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Service Delivery Innovation Profile

Group Sessions and Automated Phone Counseling Help Overweight Children in Low-Income Families Improve Health-Related Behaviors, Quality of Life, and Body Mass Index


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Snapshot

Summary

Carilion Clinic Children's Hospital's Smart Choices for Healthy Families program supported low-income parents who have overweight children in promoting a healthier diet and increased physical activity for the entire family. Parents and children participated in six biweekly, small-group discussions, led by lay community leaders, that focused on education and goal-setting. Parents received an interactive, automated phone call after each session to reinforce the discussion and promote achievement of established goals and the setting of new ones. In a pilot test, the program helped children reduce body mass index, achieve more muscle mass, improve their health-related quality of life, reduce screen time, and increase levels of physical activity. Due to limited funding, the program ended after the pilot, although elements of it are being used in one clinic, and program leaders hope to secure funding to allow other components to operate in the future.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key measures of participating children's health, including BMI, muscle mass, physical activity, screen time, body image, and health-related quality of life; additional evidence includes reports from parents about the program's impact on family health behaviors and their satisfaction with the program.
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Developing Organizations

Carilion Clinic Children's Hospital; Virginia Cooperative Extension; Virginia Polytechnic Institute and State University (Virginia Tech)
Carilion Clinic Children's Hospital is located in Roanoke, Virginia.
Virginia Polytechnic Institute and State University (more commonly known as Virginia Tech) is located in Blacksburg, Virginia.
The Virginia Cooperative Extension is located in Blacksburg, Virginia.end do

Use By Other Organizations

Kaiser Permanente adapted the original Family Connections program and now makes it available to patients and community members as the Healthy Choice Hotline. This program has many of the same components but has not been tested specifically in low-income families.

Date First Implemented

2010
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Patient Population

Age > Child (6-12 years); Vulnerable Populations > Childrenend pp

Problem Addressed

The proportion of children who are obese continues to increase, especially among those living in low-income households. The epidemic stems primarily from a decline in physical activity and an increase in intake of high-calorie foods. Despite the significant long-term health consequences of obesity, health care providers and local communities generally provide little support to low-income parents in promoting healthier diets and more active lifestyles for their overweight children.
  • Rising rates of childhood obesity: Childhood obesity rates nearly tripled between 1976 to 1980 and 2007 to 2008, from 5 to 10.4 percent of children ages 2 to 5, from 6.5 to 19.6 percent of children ages 6 to 11, and from 5 to 18.1 percent of those ages 12 to 19.1 Poor children tend to be disproportionately affected; for example, nearly 15 percent of low-income children between the ages of 2 and 5 are obese.2 In Virginia, roughly 30 percent of children are obese, just under the national average of 31 percent.3
  • Driven by limited physical activity, poor eating habits: Less than one-fourth of youth consume at least five servings of fruits and vegetables daily, less than one-fifth participate in 60 minutes of physical activity daily, and about one-third watch 3 or more hours of television daily.4,5 Low-income, inner-city families face a particular challenge in engaging in physical activity and eating properly. Urban designs discourage walking and other physical activities, while high-crime rates force parents and schools to limit children's outdoor activities (including walking or biking to and from school). These areas tend to have poorly equipped schools and neighborhoods with few if any nice playgrounds and fields, thus further limiting opportunities for physical activity. In addition, various factors cause low-income families to consume many high-calorie, high-fat foods, including economic pressures to minimize food costs, limited time available for working parents to purchase and prepare nutritious food, and a lack of stores selling such food (including fruits and vegetables) in the area.
  • Leading to various long-term health problems: Obese children face a higher risk of many significant health problems, including high blood pressure, high cholesterol, type 2 diabetes, and depression; they are also more likely to be obese as adults.6
  • Ineffective support from providers and community: Physician counseling regarding weight management has largely been ineffective at stemming the obesity epidemic.7 Providers receive few rewards for addressing weight issues with parents and children and have access to few proven strategies for promoting healthier lifestyles in young patients.8 In addition, low-income families often do not have access to affordable weight-loss services, as many community-based programs charge a fee, whereas health system programs tend to be difficult to access (e.g., because services are not offered in a convenient location, don't address childcare, and include meetings at times that are difficult for most families to attend).
  • Unrealized potential of family-focused, community-based programs: Parents play a critical role in getting their children to eat well and engage in regular physical activity. Unfortunately, traditional weight-loss programs, particularly those that are not age specific, do not involve the entire family. For example, before implementation of this program, Cooperative Extension Service obesity programs in Virginia focused on either adults or children, but not both. Yet, research shows that family-based programs are more successful in reducing body mass index (BMI) than traditional approaches.9,10 Community-based programs led by respected, local residents may be particularly effective in reaching low-income populations by overcoming barriers such as lack of trust, time, and financial resources.7 Yet, few communities offer such programs.

What They Did

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Description of the Innovative Activity

The Smart Choices for Healthy Families program supported low-income parents who have overweight children in promoting a healthier diet and increased physical activity for the entire family. Parents and children participated in six biweekly, small-group discussions, led by lay community leaders, that focused on education and goal-setting. Parents received an interactive, automated phone call after each session to reinforce the discussion and promote achievement of established goals and the setting of new ones. Key program elements are detailed below:
  • Recruiting and enrolling eligible families: The hospital used its electronic medical record system to identify children between ages 8 and 12 with a BMI at or above the 90th percentile for their age. Physicians could also refer patients to the program. Participating families had to speak English and have access to a telephone. Children could not participate if they had a genetic/metabolic growth syndrome or took medications that altered appetite in some way. The hospital sent letters signed by the family's pediatrician to introduce the program, after which a research coordinator contacted parents by phone to gauge their interest and enroll those who wanted to participate.  
  • Biweekly discussion groups led by lay community leaders: Every other week over a 12-week period, participants attended 90-minute, small-group discussions held at a local clinical building near a bus stop. Separate sessions—one for parents and one for children—were facilitated by two program assistants employed by the Virginia Cooperative Extension Service's Supplemental Nutrition Assistance Program Education (SNAP-ED) program. (See the Context section for more details.) Session leaders were residents of local, low-income neighborhoods who could relate to the challenges of the target audience, serve as role models, and build trust with attendees. Key components of the sessions are outlined below:
    • Education and related activities: The parent sessions included educational presentations along with role-playing, problem-solving, and the development of action plans. The sessions helped parents learn behavioral health skills; enhance their knowledge of weight, nutrition, and physical activity; and improve essential parenting skills, such as setting limits, creating "policies" (e.g., regular family meals), and role modeling. Specific topics included how to make smart drink choices, engage in more physical activity, reduce screen time, control portion sizes, consume more fruits and vegetables, and eat smart "on the run." The concurrent children sessions consisted of age-appropriate education and games that supported the topics covered with parents.
    • Joint goal-setting: During the last 10 minutes of each session, children and parents came together to set shared goals related to reducing screen time, increasing physical activity, and eating more healthfully. Parents and children selected a goal for the following week, choosing from a limited number of options, such as adding a vegetable to each family dinner or limiting television time to 1 hour per night. The program assistants documented each family's selected goal for reference during a subsequent automated phone call (described in the bullet below).
  • Customized guidance via automated phone calls: Parents received a personalized, automated telephone counseling call during the week after each session, at a time they chose as being convenient (generally between 7 and 9 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). As outlined below, each 5- to 10-minute call provided customized guidance and support related to achieving established goals and setting new ones, with parents using a workbook to take notes and facilitate goal-setting.  
    • Support for established goals: At the beginning of each call, the parent heard the goal they selected the previous week and rated his or her success in achieving it by pressing 1, 2, or 3 on the keypad (1 for achieving the goal, 2 for making progress, and 3 for no progress). Depending on the answer given, the automated system provided information and advice on specific topics relevant to the caller's situation. It encouraged parents to assess behavior and motivation, instructed them on how to reach collaborative agreements with their children on goals, and offered guidance on how to identify and overcome barriers. The system also provided a short lesson that built on the information provided in the previous group session.
    • Setting new goals: The system encouraged parents to select a new goal for the upcoming week from a list of options.
    • Workbook to promote progress: During the calls, parents used an easy-to-read workbook to make notes and facilitate goal-setting. The workbook also provided guidance on how to increase physical activity and consumption of fruits and vegetables, reduce screen time, and avoid intake of sugary drinks.
  • Followup report to lay leaders: The lay leaders received a report that summarized each call, which helped them follow up on goal achievement at the beginning of the subsequent class, including having participants share tips on effective strategies for overcoming barriers.

Context of the Innovation

The Carilion Clinic Children's Hospital is a 92-bed institution located in Roanoke, Virginia. Virginia Tech is a public land–grant university that also serves as the home of the state's Cooperative Extension Service. Among its many other health and nutrition-related activities, the Cooperative Extension Service delivers the SNAP-ED program, a federal/state partnership that supports nutrition education for people eligible for SNAP. As noted earlier, SNAP-ED employs lay leaders from low-income communities to educate and serve as role models for residents.

The impetus for the Smart Choices for Healthy Families program came from a group of individuals within these various organizations who wanted to address childhood obesity in low-income populations. Paul Estabrooks, PhD, the director of the Translational Obesity Research Program at Virginia Tech, had previously implemented group sessions and automated telephone calls at Kaiser Permanente Colorado; he became interested in integrating clinical and community partners into childhood obesity initiatives. For their part, Virginia Cooperative Extension personnel had previously developed separate obesity initiatives for adults and kids, and then became interested in targeting both groups together. Dr. Michael Hart, a pediatrician with Carilion Clinic Medical Center, had attempted to execute intensive weight-loss interventions with his patients, but found it difficult to retain low-income families. As a result, he wanted to partner with organizations that had experience serving low-income populations so that obesity prevention initiatives could be more effective.

Did It Work?

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Results

In a pilot test, the program helped children reduce BMI, achieve more muscle mass, improve their health-related quality of life, reduce screen time, and increase levels of physical activity. Parents reported making positive behavioral changes, along with high overall satisfaction with the program.
  • Lower BMI: A pilot study involving 26 parent–child dyads found that the participating children reduced their average BMI z-score from 3.03 at the start of the program to 2.77 three months later. This score measures the number of standard deviations above the mean BMI, adjusted for age and gender. Consequently, a decline indicates movement toward the average BMI for children of a similar age and gender.
  • Increase in muscle mass: Over the same 3-month period, participating children increased muscle mass from 68.9 to 69.1 percent. While a seemingly small improvement, this increase met the test of statistical significance.
  • More physical activity, less screen time: Participating children engaged in more physical activity and reduced screen time slightly, although these findings did not meet the test of statistical significance. 
  • Better body image: Participating children reported reductions in levels of dissatisfaction with their body, as measured by KEDS (a 14-item questionnaire used as a screening tool for eating disorders in children). Scores fell from 2.3 at the start of the study to 1.8 at completion.
  • Better health-related quality of life: Participating children reported improvements in quality of life between program start and completion, including overall health-related quality of life (which rose from 86.2 to 90.7 on the 23-item, 100-point Pediatric Quality of Life 4.0 Generic Core Scales), physical quality of life (89.7 to 95.1), and school-related quality of life (83 to 88.1). 
  • Improved parental and family behaviors: Surveys and interviews with parents suggested that the program improved their and their families' health-related behaviors, including engaging in more physical activity, cooking healthier meals, increasing fruit and vegetable intake, reducing portion sizes, and eating family meals more regularly. 
  • High parental satisfaction: Parents reported high levels of satisfaction with the program, noting that it served to motivate their children and helped them be more positive role models and remain focused on their goals.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key measures of participating children's health, including BMI, muscle mass, physical activity, screen time, body image, and health-related quality of life; additional evidence includes reports from parents about the program's impact on family health behaviors and their satisfaction with the program.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Forming program team: Dr. Estabrooks called leaders at various organizations to identify individuals interested in developing a program to address childhood obesity in low-income families. He invited these individuals to attend a meeting to discuss the possibility of collaboration. Ultimately, the team included Virginia Tech researchers, Carilion clinicians, Virginia Cooperative Extension representatives, and the SNAP-ED director and program assistants.
  • Designing program: The team designed the program, including the curriculum for the group sessions, the workbook, and an introductory letter from physicians. Team members also designed a study to evaluate the program's impact. In this work, the team drew from successful existing programs, including Healthy Weights for Healthy Kids, a Cooperative Extension-based program for children,9 and Family Connections, an evidence-based childhood obesity treatment intervention.10
  • Designing automated phone system: The team scripted the phone calls and contracted with an outside vendor to develop the automated system.
  • Introducing program to clinicians: Carilion introduced the program to its clinicians through practice-wide meetings. During these sessions, physicians learned how to screen candidates and granted permission to use their names on recruitment letters sent to parents.
  • Training program assistants: The program assistants did not require any special training, since they already worked with the target patient population and had been involved in the program's development from the outset. The program assistants conducted one group session in front of the research team, allowing the team to hone the content and provide general feedback to the assistants.
  • Pilot testing and evaluation: The team piloted the program for 12 weeks and evaluated program results.
  • Continuing specific program elements: Due to funding limitations, the program as a whole only ran during the study period. However, the team continues to meet and has examined ways to perpetuate individual elements of the program. For example, one lay leader has been integrated into a pediatric clinic that primarily serves Medicaid-eligible families. The team is currently seeking funding to continue the group sessions and automated counseling components of the program.

Resources Used and Skills Needed

  • Staffing: Existing staff designed the program, created the workbook, and scripted the automated phone calls, while outside programmers and technical contractors designed and created the interactive phone system. During the pilot test, a project manager oversaw the program, including communications with providers and patients, while two program assistants led the small-group sessions. 
  • Costs: Total program costs have not been calculated. Upfront costs included design of the phone system (roughly $15,000 to $20,000) and salaries and benefits for team members for time spent developing the program. Ongoing costs included relatively low per-hour payments to the program assistants to lead the sessions and the costs of telephone lines and program materials (e.g., the workbooks).
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Funding Sources

Carilion Clinic Children's Hospital; Virginia Polytechnic Institute and State University (Virginia Tech)
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Tools and Other Resources

More information about SNAP-ED is available at http://www.csrees.usda.gov/nea/food/fsne/fsne.html.

Information about the KEDS screening tool is available at Childress AC, Jarrell MP, Brewerton TD (1993) The kids' eating disorders survey (KEDS): Internal consistency, component analysis, and reliability. Eating Disorders. 1993;1:843-50.

Information about the PEDsQL screening tool is available at Varni JW, Seid M, Kurtin PS. PedsQL (TM) 4.0: Reliability and validity of the pediatric quality of life Inventory (TM) Version 4.0 generic core scales in healthy and patient populations. Medical Care. 2001;39:800-12. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Assess screening capabilities: 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 program. If not, customize screening protocols to accommodate each medical practice's patient record technology.
  • Include relevant stakeholders in program development: All key stakeholders, including those who will ultimately deliver the program, should participate in program development meetings. Use of this inclusive process leads to valuable feedback on program design and serves to expedite the buy-in and approval process. In addition, having the program assistants involved reduces the need for training on program components.
  • Customize educational materials: Consider using the Smart Choices workbook as a potential starting point, and then customize it 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. If necessary, contract with a programming company to develop a separate system. If an automated system is not feasible due to technological or cost barriers, biweekly phone counseling sessions can be conducted by scripted practice staff or student interns. 
  • Encourage physician participation: Introduce the program to physicians, highlighting any evidence to support its effectiveness. At the same time, solicit their input on program design, including the appropriate process for screening patients and identifying those who may or may not be good candidates. 

Sustaining This Innovation

  • Maintain parent interest: Children of highly involved and motivated parents will likely achieve the best outcomes. Program content should be developed to move parents to a more motivated state. The program highlights the role of parents in changing the home environment and helps each parent identify personally relevant motives for changing the family's eating and activity patterns.
  • Monitor participant progress: Have staff (nurses or dietitians) conduct periodic assessments of participants' progress according to an established schedule.
  • Ensure adequate referral stream: Develop and maintain mechanisms to ensure ongoing identification and referral of potential participants, including but not limited to physician referrals. For example, parents who have completed the program can serve as champions of the initiative in the community, which should help to generate self-referrals.
  • Evaluate program value: Collect, analyze, and share data on the program's impact on key measures, such as BMI and participant satisfaction. This information can be used to justify continued support of the program, and to encourage physicians to continue referring eligible families to it.
  • Share successes: To ensure ongoing support, look for ways to highlight program successes both internally (e.g., through internally distributed impact statements) and externally (e.g., through local newspapers).

Use By Other Organizations

Kaiser Permanente adapted the original Family Connections program and now makes it available to patients and community members as the Healthy Choice Hotline. This program has many of the same components but has not been tested specifically in low-income families.

More Information

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Contact the Innovator

Paul Estabrooks, BPE, MSc, PhD
Director, Fralin Translational Obesity Research Center
Virginia Tech Senior Director of Research, Carilion Clinic
1 Riverside Circle, Suite 104
Roanoke, Virginia 24016
(540) 857-6664
E-mail: estabrkp@vt.edu; paestabrooks@carilionclinic.org

Innovator Disclosures

Dr. Estabrooks reported having no financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Pinard CR, Hart M, Hodgkins Y, et al. Smart choices for healthy families: a feasibility study for the treatment of childhood obesity in low-income families. Health Education & Behavior 2012; 39: 433-445.

Footnotes

1 Centers for Disease Control and Prevention. Overweight and obesity. April 21, 2011. Available at: http://www.cdc.gov/obesity/childhood/data.html
2 Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. Obesity Prevalence Among Low-Income, Preschool-Aged Children—United States, 1998-2008. MMWR. 2009;58:769-73. Available at: http://jama.ama-assn.org/content/303/1/28.full
3 Von Kutzeleben W. The Childhood and Adolescent Obesity Epidemic Confronting Virginia Schools: 2007-2008. Environmental Public Health Leadership Institute. Available at: http://www2a.cdc.gov/nceh/ehs/ephli/states.asp?State=Virginia&id=ehs123!.
4 Centers for Disease Control and Prevention. Trends in the prevalence of physical activity and sedentary behaviors. National YRBS: 1991-2011. Available at: http://www.cdc.gov/HealthyYouth/yrbs/pdf/us_physical_trend_yrbs.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
5 Centers for Disease Control and Prevention. Trends in the prevalence of obesity, dietary behaviors, and weight control practices. National YRBS: 1991-2011. Available at: http://www.cdc.gov/healthyyouth/yrbs/pdf/us_obesity_trend_yrbs.pdf.
6 Epstein LH, Valoski A, Wing RR, et al. Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol. 1994;13(5):373-83. [PubMed]
7 Estabrooks PA. Smart choices for healthy families: a pilot study for the treatment of childhood obesity in low-income families. Unpublished manuscript.
8 Edmunds L. Parents' perceptions of health professionals' responses when seeking help for their overweight children. Family Practice. 2005;22(3):287-92. Available at: http://fampra.oxfordjournals.org/cgi/reprint/22/3/287
9 Sharma S. Family-based weight loss program effective for children and teens. Insider Medicine. June 25, 2007. Available at: http://www.insidermedicine.com/archives
/Family-based_weight_loss_program_effective_for_children_and_teens__1251.aspx
10 Savoye M, Shaw M, Dziura J, et al. Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial. JAMA. 2007;297(24):2697-704. [PubMed]
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Original publication: April 25, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 11, 2014.
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