Description of the Problem the Project Seeks to Solve
More than 25 percent of preschool children have overweight or obesity, and these rates are higher among children in low-income and minority communities. Even though many families may perceive babies with higher weight as a sign of good health, increased weight gain during infancy has been associated with later risk of developing obesity and having other health problems. One factor that might contribute to pediatric obesity is health literacy. Over 25 percent of parents have low health literacy and math skills. Low parent health literacy is associated with worse knowledge of breastfeeding; problems mixing formula correctly; difficulty understanding food labels, portion sizes, and growth charts; and higher body mass index (BMI) in children.
There are significant gaps in knowledge about how to prevent obesity in early childhood—and in particular the role of primary care providers. Few clinical trials have addressed obesity prevention in the first years of life or have examined the effect of interventions that integrate a literacy-sensitive approach or the use of health technology to improve care. Pediatric primary care clinics, where children see their healthcare providers frequently for preventive visits in the first two years of life, have an important opportunity to provide information about childhood obesity prevention that is family centered and adapted to the literacy needs of families. Additionally, engaging pediatric residents in primary clinics also represents an important opportunity to improve health disparities since these clinics care for one-fifth of the socioeconomically disadvantaged families in the country, and represent an opportunity to train pediatric residents in improved approaches to healthcare delivery that they can adopt as future pediatricians. The use of health technology such as web-based or mobile tools and text messaging can help to support families when they are outside the clinic setting.
Over the past 10 years, the project team developed and implemented the Greenlight intervention, which applies evidence-based health literacy and health communication approaches to help clinicians work with families to prevent childhood obesity in children 2-24 months of age. The Greenlight intervention was developed with iterative input from families, clinicians, experts in health communication, pediatric residents, the Academic Pediatric Association, and the American Academy of Pediatrics. The study recruited and followed 865 English- and Spanish-speaking families and over 400 pediatric resident physicians in a randomized trial. The results found that children at Greenlight intervention sites had significant improvement in weight status (BMI z-score) through the first 18 months of life compared to children at comparison sites, but not at 24 months. The proposed PCORI study will evaluate the scalability/effectiveness of a more robust Greenlight program that begins in the newborn period (rather than at 2 months) and leverages technology to provide more continuous support outside the clinical setting, including asynchronous support as health visits decline in the second year of life.
Outcomes the Project Team Hopes to Achieve
The researchers will perform a randomized trial including 900 families to compare two different approaches to early childhood obesity prevention in children 0-2 years of age. The families will be recruited during the newborn stage and cared for at six pediatric clinics that participate in both CORNET, a national practice-based research network of pediatric residency primary care practices supported by the Academic Pediatric Association, and PCORnet, the national research network supported by PCORI. In the newborn period, English- and Spanish-speaking families with new babies will be consented and randomized to one of two arms. In Arm 1, during each of the nine recommended well visits from 0-18 months, pediatric residents, trained in clear health communication skills and shared goal setting, will use the Greenlight Toolkit of low-literacy, age-specific, parent-education booklets to promote healthy family behaviors and obesity prevention. In Arm 2, known as Greenlight Plus, families will receive the Greenlight intervention plus a health technology program aimed at supporting family goal setting and behavior change. The technology program includes a customized web/mobile platform for education and behavior change supplemented by a text-messaging system designed and validated for lower socioeconomic status populations. This study design will allow us to determine whether added technology can provide support outside the clinic to promote behavior change and obesity prevention.
The study will compare the effectiveness of the two arms on children’s weight status and family-reported diet and physical activity behaviors and satisfaction with pediatric care through age 2. The project team anticipates that these outcomes will be better in the Greenlight Plus group compared with the standard Greenlight group. The researchers will also examine the impact of the intervention on key groups by race, ethnicity, language proficiency, and health literacy, and anticipate that the team’s literacy-sensitive and culturally sensitive approach to obesity prevention will result in equal improvements among subgroups.
Brief Background on Why this Project Is Important to Patients
Parents and other caregivers are concerned about childhood obesity, the potential long-term health consequences of obesity, and how it can be best prevented and treated. Parents want to learn and adopt practices that help their children to develop healthy lifestyles and grow in a healthy way, without becoming overweight. Parents want approaches that are easy to apply, and that provide them increased knowledge, and increased interaction and satisfaction with their healthcare providers and the healthcare system.
Explanation of How patients and Other Stakeholders Will Help to Make the Project Successful
The study will engage families, clinicians, and health system leaders as co-investigators and advisors, the PCORnet Obesity/Diabetes Collaborative Research Group, and professional organizations in ongoing partnerships for study design, implementation, analysis, and dissemination. If proven successful, the project team plans to develop a scalable approach to the Greenlight Plus program and will work with families, health systems, the APA, American Academy of Pediatrics, and other stakeholders to implement the program in pediatric clinics across the nation to help improve the health of young children.