When a study doesn’t produce an expected result, it’s often considered a failure. But in a PCORI-supported trial involving childhood obesity, researchers don’t see it that way at all.

In the study, children whose weight was higher than the healthy range were randomly assigned to one of two groups. In both groups, the children’s clinicians received tools to help them identify and counsel children with an unhealthy weight. Parents also got materials about family behavior changes. In one group, parents also received tailored health coaching and regular text messages.

The research team expected that the group receiving intensive coaching and text messaging would better improve their weight status. However, the researchers reported in JAMA Pediatrics, children in both groups achieved healthier weights after a year.

Parents in families who received coaching reported high satisfaction with their child’s health care. Researchers believe that other families’ help designing the program contributed to participants’ satisfaction.

“We convened parents to have them help shape the study,” says Earlene C. Avalon, PhD, MPH, who chaired the study’s family advisory board and leads health management and health science programs at Northeastern University, in Boston. “Their insight and personal experiences were extremely valuable in how we implemented the study.”

"Positive-Outlier" Approach Yields Insights

The study took place at six Massachusetts pediatric primary care offices in obesity hot spots: geographic areas in which more than 15 percent of children have obesity. That’s where researchers identified 12 “positive-outlier” families, who had helped their children successfully address their weight.

Through a series of meetings, those families shared what worked for them. Their suggestions became key parts of the study, such as using text messages and video conferencing to allow families greater communication with healthcare providers. (See original story, Learning from the Success Stories.)

Then, the research team recruited 721 children aged 2 to 13 with body mass indexes (BMI) at or above the 85th percentile. All children and their families received enhanced primary care. The children’s clinicians used decision support tools in electronic health records that helped them assess and manage childhood obesity. In addition, families received monthly text messages with web links supporting healthy behaviors (such as to Michelle Obama’s Let’s Move! program). Families also got a neighborhood guide that listed places that support healthy living, such as food pantries, farmers’ markets, youth-based organizations, and social service offices.

Half of the families were randomly assigned to receive a coaching intervention. The researchers built the intervention on practices of the positive-outlier families, as well as strategies recommended by parents, children, pediatricians, community members, and others.

The intervention involved contact with specially trained coaches every other month, either by phone, video conference, or face-to-face meetings—families chose the method they preferred—and twice-weekly text messages or emails with educational materials to support the families’ goals. Families also received an online map of resources tailored to their location and specific goals, a one-month free YMCA membership, and a healthy grocery shopping program called Cooking Matters. A decision tool helped families identify specific outcomes that mattered most to them and motivators to achieve those goals.

After one year, children in both groups showed improvements in BMI. About 9.3 percent of the enhanced primary care group and 11.6 percent of those who also received coaching dropped their BMI out of the overweight and obese zones. This difference in BMI improvement between the two groups wasn’t statistically significant.

But a significant difference did emerge: 63 percent of the families in the coaching group reported that their satisfaction with their child’s health care increased, compared with 48 percent of those who didn’t get the coaching.

Enhanced Care as a Winning Strategy

Daniel H. Slater, MD, chair of pediatrics at Atrius Health and a study co-investigator, thinks part of the reason for both groups’ decreases in BMI was that the study’s six practices already used optimal methods for helping families address children’s health. Atrius Health runs the six practices.

“Usual care at Atrius Health has been improved upon through more than a decade of research and quality improvement work,” Slater says.

Nonetheless, the study changed the way Atrius Health delivers pediatric care, he says.

“Our positive outliers taught us that we needed to attend to the social and emotional well-being of our patients, that we needed to emphasize shared decision making with families, and that by activating meaningful resources in the community, we can enhance our families’ sense of empowerment,” Slater says.

Study project manager Christine Horan, MPH, of Massachusetts General Hospital for Children, adds that engaging families helped the research team “find out what they think is important. That way, we were addressing how to make behavioral changes in a way that was best received.”

Horan wonders whether the children’s BMIs would have improved even more had the study gone on longer or provided more-frequent contact with coaches.

In any case, Slater says, “It is time to disseminate these effective tools—the decision support tools for clinicians and the neighborhood resource guide and text messages for parents. These tools improve care for patients in the clinic and connections with the community as the country struggles with positive interventions for the obesity epidemic. We hope to see other practices engage their patients similarly to address this and other medical challenges.”

Posted: September 28, 2017