its potential to prevent costly health-related problems (such as asthma) later in childhood. This approach may convince some forward-thinking payers to cover program services as a way to improve health outcomes and reduce costs.

More Information

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Contact the Innovator

Lori J. Stark
Professor of Pediatrics at the University of Cincinnati College of Medicine
Director of Division of Behavioral Medicine and Clinical Psychology
MLC 3015
Cincinnati Children's Hospital Medical Center
3333 Burnet Ave
Cincinnati, OH 45229-3039
Phone: (513) 636-7116
Fax: (513) 636-3677
E-mail: lori.stark@cchmc.org

Innovator Disclosures

Ms. Stark reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

Stark LJ, Spear S, Boles R, et al. A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers. Obesity. April 15, 2010; 1-10 (Epub ahead of print). [PubMed]

Boles RE, Schar C, Stark LJ. Developing a treatment program for obesity in preschool age children: preliminary data. Child Health Care. 2010;39(1):34. [PubMed]

Footnotes

1 Ogden CL, Flegal KM, Carroll MD, et al. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288:1728-32. [PubMed]
2 Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549-55. [PubMed]
3 Williams CL, Strobino B, Bollella M, et al. Body size and cardiovascular risk factors in a preschool population. Prev Cardiol. 2004;7:116-21. [PubMed]
4 Mannino DM, Mott J, Ferdinands JM, et al. Boys with high body masses have an increased risk of developing asthma: findings from the National Longitudinal Survey of Youth (NLSY). Int J Obes (Lond). 2006;30:6-13. [PubMed]
5 Datar A, Sturm R, Magnabosco JL. Childhood overweight and academic performance: national study of kindergartners and first-graders. Obes Res. 2004;12:58-68. [PubMed]
6 Nader PR, O’Brien M, Houts R, et al. National Institute of Child Health and Human Development Early Child Care Research Network. Identifying risk for obesity in early childhood. Pediatrics. 2006;118:e594-601. [PubMed]
7 Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120 Suppl 4:S254-88. [PubMed]
8 Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120 Suppl 4:S164-92. [PubMed]
9 Stark LJ, Spear S, Boles R, et al. A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers. Obesity (Silver Spring). 2011;19:134-41. [PubMed]
10 Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111:1999-2012. [PubMed]
11 Boles RE, Schar C, Stark LJ. Developing a treatment program for obesity in preschool age children: preliminary data. Child Health Care. 2010;39(1):34. [PubMed]
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Original publication: November 10, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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