A Nurse’s Role in Childhood Obesity...this paper as physicians, physician’s assistants, nurse practi-tioners, registered nurses working in a primary care setting (e.g., community

A Nurse’s Role

in Childhood Obesity

Hindawi Publishing CorporationJournal of ObesityVolume 2013, Article ID 172035, 17 pageshttp://dx.doi.org/10.1155/2013/172035

Review ArticleExpanding the Role of Primary Care in the Prevention andTreatment of Childhood Obesity: A Review of Clinic-and Community-Based Recommendations and Interventions

Michaela Vine,1 Margaret B. Hargreaves,1 Ronette R. Briefel,2 and Cara Orfield3

1 Mathematica Policy Research, 955Massachusetts Avenue, Suite 801, Cambridge, MA 02139, USA2Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002-4221, USA3Mathematica Policy Research, 220 East Huron Street, Suite 300, Ann Arbor, MI 48104-1912, USA

Correspondence should be addressed to Michaela Vine; [email protected]

Received 11 February 2013; Accepted 20March 2013

Academic Editor: Roya Kelishadi

Copyright © 2013 Michaela Vine et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Although pediatric providers have traditionally assessed and treated childhood obesity and associated health-related conditionsin the clinic setting, there is a recognized need to expand the provider role. We reviewed the literature published from 2005to 2012 to (1) provide examples of the spectrum of roles that primary care providers can play in the successful treatment andprevention of childhood obesity in both clinic and community settings and (2) synthesize the evidence of important characteristics,factors, or strategies in successful community-based models. The review identified 96 articles that provide evidence of howprimary care providers can successfully prevent and treat childhood obesity by coordinating efforts within the primary care settingand through linkages to obesity prevention and treatment resources within the community. By aligning the most promisinginterventions with recommendations published over the past decade by the Institute of Medicine, the American Academy ofPediatrics, and other health organizations, we present nine areas in which providers can promote the prevention and treatmentof childhood obesity through efforts in clinical and community settings: weight status assessment and monitoring, healthy lifestylepromotion, treatment, clinician skill development, clinic infrastructure development, community program referrals, communityhealth education, multisector community initiatives, and policy advocacy.

1. IntroductionThe identification of effective strategies to address the pre-vention and treatment of childhood obesity is critical toimproving the health of the US population. National datafrom 2009 and 2010 show that nearly one in three childrenin America is either overweight or obese, and the numbersare even higher among certain demographic groups [1]. Inthe short term, obesity poses significant risks for children’sphysical health and psychosocial well-being [2, 3]. In the longterm, many of today’s children will age into adulthood withobesity that began in childhood and will experience the neg-ative health consequences associated with obesity as adults,such as type II diabetes [4]. Addressing the high prevalenceof childhood obesity will require coordinated and collectiveefforts in multiple sectors and settings—government, health

care, school, workplace, and community—that influence thefood and physical activity environments in which childrenlive [2, 5].

Primary care providers (PCPs), defined for purposes ofthis paper as physicians, physician’s assistants, nurse practi-tioners, registered nurses working in a primary care setting(e.g., community health center), or clinicians working in aschool-based health center setting, have important roles inmeeting obesity prevention goals. Primary care providershave traditionally measured patients’ heights and weights toassess growth, development, and bodymass index (BMI) andtreated obesity and health-related conditions, but there is arecognized need to expand these roles to include advocacy,modeling healthful behaviors in the community, and counsel-ing individuals and families about obesity prevention [5, 6].

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A number of scientific organizations have publishedrecommendations or guidelines for primary care providersto address childhood obesity prevention and treatment (seeTable 1).The most recent, by the Institute of Medicine (IOM)in its 2012 report “Accelerating Progress in Obesity Preven-tion,” includes the goal to “expand the role of health careproviders, insurers, and employers in obesity prevention.”Health care providers have a role in each of the four strategiesrecommended by the IOM to achieve this goal:

(1) Strategy 4-1: provide standardized care and advocatefor healthy community environments;

(2) Strategy 4-2: ensure coverage of, access to, and in-centives for routine obesity prevention, screening,diagnosis, and treatment;

(3) Strategy 4-3: encourage active living and healthy eat-ing at work; and

(4) Strategy 4-4: encourage healthy weight gain duringpregnancy and breastfeeding and promote breast-feeding-friendly environments.

Recommendations by the White House Task Force onChildhood Obesity [7], the American Academy of Pediatrics[8, 9], the American Heart Association [10], and other healthorganizations have focused primarily on the health careprovider’s role of assessment andmonitoring of BMI, encour-aging and supporting recommendations for physical activityand healthy eating, and serving as positive role models forobesity prevention [11].The Guide to Community PreventiveServices recommended behavioral interventions to reducescreen time but noted insufficient evidence for provider-oriented interventions (e.g., provider education, feedback, orreminders) for obesity prevention and treatment [12].

1.1. Motivation for the Study. Despite these recommenda-tions, PCPs are not doing as much as they should to preventand treat childhood obesity. Data from a 2008 nationalsurvey of PCPs found that fewer than half of all PCPsassessed BMI percentiles regularly in children, and only18% reported referring children for further evaluation ormanagement [11]. Most (58%) reported never, rarely, or onlysometimes tracking patients over time concerning weightor weight-related behaviors [11]. National survey data from2007 found that 12% of physician office visits of all child oradult patients included counseling about nutrition or diet[13]. Obstacles limit the ability and activity of PCPs to meetthese recommendations. Several studies identified a lack ofoffice time to gather background information from familiesas a major impediment to addressing healthy weight [14–17]. Other obstacles include lack of awareness of the issue,lack of comfort or skill counseling families on the issue,need for organizational prompts, and lack of familiarity withavailable community resources for lifestyle counseling orobesity prevention programs [5, 11, 18–21].

Evidence suggests that with the right interventions andactivities, PCPs can effectively play an expanded role in pre-venting and treating obesity among children and adolescents[20]. Obstetricians and gynecologists also play an important

role in prenatal care, monitoring maternal weight gain, andencouraging and supporting breastfeeding [22].The purposeof this review is to identify effective or promising practices inthe expanded roles that are now recommended for PCPs (seeTable 1).These roles include the following:

(1) weight status assessment and monitoring: assessmentand monitoring of BMI, nutritional intake, physicalactivity level, and other indicators of weight status inchildren and adolescents;

(2) healthy lifestyle promotion: dissemination of healthylifestyle recommendations and materials as part ofprimary prevention efforts in the primary care set-ting, excluding healthy lifestyle promotion that is partof patient treatment (item no. 3);

(3) patient treatment: use of evidence-based techniques,such as behavioral andmotivational counseling, with-in the primary care setting to treat patients identi-fied as overweight or obese (treatment may includehealthy lifestyle promotion);

(4) clinician skill development: education and trainingon evidence-based assessment and counseling tech-niques;

(5) clinical infrastructure development: implementation ofcapacity building within the primary care setting,such as improvements to organizational systems orcare models used by providers;

(6) community program referrals: referral of patients tocommunity-based obesity treatment programs out-side of the primary care setting;

(7) community health education: dissemination of healthylifestyle recommendations and materials as part ofprevention efforts in the community setting;

(8) multisector community initiatives: participation inmultisector obesity prevention and treatment initia-tives to achieve policy and systems goals; and

(9) policy advocacy. support of and advocacy for policychanges in the broader community setting.

This review, guided by a socioecological framework anda systems approach [5, 23], focuses on the intersectionbetween PCPs (including community health centers) andpublic health in the community. Studies of child or familyinterventions in primary care settings or community inter-ventions with a direct link to primary care (e.g., a communityintervention with active referral to PCPs) were the focus ofthe review. Although other reviews on childhood obesity andhealth care have been published since IOM’s 2005 report on“Preventing Childhood Obesity,” the extent to which theysummarize the specific roles of primary care providers inimplementing the intervention varies [24–26]. This reviewupdates the most recent reviews of literature on the primarycare role in obesity prevention and treatment published from2005 to 2012, addresses 2012 IOM recommendations thatemphasize both a clinical and community advocacy role forPCPs [5], and incorporates multisector interventions andcommunity advocacy-specific interventions involving PCPs.

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3Table 1: Recommendations for primary care providers for the prevention and treatment of obesity and selected citations.

Recommendation types (source)Desired outcome Citations for promising

evidence-basedinterventions

Activeliving

Healthyeating

Otherhealth

behaviorsClinicalpractice

Communitypolicy

Weight status assessment and monitoringPrimary care providers (PCPs) should screen children aged 6 and older for obesity (USPSTF 2010)[28]. ×

Ewing et al., 20091 [33]Kopp and Hornberger,

2008 [30]Kubik et al., 2008 [15]Mckee et al., 2010 [17]Perrin et al., 20072 [20]Perrin et al., 2008 [31]

Polacsek et al., 2009 [32]Savinon et al., 2012 [29]Van Gerwen et al., 20092

[19]

PCPs should inquire about nutritional intake, calculate and plot BMI, and identify obesity-relatedcomorbidities (AAP 2003) [9]. × ×PCPs should routinely track BMI and offer relevant evidence-based counseling and guidance aboutobesity prevention (IOM 2005) [2]. ×PCPs should encourage parents to discuss weight status with their child’s health care provider andmonitor age- and gender-specific body mass index (BMI) percentiles (IOM 2005) [2]. ×PCPs should calculate and plot BMI once a year in all children and adolescents and use change in BMIto identify rate of excessive weight gain relative to linear growth (AAP 2003) [9]. ×PCPs should identify and track patients at risk by virtue of family history; birth weight; orsocioeconomic, ethnic, cultural, or environmental factors. Recognize and monitor changes inobesity-associated risk factors for adult chronic disease, such as hypertension, dyslipidemia,hyperinsulinemia, impaired glucose tolerance, and symptoms of obstructive sleep apnea syndrome(AAP 2003) [9].

×Healthy lifestyle promotion

PCPs should make AAP guidelines on screen time more available to parents, and young childrenshould be encouraged to spend less time using digital media and more time being physically active(WH 2010) [7].

×Kubik et al., 2008 [15]Perrin et al., 20072 [20]Plourde, 2006 [39]

Pomietto et al., 2009 [38]Waldrop and Ferguson,

2008 [21]

PCPs should inform pregnant women and women planning a pregnancy of the importance ofconceiving at a healthy weight and having a healthy weight gain during pregnancy, based on therelevant recommendations of IOM (WH 2010) [7].

×PCPs should provide information to pregnant women and new mothers on breastfeeding, includingthe availability of educational classes, and connect pregnant women and new mothers to breastfeedingsupport programs to help them make an informed infant feeding decision (WH 2010) [7].

×PCPs should use behavioral interventions aimed at reducing screen time based on sufficient evidenceof effectiveness for reducing measured screen time and improving weight-related outcomes.Interventions can be single component or multicomponent and focus on changing screen timethrough classes aimed at improving children’s or parents’ knowledge, attitudes, or skills (CommunityGuide 2011) [12].

×PCPs should promote healthy eating (AAP 2006) [8]. ×PCPs should encourage parents to limit sedentary activity and make physical activity and sportrecommendations to parents and caregivers that are consistent with the developmental level of thechild (AAP 2006) [8].

×PCPs should recommend parent, guardian, and caregiver responsibilities for children’s nutrition: (1)control when food is available, (2) provide social context for eating, (3) teach about food and nutritionwhen cooking and at the grocery store, (4) counteract inaccurate information from the media andother influences, (5) teach other caregivers what parents want their child to eat, (6) serve as rolemodels and lead by example, and (7) promote and participate in regular daily physical activity (AHA2006) [36].

× × ×

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Table 1: Continued.



Activeliving

Healthyeating

Otherhealth


Communitypolicy

PCPs should promote guidelines for improving nutrition in young children: (1) parents choosemealtimes, not children; (2) provide a wide variety of foods; (3) pay attention to portion sizes; (4) usenonfat or low-fat dairy products; (5) limit snacking; (6) limit sedentary behaviors; (7) allowself-regulation of total caloric intake in the presence of normal BMI; and (8) have regular familymealtimes (AHA 2006) [36].

×PCPs should promote guidelines for nutritional quality after weaning: (1) delay the introduction ofjuice until at least 6months of age, (2) respond to satiety cues and do not overfeed, and (3) includehealthy foods and continue offering if initially refused (AHA 2006) [36].

×PCPs should promote breastfeeding for first nutrition and try to maintain it for 12months (AHA2006) [36]. ×PCPs should support and promote healthful dietary patterns among diverse ethnic groups, taking intoconsideration regional and cultural differences (ADA 2004) [34]. ×PCPs should support and promote (1) Dietary Guidelines for Americans for healthy children after theage of 2 years; (2) use of the US Department of Agriculture’s Food Guide Pyramid as a guide formeeting dietary recommendations with use of the Food Guide Pyramid for Young Children aged 2 to6; and (3) use of the Fitness Pyramid for Kids to encourage physical activity among children (ADA2004) [34].

× ×PCPs should encourage parents and caregivers to promote healthy eating patterns by offeringnutritious snacks, such as vegetables and fruits, low-fat dairy foods, and whole grains; encouragingchildren’s autonomy in self-regulation of food intake and setting appropriate limits on choices; andmodeling healthy food choices (AAP 2003) [9].

×PCPs should encourage, support, and protect breastfeeding (AAP 2003) [9]. ×

Patient treatmentPCPs should offer or refer children aged 6 and older to intensive counseling and behavioralinterventions to promote improvements in weight status (USPSTF 2010) [28]. × Dalton et al., 2011 [48]

Henes et al., 20101 [44]Jacobson and Melnyk, 20111

[90]Jacobson and

Gance-Cleveland, 20112[24]

Kubik et al., 2008 [15]Kwapiszewski and LeeWallace, 20111 [43]

Mcclaskey, 20101 [49]Siegel et al., 20091 [45]Stahl et al., 2011 [40]Taveras et al., 2011 [41]

PCPs should use technology-supported multicomponent coaching or counseling interventionsintended to reduce weight on the basis of sufficient evidence that they are effective in improvingweight-related behaviors or weight-related outcomes.The Task Force on Community PreventiveServices recommends technology-supported multicomponent weight coaching or counselinginterventions intended to maintain weight loss on the basis of sufficient evidence that they areeffective in maintaining weight-related behaviors or weight-related outcomes.These interventionsoften also include other components, which can be technological or nontechnological (e.g.,computers; videoconferencing; in-person counseling; written feedback; or computerized telephonesystem interventions that target physical activity, nutrition, or weight) (Community Guide 2011) [12].

×PCPs should offer pregnant women counseling, such as guidance on dietary intake and physicalactivity that is tailored to their life circumstances (IOM 2009) [22]. × × ×PCPs should routinely offer relevant evidence-based counseling and guidance about obesityprevention (IOM 2005) [2]. ×

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Table 1: Continued.



Activeliving

Healthyeating

Otherhealth


Communitypolicy

Clinician skill developmentPCPs should provide education and training in breastfeeding for all health professionals who care forwomen and children (SG 2011) [91]. × Cluss et al., 2010 [56]

Cronk et al., 20111 [54]Haemer et al., 2011 [50]Holt et al., 2011 [51]

Jacobson and Melnyk, 20111[90]

Maher et al., 2010 [57]McGaffey et al., 2011 [52]Perrin et al., 2008 [31]

Polacsek et al., 2009 [32]Pomietto et al., 2009 [38]Stahl et al., 2011 [40]

Schwartz et al., 20071 [53]Savoye et al., 2011 [55]

Medical and other health professional schools, health professional associations, and health caresystems should ensure that health care providers have the necessary training and education toeffectively prevent, diagnose, and treat obese and overweight children (WH 2010) [7].

× ×Medical student, resident, and continuing medical education programs should consider andperiodically review basic community pediatric competencies to be included in training andmaintenance of certification efforts for pediatricians (AAP 2005) [35].

×Training programs and certifying entities should require obesity prevention knowledge and skills intheir curricula and examinations (IOM 2005) [2]. ×PCPs should foster communication by building partnerships across health-related disciplines andprofessional organizations and conduct effective nutrition education training programs for physicians,child nutrition personnel, and other health care providers on strategies that can be used with childrento promote healthier eating habits (ADA 2004) [34].

× ×Clinical infrastructure development

Hospitals and PCPs should use maternity care practices that empower new mothers to breastfeed,such as baby-friendly hospital standards (WH 2010) [7]. × × Anand et al., 2010 [58]

Ariza et al., 2009 [59]Ariza et al., 2012 [60]

Pomietto et al., 2009 [38]Polacsek et al., 2009 [32]Whitlock et al., 2008 [92]

PCPs should use interventions during pregnancy and after birth to promote and supportbreastfeeding (USPSTF 2010) [28]. ×Insurers and accrediting organizations should provide incentives for maintaining healthy body weightand include screening and obesity prevention services in routine clinical practice and qualityassessment measures (IOM 2005) [2].

×Referrals to community programs

PCPs should educate themselves concerning the availability of community resources that affect thehealth and well-being of the children they serve (AAP 2005) [35]. × Dreimane et al., 20071 [62]

Estabrooks et al., 20091 [67]Foster et al., 20121 [68]

Heinberg et al., 20101 [63]Paul et al., 20111 [64]Pinard et al., 20121 [65]Quattrin et al., 20121 [69]Stark et al., 20111 [70]Taylor et al., 20051 [71]

PCPs and insurance companies should provide information to pregnant women and new mothers onbreastfeeding, including the availability of educational classes, and connect pregnant women and newmothers to breastfeeding support programs to help them make informed infant feeding decisions(WH 2010) [7]. ×

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Table 1: Continued.



Activeliving

Healthyeating

Otherhealth


Communitypolicy

Community health educationPCPs should make AAP guidelines on screen time more available to parents, and young childrenshould be encouraged to spend less time using digital media and more time being physically active(WH 2010) [7].

×Agrawal et al., 2012 [77]

Eisenmann et al., 2008 [74]Gombosi et al., 2007 [75]Moore et al., 2009 [76]

Education and outreach efforts about prenatal care should be enhanced through creative approachesthat take into account the latest in technology and communications (WH 2010) [7]. ×PCPs should become involved in the education of residents and medical students in communitysettings. Pediatricians have the unique opportunity to model roles outside the traditional clinical rolesthat students and residents encounter. Pediatric academicians should use resources from the AAP andthe Ambulatory Pediatric Association to engage community pediatrician as educators, both in thecare of individual patients in community-based practice and in roles related to promotion of thewell-being of all children in the community. Community-based resources outside the bounds of thetraditional hospital and outpatient office setting should be used to instruct residents on the effect ofthe community on child health status and the positive effect of interdependent collaboration ofcommunity agencies with health professionals on child health (AAP 2005) [35].

×Multisector community initiatives

Local health departments and community-based organizations, working with health care providers,insurance companies, and others should develop peer support programs that empower pregnantwomen and mothers to get help and support from other mothers who breastfeed (WH 2010) [7].

× ×Multi-sector:

Chang et al., 2010 [78]Chomitz et al., 20101 [83]Cousins et al., 2011 [80]

Economos et al., 20071 [82]Karanja et al., 20101 [79]Samuels et al., 2010 [81]

School-PCP:Edwards, 2005 [87]

Stephens et al., 2011 [85]Tyler and Horner, 2008 [86]Whaley et al., 2010 [14]

PCPs should ensure that maternity care practices throughout the United States are fully supportive ofbreastfeeding and develop systems to guarantee continuity of skilled support for lactation betweenhospitals and health care settings in the community (SG 2011) [91].

×PCPs and other members of the community should interact and advocate to improve all settings andorganizations where children spend time (e.g., child care facilities, schools, and youth programs).School and community resources should be considered as assets in developing strategies for theproblems that children will face now and throughout their lives (AAP 2005) [35].

×PCPs should become comfortable with an interdisciplinary collaborative approach and advocacyeffort to child health. Pediatricians can play an important role in coordinating and focusing new andexisting services to realize maximum benefit for all children (AAP 2005) [35].

×PCPs should work collaboratively with public health departments and colleagues in relatedprofessions to identify and decrease barriers to the health and well-being of children in thecommunities they serve (AAP 2005) [35].

×PCPs should foster communication by building partnerships across health-related disciplines andprofessional organizations. Conduct effective nutrition education training programs for physicians,child nutrition personnel, and other health care providers on strategies that can be used with childrenthat promote healthier eating habits (ADA 2004) [34].

× ×

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Table 1: Continued.



Activeliving

Healthyeating

Otherhealth


Communitypolicy

Policy advocacyPCPs should use community data (epidemiologic, demographic, and economic) to increase theirunderstanding of the health and social risks on child outcomes and of the opportunities for successfulcollaboration with other child advocates (AAP 2005) [35].

×Include basic support for breastfeeding as a standard of care for midwives, obstetricians, familyphysicians, nurse practitioners, and pediatricians, and ensure access to services provided byInternational Board Certified Lactation Consultants (SG 2011) [91].

×PCPs should advocate for the appropriate allocation of funding for quality research in the preventionof childhood obesity (AAP 2006) [8]. ×PCPs should advocate for (1) a school curriculum that teaches children and youth the health benefitsof regular physical activity; (2) comprehensive community sport and recreation programs; (3)reinstatement of compulsory, quality, and daily physical education (PE) classes in all schools taught byqualified, trained educators; (4) provision of a variety of physical activity opportunities in addition toPE; and (5) development and implementation of a school wellness counsel on which local physicianrepresentation is encouraged (AAP 2006) [8].

× × Mayer, 20092 [88]McPherson et al., 2012 [89]

PCPs should advocate the AHA 2006 Diet and Lifestyle Goals for Cardiovascular Disease RiskReduction: consume an overall healthy diet, aim for healthy body weight, and encourage regularphysical activity (AHA 2006) [8].

× × ×PCPs should advocate for the development and implementation of a school wellness counsel on whichlocal physician representation is encouraged (AAP 2006) [8]. ×PCPs should work with local governments to change their planning and capital improvementpractices to give higher priority to opportunities for physical activity (IOM 2005) [2]. × ×PCPs and other members of the community should interact and advocate to improve all settings andorganizations in which children spend time (e.g., child care facilities, schools, and youth programs).School and community resources should be considered as assets in developing strategies for theproblems that children will face now and throughout their lives (AAP 2005) [35].

×PCPs should become comfortable with an interdisciplinary collaborative approach and advocacyeffort to child health. Pediatricians can play an important role in coordinating and focusing new andexisting services to realize maximum benefit for all children (AAP 2005) [35].

×PCPs should support and advocate for social marketing intended to promote healthful food choicesand increased physical activity (AAP 2003) [9]. × × ×AAP: American Academy of Pediatrics; ADA: American Dietetic Association; AHA: American Heart Association; Community Guide: The Community Guide to Preventive Services; IOM: Institute of Medicine;SG: Surgeon General’s Call to Action to Support Breastfeeding; USPSTF: United States Preventive Services Task Force; WH: White House Task Force on Childhood Obesity; see the list of references for completecitation.1Indicates article describing an intervention that had a statistically significant effect on participants’ weight or weight status.2Indicates review article.


Initial database searchJanuary 2005–March 2011 publication date

resulted in 669 articles

Article abstract reviewresulted in 112 articles

Article full-text reviewresulted in 60 articles

Article abstract reviewresulted in 84 articles

Article full-text reviewresulted in 36 articles

March 2011: initial database search January 2013: updated database searchUpdated database search

March 2011–December 2012 publication dateresulted in 233 articles

Included in analyses96 articles

63 articles describing specific interventions14 review articles

13 articles summarizing recommendations6 articles summarizing results of focus groups

with parents, patients, or providers

Figure 1: Literature review process.

Table 2: Literature review search terms.

Search term Search term Search term Search termHealthy weight OR AND/OR Child OR AND Intervention OR AND Community intervention OROverweight OR Family OR Program OR Community health services ORObesity OR Families Initiative OR Primary health care ORWeight-loss Strategy OR Tribe OR

Strategies OR Tribal ORNative American ORFirst Nation ORAmerican Indian

Indian Health Service ORIndigenous ORIslander OR

Primary care ORPrimary health care ORCommunity health

Note: search limits included humans, English, United States, and publication date from January 1, 2005, to December 31, 2012.

It also recognizes the new imperatives or opportunities to domore based on the Affordable Care Act changes requiringpreventive care as an essential health benefit and eliminatingcost sharing for preventive services [27].

2. Materials and Methods

We conducted a review of clinic- and community-based obe-sity interventions with a primary care component to identifyevidence of effective roles of primary care in addressing theepidemic.The first phase of the scan was conducted inMarch2011 (Figure 1). We searched for literature published from2005 to 2011 using search terms listed in Table 2. Our searchincluded PubMed and other databases (ESCO AcademicSearch Premier, Cochrane Central Register of Controlled Tri-als, ERIC, and Health Technology Assessments) and resultedin 669 articles. For these articles, we reviewed abstracts forrelevance and to ensure that the intervention took place inthe United States, which refined the list to 147 articles. We

retained the articles that described an obesity interventionfor children and/or families that took place in a primarycare setting, a school health center, or a community setting(community health center; pediatrician; tribal health center;Special SupplementalNutrition Program forWomen, Infants,and Children (WIC) clinic; and so on) with some link toprimary care. The elimination of unrelated school-based,policy, environmental change, and workplace interventionsthat did not include a link to the primary care setting,as well as articles that focused primarily on primary carerecommendations (rather than primary care interventions),further refined the scan to 112 articles.

We reviewed the remaining 112 full-text articles to ensurethat each article fits the original criteria and to documentthe findings. Of the full-text articles reviewed, 60 met thecriteria. We updated the review in January 2013 for theliterature published in 2011 and 2012. The additional reviewresulted in 36 articles that met our criteria, for a total of96 articles considered in this paper. These sources included

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63 articles describing specific interventions; 14 that reviewedexisting interventions; 13 summarizing recommendations forthe treatment and prevention of childhood obesity; and 6 thatsummarized the results of topic-related focus groups withparents, children, or clinicians. The full list of citations forarticles considered in this review is available upon requestfrom the authors.

3. Review Findings

The 96 articles that met the criteria for this review provideexamples of how pediatricians, PCPs, and communities haveimplemented clinic- and community-based programs andinitiatives targeting the prevention, screening, diagnosis, andtreatment of obesity among children and adolescents. Theinterventions reviewed typically took place in a primary careclinic, pediatrician’s office, community health center, school-based health clinic, university research program, WIC clinic,or other community setting. In this section, we summarizethe paper findings regarding the efficacy of these efforts,when available, and describe how these interventions alignwith current recommendations for obesity prevention andtreatment in the nine areas identified in Table 1. Because anarticle could address multiple primary care physician roles(e.g., weight assessment as well as treatment of obesity),articles can be cited in more than one category. Interven-tions reporting statistically significant improvements in childweight status are noted in Table 1. Methods used to assesschanges in children’s weight status include change in BMI;BMI "-score (i.e., the number of standard deviations of thevalue for an individual away from the mean value of thereference population); BMI percentile for age and gender;BMI velocity; kilograms or pounds lost; percent healthyweight, overweight, and/or obese; and waist and hip girth.The majority of interventions lasted between four and 12weeks, and most follow-up efforts occurred over less than 12months.

3.1.Weight Status Assessment andMonitoring. Annual assess-ment of weight status through the use of BMI compared withage-sex BMI percentiles in growth charts in children andadolescents is widely recognized as a standard of care in theprimary care setting [2, 9, 28]. Although a healthy weightassessment routinely involves some form of measuring bodyweight, evidence suggests that a complete assessment shouldalso include indicators of healthy diet, active living, andchild and family health history [8, 9]. Most interventionsreviewed included an evaluation of the patient’s overall healththrough patient and/or parent discussions or questionnairesin addition to assessment of weight status by use of BMI orgrowth charts. Methods used to assess or monitor weightincluded BMI, BMI "-scores, and comparisons to referencegrowth charts and standards for overweight and obesity.McKee et al. [16] integrated parent-completed questionnairesinto routine primary care visits to assess family historyof diabetes and cardiovascular disease, parents’ height andweight, child’s television and play habits, and child’s intake ofmeals in front of the television; information collected from

parents was used to inform weight assessment and guidethe content of counseling and goal setting for overweightpatients.

Recommendations state that PCPs should track annualBMI assessments over time to assist clinicians in recog-nizing major changes in weight relative to height [8, 9].Two articles reviewed suggested that integration of BMIassessment into frequently used electronic medical record(EMR) systems or hand-held personal digital assistants couldfacilitate increased use of BMI as a screening tool and asa method of effectively tracking BMI over time for thepurposes of monitoring [18, 20]. However, only one articlereviewed specifically discussed integration of BMI collectioninto EMR systems. Savinon et al. [29] found that customizedEMR templates designed to facilitate assessment of BMI andscreening and counseling for overweight patients increasedthe frequency of children screened for BMI, as well as thediagnostic rate for overweight and obesity.

Articles reviewed suggest that multiple barriers mightlimit the assessment and monitoring of BMI in the clinicsetting, including lack of familiarity with the use of BMI;lack of agreement about the utility of BMI as a screeningand intervention tool; lack of office time to gather back-ground information from families; and lack of practice-level resources conducive to simple, frequent use of BMI[11, 18–21]. Several articles noted the importance of famil-iarizing clinicians with weight assessment tools, includingBMI assessment calculators, Centers for Disease Controland Prevention guidelines for BMI interpretation, and edu-cational materials to increase uniformity of screening andimprove clinician self-efficacy [20, 30–32]. Perrin et al. [20,31] suggested that age-specific office-based tools may assistpractitioners in communicating results of BMI assessment tofamilies and in evaluating the patient’s readiness to change.Another study that promoted use of BMI tools found a signif-icant decrease in BMI at 5months, but not 12months, amongchildren participating in a primary care-based program thatcombined clinician training in weight assessment with aneight-week, family-based behavioral intervention [33].

3.2. Healthy Lifestyle Promotion. Multiple recommendationssuggested that promotion of healthy lifestyle behaviors suchas adherence to recommended dietary guidelines, increasedparticipation in physical activity, and limiting screen timeand sedentary behavior should be incorporated into stan-dard clinical practices for clinicians who serve children andadolescents [7–9, 12, 34–36]. These recommendations applyto both prevention and treatment of obesity in the primarycare setting. Healthy lifestyle promotion as used in clinic-based treatment interventions is discussed in more detail inthe following section; here, we describe notable examples ofhealthy lifestyle promotion as it pertains to the preventionof overweight and obesity in children and adolescents. Weidentified significantly fewer articles in this category.

The IOM suggests that providers utilize a multifacetedapproach to patient education, recognizing that patients mayhave different learning styles, needs, and preferences [37].Incorporation of healthy lifestyle promotion in the primary


care settingmay involve distribution or display of educationalmaterials on nutrition, physical activity, and screen time inconjunction with verbal counseling of patients. Kubik et al.[15] described a prevention intervention that incorporateseducational brochures on behavior-regulated activities, aKid’s Goal Board, and a Parent Tip Board in the waiting roomarea. Perrin et al. [20] suggested that PCPs should incorporatemessages about healthy weight management, such as limitingscreen time and sugar-sweetened beverages and increasingphysical activity, into conversations with patients and parentsduring regular office visits. These conversations might beparticularly important for children who are more likely tobe overweight. Materials including healthy weight messagesshould bemade available inmultiple languages representativeof the populations served by the clinic [38].

It is notable that recommendations by health organi-zations regarding reduced screen time have become morecommon in recent years [7, 12]. This is expected as screentime is a more recently accepted measure of inactivity (i.e.,as one measure of physical activity) compared to moreestablished measures such as healthy eating. It is also notablethat, although several recommendations stated the need forPCPs to promote healthy weight gain during pregnancy,provide information and resources on breastfeeding, andpromote guidelines for weaning children at the appropriateage [7, 9, 35, 36], few articles reviewed specifically addressedhealthy lifestyle promotion among pregnant or breastfeedingmothers. Those that did [20, 21, 39] summarized recom-mendations for incorporating healthy lifestyle messages intoprenatal or postnatal visits; however, none described specifichealth promotion interventions for pregnant or breastfeedingwomen in the primary care setting.

3.3. Patient Treatment. Although few health organizationrecommendations specifically addressed the role of the PCPin the treatment of overweight and obesity in children andadolescents [2, 12, 28], most of the articles reviewed thatoccurred in or were intended for the primary care settinginvolved interventions that were designed to treat the chil-drenwhowere identified as overweight or obese throughBMIassessment. The format of the treatment and the intensity,frequency, and length of engagement with clinicians variedacross studies.Many of the health organization recommenda-tions on promotion of healthy lifestyle discussed in the pre-vious section also apply to obesity treatment interventions;most of the interventions shown to be successful includedpromotion of improved nutrition and exercise habits andreduced screen time.

For children with a BMI above a specified percentile,treatment interventions that incorporated individual casemanagement or patient-centered counseling as a means forachieving a child’s healthy weight showed some evidence ofsuccess. Examples of individual case management includeprivate, age-appropriate conversations with clinicians regard-ing achieving healthy weight; goal setting; motivationalinterviewing; and conversations with registered dieticiansabout patient readiness, diet, and exercise. Of the seven stud-ies in this category, six measured positive results—including

weight loss, improved lifestyle habits, or increased parentconfidence using provider recommendations—after patientsparticipated in multiple individual sessions with the provid-ers [15, 40–45]. Successful studies emphasized the need forproviders to engage the patient in a dialogue about lastinglifestyle changes and the benefits of training clinicians on howto address ambivalence about making behavioral changes.The tone and language used to communicate messagesregarding obesity and being overweight is important. Twoarticles discussed strategies that PCPs could use to deliverdiagnosis and treatment options. In focus groups, parentsexpressed preferences for health care providers to commu-nicate using clinical terms to explain the rationale for theirconcern and to provide specific treatment recommendations[46, 47].

When a treatment plan is established for an individual,many primary care practices sponsor or refer patients tointerventions that provide group classes or activities tosupport individuals and families. Content of primary-care-based group interventions was diverse, including in-personphysical activities, educational grocery store visits, interactivenutrition and exercise sessions, family cooking courses, andgroup discussions. Though the PCP might make the initialreferral to interventions of this type, his or her role inthe actual group treatment intervention was less clear fromthe articles reviewed. Dalton et al. [48] described a group-based intervention for parents using the National Instituteof Health’s We Can! curriculum, which is facilitated byPCPs; McClaskey [49] described a community-health centerintervention involving group nutrition and physical sessionsled by physicians. However, dieticians, interventionists, ornurses carried out the majority of primary care-based groupinterventions.

Multiple recommendations from health organizationscited the role that PCPs can play in educating parents abouthealthy eating, physical activity, and reduced screen time [7–9, 35, 36]. Kwapiszewski and LeeWallace [43] found it criticalto have full support from all intervention partners (providers,parents, and children) in commitment to lifestyle changes totreat obesity. Most interventions in both the patient-basedor group format involved some form of parent involvement,with parents present during individual or group counselingsessions with a PCP or in attendance at parent-only meetingswith a focus on goal setting, modeling healthy behaviors, ornutrition and/or physical activity decision making.

3.4. Clinician Skill Development. Recommendations suggestthat in order to effectively prevent, diagnose, and treatobesity and overweight in children and adolescents, cliniciansmust be adequately trained in standardized, evidence-basedassessment and counseling techniques [7]. Moreover, clini-cians must be comfortable communicating results of weightassessment and monitoring to patients and their families.Haemer et al. [50] suggested that trainings that include thefull spectrum of care, rather than weight assessment alone,might be more effective in improving efficacy, as providerscould be more likely to diagnose a child as overweight or


obese when they have the tools and comfort level to providecounseling and treatment.

Multiple articles reviewed suggested the need for physi-cian training and decision support for use of techniquesand tools for counseling on behavioral treatment approachesfor childhood obesity [11, 24, 50, 51]. Seven of the articlesreviewed involved training for physicians, nurses, and/orregistered dieticians on the use of motivational interviewingtechniques, goal setting for parents and children, and/orevidence-based tools for facilitating discussions on obesity.In most cases, training took place in person in a groupformat, though Stahl et al. [40] described a successful web-based training program for clinicians. Two studies describedthe results of provider education interventions. Clinicianstrained on the use of a brief, structured intervention forschool-age children involving the use of flash-cards andtake-home games reported increased physician comfort andcompetence discussing obesity issues [52]. Pediatricians andregistered dieticians who received training on motivationalinterviewing techniques reported the need for more role-playing activities and experience asking open-ended ques-tions [53].

Web-based or in-person primary care clinician trainingsfor assessment of BMI, healthful eating, and active livinghabits among children and adolescents were found to beeffective in increasing provider confidence in weight assess-ment [31, 40], rates of BMI assessment, and use of behavioralscreening tools after at least a year [32, 38]. Trainings includedreference charts for BMI and laboratory values, guidelinesfor discussion about healthy behaviors, and decision supportcharts. At least one training included guidance on assessmentof parental readiness for change [31].

In 2004, the American Dietetic Association stated theneed for PCPs to take into account regional and culturaldifferences when promoting healthy diet patterns amongdiverse populations and ethnic groups [34]. We examinedfive studies that took actions to make interventions cultur-ally competent. Examples of ways that interventions tookthe cultural, linguistic, or literacy needs of their subjectsinto account included providing materials and activities inmultiple languages, offering recipes to groups that incor-porate cultural food preferences, or tailoring materials tofamilies who might have low literacy levels. Of the threestudies that explicitly described their efforts to adapt obesityinterventions to their population(s), three reported improvedweight status among participants [54–56].These studies useddiverse means to adapt to the needs of their populations,which included Latino families (bilingual and biculturalproject staff), ethnically diverse youth (traditional recipes),and families with low literacy levels (adapted educationalmaterials). Results from a focus group with Latino parentssuggest that, among this population, health messages canbe especially well received coming from a trusted healthcare provider [46]. However, a culturally competent healtheducator might help to extend the benefits of an obesitytreatment program beyond a brief encounter with a provider[57].

3.5. Clinical Infrastructure Development. Few recommenda-tions cited the need for PCPs to advocate for systemic changesin clinical practices to promote screening, diagnosis, andtreatment in the primary care setting. However, five of thearticles reviewed focused specifically on an intervention thatimplemented some formof capacity buildingwithin the clinicsetting, such as improvements to organizational systems orcare models used by providers. Each identified structural gapin primary care services and implemented systemic solutionsfocused on reorganizing clinical care delivery. One suchstudy evaluated the implementation of a patient-centeredmedical home system in a community health center andfound positive outcomes in lifestyle changes, reduced BMI,and increased physical activity in the patients one year afterimplementation [58]. Another study evaluated the adop-tion of principles of continuous quality improvement andadult learning theory in the office environment; physiciansfound these tools helpful, which resulted in increased BMIscreening documentation [59]. A third study assessed theeffectiveness of integrating practice-based pediatric obesityprevention and treatment clinics within existing primary caresettings; these clinics were shown to be helpful in improvingnutrition status among obese children [60].

Several studies reviewed involved systems changes tar-geted at multiple primary care clinics or health care organiza-tions. Pomietto et al. [38] described the Steps to Health KingCounty (STEPS) initiative, which promoted clinic staff train-ing and integrated clinic systems changes across three localhealth care organizations. This effort eventually grew to alarger program used throughout the state ofWashington.TheMaine Youth Overweight Collaborative sought to improveclinical decision support in 12 primary care sites; findingsshowed increased assessment of BMI and use of behavioralscreening tools, as well as increased parental satisfaction withservices [32].

3.6. Community Program Referrals. An activity frequentlycited in journal articles is the physician’s role in the identi-fication and recruitment of children and families into obesityprevention or treatment interventions. Of the 38 articlesreviewed that described community-based interventions,14 reported physicians referring their patients to researchstudies (8 articles) or other community-based programs (6articles). However, physician recommendations rarely calledout this role, with one exception. In 2010, the White Houserecommended that PCPs and insurance companies connectpregnant women and new mothers to breastfeeding supportprograms [7].

The obesity interventions described in these articles weremostly family-based counseling and treatment programs,lasting from eight weeks to six months, including groupeducation sessions for parents and children, home visits,follow-up telephone calls, automated messages, and/or otherfamily-oriented activities. Some were branded with programnames and set curricula, including Kids on the Geaux [61],Kids N Fitness [62], Healthy Kids Healthy Weight [63],ENERGIZE! [64], Smart Choices for Healthy Families [65],and Family Insulin Resistance Management—FIRM [66]. Of


the 14 articles reviewed, nine reported positive outcomes,includingweight loss or reductions in BMI scores [62–65, 67–71]. However, some study limitations included a small samplesize [70] and a low participant retention rate [62, 65]. Factorsthat reportedly contributed to the success of the programsincluded the dosage of the intervention, the use of healthyeating strategies and behavior modification techniques, andfamily participation in physical activities [62].

Three of the articles assessed the value of the PCPs’referral role in the interventions. Pinard et al. [65] reportedthat, in the Smart Choices for Healthy Families program,physician involvement was seen as a valuable partnership.While physicians recognized the importance of referringpatients to community-based programs that they did not havetime to offer, program lay leaders saw the benefit of physicianreferrals, including improved behavior change among theprovider’s patients. Quattrin et al. [69] reported that parentsperceived the obesity treatment program as an extensionof their pediatrician’s care because of the close partnershipbetween the pediatrician and program trainers, the pedi-atrician’s recommendation of the program, and followupwith patients who were in the program. However, a thirdarticle compared physician referrals less favorably with othercommunity program recruitment strategies. Because thenumber of physician referrals was not as high as expected, theprogram deployed additional recruitment methods, includ-ing the use of radio ads and posting of program flyers [72].

3.7. Community Health Education. Outside of their usualclinical role, PCPs have a unique opportunity to serve asrole models, educators, and promoters of healthy lifestylepractices to their patients and other community residents. In2005, theAmericanAcademy of Pediatrics encouraged physi-cians to make use of community-based resources outsideof their traditional hospital and outpatient office settings toinstruct residents on the effects of individual and communityfactors on child health status and to promote the well-being of all children in the community [35]. This mightseem a natural role for physicians, extending their healthpromotion efforts with their patients to the community.Unfortunately, althoughmanyhealth care providers are awareof the childhood obesity epidemic, are concerned about itshealth impacts, and want to work on its prevention, theycontinue to see themselves primarily as clinical practitionersand not as health educators or advocates in the broadercommunity [73].

PCPs can fill several roles in such community healtheducation efforts by serving on leadership teams; providingadvice on community messages; volunteering as institutionalpartners in the funding, planning, and evaluation of commu-nity awareness campaigns; and collaborating with commu-nity partners onmarketing healthy food choices and physicalactivity. Of the articles reviewed, four focused on the physi-cian’s role in community-level obesity prevention initiatives.Health care providers served on the leadership team of theSWITCH program, which included a community awarenesscampaign tomodify key health behaviors, increasing physicalactivity, improving nutrition, and reducing screen time [74].

PCPs also served on the community task force that ledthe Tioga County Fit for Life initiative, a comprehensiveprimary prevention program that used school-based healtheducation classes, a virtual wellness club, and communityhealth fairs to promote healthy nutrition and physical activity[75]. Two other studies reported that health care providerswere involved in community initiatives that implementedthe national We Can! program developed by the NationalHeart, Lung, and Blood Institute (although their roles werenot specified) [76, 77].

Although it is important to note the participation ofhealth care providers in these initiatives, outcomes were notreported in three of the four articles [74, 76, 77]. The fourthstudy, a five-year longitudinal analysis of grade-specific ratesof overweight and obesity of participating children, showedthat overweight and obesity rates increased in all cohorts.Factors cited for the program’s failure included inadequatereach of key health messages and lag time between themessages’ dissemination and uptake [75]. It is fair to assumethat the involvement of PCPs in these initiatives was notresponsible for their lack of reported success. In contrast,health care providers have played important roles in numer-ous more effective community interventions targeting bothobesity prevention and treatment (see the next section).

3.8. Multisector Community Initiatives. Over the past decade,PCPs have been encouraged to build partnerships acrossdisciplines to work collaboratively with public health depart-ments and other colleagues, to identify and decrease bar-riers to the health and well-being of the children in theircommunities, and to coordinate and focus new and existingservices for the benefit for all local children [34, 35]. In thearticles we reviewed, health care providers participated insix multisector obesity prevention and treatment initiativesthat achieved intermediate policy and systems goals [78–80];changes in children’s food and physical activity environments[80, 81]; and population-level health outcomes, includingreduced BMI scores [82, 83] and changes in overweight andobesity prevalence trends [78, 79, 83].

Two projects used a multisector intervention modelthat started as a community-based research study at TuftsUniversity. In Shape Up Somerville, 50 medical profession-als were trained on childhood obesity guidelines and cur-rent BMI screening practices as part of a community-wide effort in Somerville, Massachusetts, to increase dailyphysical activity and healthy eating through programming,physical infrastructure improvements, and policy work [82].North Carolina’s HealthDepartment patterned its ChildhoodObesity Prevention Demonstration Projects after Shape UpSomerville.The state offered grants, training, technical assis-tance, and state-level partnerships and other resources tosupport local obesity prevention and treatment efforts in fivecounties. This included training PCPs to assess and treatchildhood obesity in their communities [80].

PCPs were also involved in BMI assessment and treat-ment in community initiatives in Delaware and California.Delaware’s 5-2-1-Almost None initiative targeted multiplesectors, including schools, child care providers, and primary


care settings, to implement policy and practice changes, inaddition to implementing a media-based social marketingcampaign. PCPs promoted universal BMI assessment, pre-ventive health messages, and early intervention and treat-ment of childhood obesity [78].The California Endowment’sHealthy Eating Active Communities program worked in sixcommunities to prevent childhood obesity in five childhoodenvironments—schools, after-school programs, neighbor-hoods, health care, and advertising. As part of the initiative,PCPs were trained on the importance of tracking BMI scores,delivering obesity prevention messages, linking families tocommunity programs, and improving local nutrition andphysical activity environments [81].

Two other communities included community-basedBMI assessments in their multisector initiatives. In theHealthy Living Cambridge Kids program in Cambridge,Massachusetts, schools conducted BMI assessments and thenreferred students with high BMI scores to pediatricians forfollowup. The initiative included changes in city policies,implementation of a 5-2-1 community awareness messagingcampaign, physical education enhancements in schools, foodservice reforms, family outreach, and farm-to-school-to-homeprograms [83]. In theKaranja research study, AmericanIndian/Alaska Native tribes were randomly assigned to eithera community-wide intervention that used five strategies—raising community awareness; providing health education;supporting behavior change; enhancing public health prac-tice; andmodifying local breastfeeding environments or poli-cies to increase breastfeeding, limit consumption of sugar-sweetened drinks, and promotewater consumption—or to anintervention that combined these community-wide activitieswith family-level interventions, including BMI assessment,counseling, and treatment. Health care providers conductedthe BMI assessments in WIC clinics and maternal childhealth practices as part of routine visits [79].

Another promising initiative is the Healthy Weight Col-laborative (HWC), a national quality improvement effort toshare and spread promising and evidence-based practicesto prevent and treat obesity among children [84]. In thislearning collaborative, the National Initiative for Children’sHealthcare Quality is working with about 50 communityteams of primary care, public health, and community-basedorganizations to implement and test an integrated changepackage of strategies.These include (1) building a communitycoalition; (2) implementing a healthy weight messagingcampaign; (3) conducting weight status assessments andfollow-up plans; (4) integrating activities across communitysectors; and (5) advocating for food and physical activitypolicy change. The HWC evaluation will be completed in2013.

Seven other studies in the review featured school-primarycare partnerships or primary care interventions in school-based health centers. In four projects, nurses, nurse prac-titioners, and physicians in a school-based health centeror WIC clinic offered counseling and treatment servicesto students identified with high BMI scores. The results ofthese programs were either not evaluated [85], minimal [14,86], or mixed [87]. The other articles described school BMI

assessment projects and a student walking project, whoseoutcomes were not evaluated.

3.9. Policy Advocacy. Several recommendations encouragehealth care professionals to support and advocate publiclyfor a number of policy changes, including increasing fundingfor childhood obesity prevention research; prioritizing capitalimprovement projects and school and community sportsprograms to increase opportunities for physical activityamong students; and social marketing to promote healthfulfood choices, breastfeeding, and other healthy behaviors [2,8, 9]. Although multisector community initiatives have usedpolicy advocacy successfully to alter obesogenic communityenvironments [88], one article reported on an initiative toincrease public advocacy activity among PCPs [89]. Fundedby the Robert Wood Johnson Foundation, the project soughtto recruit, train, and reinforce 160 PCPs to become changeagents and leaders in community advocacy to prevent child-hood obesity. Physicians received a six-hour training usingan advocacy resources guide. Posttraining surveys showedthat the training had increased participants’ comfort andmotivation advocating publicly for healthy behaviors, includ-ing active living (26%), healthy eating (25%), breastfeeding(24%), and school and worksite policies (15%).

4. Conclusions

Identifying successful models that integrate primary care,public health, and community-based efforts is important toaccelerating progress in preventing childhood obesity. Thisreview aimed to identify the roles that PCPs play in childhoodobesity prevention and treatment initiatives in the UnitedStates and, in doing so, to determine effective or promisingstrategies for primary care and community settings. Thereview, based on 96 peer-reviewed articles published from2005 to 2012 that met study criteria, demonstrates thatPCPs are increasingly being included in childhood obe-sity interventions, consistent with current recommendationsfrom scientific and professional organizations. The reviewindicated an average of about 10 relevant articles publishedyearly during the period from 2005 to 2011 and nearly twicethat number in 2012, supporting the increased attention tohealth care providers in the prevention of childhood obesity.

The rise in obesity among children indicates the needfor new strategies that encompass more than individual-levelbehavior change or postassessment treatment. The prenataland early childhood periods are critical times for growth andhealthy lifestyle development. In the first two years of life, pri-mary care pediatricians, WIC clinics, and community healthcenters have several opportunities during well-child visits tocounsel parents about healthy lifestyles, to model healthfulbehaviors, and to refer families to community resources.Outside of their clinical role, primary care physicians can alsoserve as role models, educators, and promoters of healthylifestyle practices and serve as leaders in community obe-sity treatment and prevention initiatives. However, nationalsurvey data on health practitioners and research studiessuggest that PCPs continue to see themselves primarily as


clinic-based practitioners and not as health educators oradvocates in the broader community.

4.1. Study Limitations. Although this review identified nearly100 articles addressing the topic, the ability to draw con-clusions about the effectiveness of PCPs’ roles in childhoodobesity initiatives based on the review is limited by the lackof consistent reporting across studies about (1) specific PCProle(s) beyond referral and BMI assessment, (2) the level andduration of PCP involvement, and (3) child clinical outcomesor process outcomes. Interventions ranged from four to 12weeks in duration, depending on the study and interventionmethods. In addition, there was a general lack of long-termfollowup results; of the 20 interventions reviewed that had asignificant impact on weight status, nine included followupover more than six months [33, 43, 54, 67, 70, 71, 79, 82,83], and only three followed participants for more than oneyear [71, 79, 83]. In many cases, evaluations of the initiativewere either not conducted or results were not reported.Interventions that did include an evaluation component useda range of outcome measures, including improved weightstatus, increased provider or parent knowledge, or increasedrates of provider assessment of weight status or use ofcounseling tools, which made it difficult to compare theefficacy of results across articles reviewed. While change inweight or weight status was a frequently used outcome, themethods of weight assessment varied between interventions.Moreover, very few of the interventions reviewed utilized arandomized control study design, further limiting the abilityto drawmeaningful conclusions about the effectiveness of theinterventions reviewed. For these reasons, the results of thisreview are primarily descriptive.

While it is difficult to draw conclusions about the efficacyof the interventions considered due to the limitations men-tioned previously, multisector community childhood obesityinitiatives with primary care involvement were more likely toreport positive outcomes than obesity initiatives in a singlesetting (school or clinic based). Multisector obesity pre-vention and treatment initiatives that achieved intermediatepolicy and systems goals included partnerships across disci-plines, including PCPs, addressed children at all points alongthe prevention continuum, and used an ecological approachtargeting individual, organization, system, and policy change.Positive outcomes included improvements in children’s foodand physical activity environments, reduced BMI scores, andchanges in overweight and obesity prevalence. Successfulmodels that integrated primary care, public health, andcommunity-based efforts also shared several similarities:

(i) multisector messaging within a community;(ii) weight assessment training for clinicians;(iii) modeling of healthy behaviors for children (to rein-

force their understanding of the concept);(iv) promotion of culturally competent approaches;(v) parental involvement.

Because interventions of this type inherently involvemultiple components, it is difficult to disentangle the roles

to ascertain which individual components were especiallysuccessful or effective. Additionally, very few studies docu-mented long-term effectiveness of interventions of this type,demonstrating a need for studies that measure the impactof multisector obesity initiatives over multiple years. Despitethese limitations, this review provides a useful resource forPCPs, community organizers, researchers, and policymakersplanning childhood obesity initiatives in their communitiesor primary care settings.

4.2. Next Steps. Future research on community-based child-hood obesity interventions should collect and report infor-mation on the specific roles that PCPs played in the initiative,including the level of training and counseling skills, presenceof role modeling, referrals to community resources, numberand type of community partnerships, and public advocacyactivity. Reporting on the process or implementation of theinitiative as well as child-level and population-level outcomeswill contribute to the evidence base for effective strategies byPCPs in the prevention and treatment of childhood obesity.

References

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[5] Committee on Accelerating Progress in Obesity Prevention andInstitute of Medicine, Accelerating Progress in Obesity Preven-tion: Solving theWeight of theNation, National Academies Press,2012.

[6] S. E. Barlow, W. H. Dietz, W. J. Klish, and F. L. Trowbridge,“Medical evaluation of overweight children and adolescents:reports from pediatricians, pediatric nurse practitioners, andregistered dietitians,” Pediatrics, vol. 110, no. 1, pp. 222–228,2002.

[7] M. Barnes, “Solving the problem of childhood obesity withina generation,” Whitehouse Task Force on Childhood ObesityReport to the President, 2010.

[8] T. M. McCambridge, D. T. Bernhardt, J. S. Brenner et al.,“Active healthy living: prevention of childhood obesity throughincreased physical activity,” Pediatrics, vol. 117, no. 5, pp. 1834–1842, 2006.

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"This course was developed from the open access article:

Michaela Vine, Margaret B. Hargreaves, Ronette R. Briefel, and Cara Orfield, “Expanding the Role of Primary

Care in the Prevention and Treatment of Childhood Obesity: A Review of Clinic- and Community-Based

Recommendations and Interventions,” Journal of Obesity, vol. 2013, Article ID 172035, 17 pages, 2013.

(doi:10.1155/2013/172035), used under the Creative Commons Attribution License."

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A Nurse’s Role in Childhood Obesity...this paper as physicians, physician’s assistants, nurse practi-tioners, registered nurses working in a primary care setting (e.g., community