If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Childhood overweight and obesity rates in the United States continue to climb. Providers must identify feasible interventions to improve health habits to prevent and treat obesity in children.
Methods
Parents (n = 91) of four-to eight-year-old children were recruited and surveyed regarding their child’s current health habits and perception of their child’s weight status. A conversation starter tool was developed and utilized to improve health habits in children ages four-to-eight over a period of four-to-six weeks.
Findings
Health habits in children improved in the comparison and intervention groups. There was a 42% improvement in health habits in the intervention group who chose a specific goal to work on compared to 30% improvement in the comparison group. There was no statistically significant relationship between health habit adherence and the assigned group when assessing the health habits individually.
Discussion
Overall, 42% of the selected goals were met, according to parent report at the follow-up survey; however, use of the conversation starter tool did not demonstrate statistically significant improvement in health habits. Parental perception of children’s weight status remained unchanged. Health habits in children improved in the comparison and intervention groups. Further studies should enroll a larger sample to assess differences between these two groups.
Application to practice
The conversation starter tool was designed to be implemented into practice without the need for any specific training. The tool can be used on all children to promote improved health habits.
). Overweight in children is defined as a body mass index (BMI) at or above the 85th percentile, while BMI at or above the 95th percentile is considered obese (
). Children with obesity are more likely to suffer from hypertension, hyperlipidemia, insulin resistance, type 2 diabetes, asthma, sleep apnea, joint pain, fatty liver disease, cholelithiasis, gastro-esophageal reflux, orthopedic problems, and psychiatric disorders (
Childhood obesity is estimated to cost between $16,310 and $19,350 per person in annual medical costs throughout the lifespan, relative to a normal weight child (
). Without an interruption in the increasing obesity rates, the overall health of the US can be expected to decline while healthcare costs skyrocket. This represents a significant burden for the US health care system. Drastic measures are needed to halt this progression. Changes must be made at the individual, community, and societal levels. Implementing individual and familial measures during early childhood development is essential, as treatment of obesity tends to become more difficult as the patient matures (
). Unfortunately, many parents underestimate their child’s weight status, which may affect a parent’s attitude regarding changes that can be made in the home (
). Prevention and treatment of childhood overweight and obesity typically requires fewer interventions to make a positive change than obesity in adulthood, so efforts focused on this population are essential (
The use of measures of obesity in childhood for predicting obesity and the development of obesity-related diseases in adulthood: A systematic review and meta-analysis.
). Because of the rapidly increasing rates of obesity in the US, it is imperative to find solutions for prevention and treatment focusing on improving health habits in young children.
The AAP published clinical updates describing the role of providers in the prevention and treatment of childhood obesity (
). The report cited the importance of primary care providers becoming familiar with behavior modification techniques and general promotion of parenting interventions (
). It also identified important health habit recommendations to discuss with families, including reducing sugar-sweetened beverages, promoting a healthy diet and physical activity, and reducing sedentary activities (
). In a textbook published by AAP, author Sandra Hassink advised that lifestyle guidance be coupled with strategies to assist parents in implementing these habits in the home to improve weight status (
). A Cochrane review of 153 randomized controlled trials evaluating childhood obesity prevention strategies found that diet and activity interventions can moderately improve BMI and reduce the risk of obesity in young children (
A review of relevant literature reveals a significant public health issue, recommendations for treatment, and gaps in identifying effective, generalizable implementation strategies at the primary care level. Pediatric providers have identified a desire for childhood obesity management counseling tools that can be used in practice (
). For this study, a conversation starter tool was designed to assist providers in identifying health habits needed for improvement, educating parents on rationales for improvement, and assisting parents in setting a specific goal to improve a health habit needed for improvement. The purpose of this study was to determine whether the introduction of the conversation starter tool improved selected health habits in four-to eight-year-old children over four-to-six weeks compared to standard care. A secondary aim of this study was to determine whether the accuracy of parental perception of children’s weight status improved when providers were made aware of the parent’s perception before the visit.
Conceptual framework
This study utilized social cognitive theory (SCT) as the conceptual framework (
). SCT is a tool to assist researchers in developing interventions that increase self-efficacy and motivation to promote health. SCT aims to provide individuals with the tools and confidence to self-manage chronic diseases and change health behaviors. Knowledge, perceived self-efficacy, outcome expectations, goals, and perceived facilitators and impediments are vital concepts that affect behaviors (
notes that without knowing that certain health habits negatively affect one’s health, there is little reason to change harmful practices. Motivation is enhanced when people understand personal benefits achieved through change. Short-term goals guide people to action. Perceived facilitators and impediments affect self-efficacy, and self-efficacy shapes outcomes. This study addressed motivation, self-efficacy, and outcome expectations to promote adherence to health habits by developing and using a conversation starter tool to be used in the primary care of children.
In this study, self-efficacy was defined as the parent’s personal belief that effective change in health habit adherence can be made. This study aimed to enhance self-efficacy by helping parents choose small, attainable goals. Shared goal-setting was used to help parents identify specific ways they can influence their child’s health habits. One study using SCT noted improved self-efficacy and performance when Specific, Measurable, Achievable, Realistic, and Timely (SMART) goal-setting techniques were used (
). The “Healthy Habits for Kids” handout used in this study’s intervention aimed to enhance self-efficacy by providing parents with SMART-focused interventions following the SMART goal-setting technique (
). Outcome expectancy is the belief that changes in health habits will be effective in improving health status. This was addressed in this study by providing education regarding health habits and their relationship to various health outcomes. Providers addressed motivation by evaluating the parental perception of children’s weight status compared to actual weight status per growth chart BMI percentile. Parents who underestimate their children’s weight status may feel motivated to change health habits if they properly perceive their child’s weight status.
Methods
Design and setting
A pre-test, post-test quasi-experimental study was conducted between May and August 2021 to evaluate the effectiveness of a provider-initiated conversation starter tool in improving health habit adherence in four-to eight-year-old children. The tool included a questionnaire and an educational handout. Parents of four-to eight-year-old children who presented to the clinic for a well-child check were recruited for participation in the study. Funding was received through the Purdue Helene Johnson Fund to provide a water bottle to children as a token of gratitude for the parent’s participation. This study was approved by Beacon Health System and Purdue University Institutional Review Boards. A convenience sample of 91 parents who presented for well-child checks in a suburban northern Indiana pediatric primary care clinic that employs seven pediatricians was used.
Conversation starter tool
The conversation starter tool was two-part: a questionnaire and a “Healthy Habits for Kids” handout. It aimed to help providers assess current health behaviors, target behaviors needed for improvement through an educational handout, and assist parents in making a goal for an improved health habit. The tool was designed for clinicians who have not undergone formal motivational interviewing training in order to increase feasibility to implement into practice. It was also designed to be a low cost intervention, as the only costs incurred are printed materials. A secondary aim was to help providers identify the parent’s perception of their child’s weight status.
Questionnaire
A questionnaire was developed and utilized to gather demographic information, parental perception of children’s weight status, and current health habit adherence (Figure 1). The questionnaire was available in Spanish and English. The demographic data included gender, ethnicity, family size and income, and the highest level of education completed by the parent completing the questionnaire. Parents were asked to identify whether they considered their child underweight, healthy weight, or overweight. For this study, BMI over the 85th percentile was labeled “overweight” to limit stigmatizing terms. Parents were also asked five yes or no questions regarding their child’s specific health habits that have been identified as essential health behaviors providers should address for a healthy weight (Figure 1) (
All questionnaires were kept at the clinic in a locked folder stored within a locked filing cabinet. After the follow-up phone call, the surveys were de-identified. Names, telephone numbers, and birth dates were removed and destroyed.
Health habits for kids handout
A “Healthy Habits for Kids” handout was developed to address the same essential health habits assessed in the questionnaire (Figure 2). The handout intended to improve self-efficacy and motivation and included the five important health behaviors assessed on the questionnaire. The handout was available in English and Spanish. A readability calculator assessed the handout to be written at or below a seventh grade reading level.
The Expert Committee for recommendations on evaluation and treatment of child and youth obesity advises that providers assess and address health habits within the context of parent values and current health habits (
). Not all parents are concerned about weight status. Some parents, for example, may be more concerned about school performance or mental health. By educating parents on the role of limiting screen time in improving school performance and reducing the risk of depression, these parents may be more likely to implement health habit changes in the home. In their study on underestimation of children’s weight status and preferred body size among Mexican-American families, Pasch et al. concluded that working to correct children’s weight status may damage rapport with the provider (
). The “Healthy Habits for Kids” handout was created to address many health benefits that parents can expect from improved health habits. These include improved school performance, health, behavior, memory, mental health, focus, self-esteem, and flexibility, as well as a decreased risk of heart disease, obesity, diabetes, stress, behavior issues, anger, and school problems (
). The handout also provided specific examples to help parents implement changes, such as physical activity ideas, proper portion sizes, and examples of fruits and vegetables (
). The “Healthy Habits for Kids” handout contained a goal-setting box. Goals were selected from among health habits the child was not adhering to. Pediatricians worked with parents to identify a specific health habit goal to work on. Once a goal was set, the handout was marked and given to the parent. The pediatrician also marked the questionnaire with the same goal.
Intervention, measures, and procedures
Pediatricians were given a brief training on the rationale for this study and how to use the conversation starter tool. The questionnaire was reviewed to aid providers in quickly identifying health behaviors needed for improvement. The answers on the questionnaire were utilized to help providers in the intervention phase know where to focus their education using the “Healthy Habits for Kids” handout. The pediatricians were also encouraged to review the parental perception of children’s weight status to frame their conversations within the context of the parent’s current perception. For example, if a parent feels that their overweight child is underweight, they may not be motivated to change health habits. After assessing the parents’ perceptions of their child’s weight status, pediatricians used the body mass index (BMI) growth chart in the patient chart to identify actual weight status.
Recruitment took place May through August 2021, followed by analysis. Participants included in the study were parents of four-to eight-year-old children who presented to the clinic for a well-child exam. The medical assistants (MAs), registered nurses (RNs), or licensed practical nurses (LPNs) rooming the patients completed standard rooming procedures, including documentation of height, weight, and BMI into the patient chart for the pediatrician to review. These metrics automatically populated the electronic medical record CDC growth charts. The MA/RN/LPN alerted the investigator of a patient meeting criteria. The investigator entered the eligible patient exam rooms after the MA/RN/LPN. The investigator obtained parental consent and distributed the questionnaire. An email address for the investigator was provided to participants. All patients were assigned to the comparison group at the initiation of the study. Once 45 participants were recruited to the comparison group, all new participants were assigned to the intervention arm.
The comparison arm received the questionnaire and standard care. Pediatricians in the comparison group were blinded from parent answers on the questionnaire. Standard care included distributing a “95210” handout, which encouraged nine hours of sleep per night, five servings of fruits and vegetables, two hours or less of screen time, one hour or more of physical activity, and zero sugar-sweetened beverages. Copies of these handouts were displayed throughout the office.
The intervention arm received the questionnaire and “Healthy Habits for Kids” handout in addition to the standard “95210” office handout. Once the parent had completed the questionnaire, the demographic information was removed, and pediatricians were given the answers to the six questions on weight perception and health habits. The pediatrician entered the exam room with the “Healthy Habits for Kids” handout and parent-completed questionnaire. The pediatrician reviewed the questionnaire items assessing the parental perception of children’s weight status and health habit adherence. The pediatrician identified where health habit adherence may be lacking and targeted a brief overview of health habits via the “Healthy Habits for Kids” handout. The handout gave key phrases and motivators for pediatricians to use with parents. Upon reviewing the health habits, the pediatrician asked the parent which goal they would like to work on. The goal was marked on the parent’s handout to take home as well as the questionnaire that was returned to the investigator. If the parent identified on the questionnaire that they were already adhering to all of the goals, the pediatrician was encouraged to reinforce these health habits and mark “no goal” on the questionnaire.
The investigator gave the second questionnaire via telephone four-to-six weeks later to re-assess adherence with the same key health habits and perception of children’s weight status from the first questionnaire. Both the comparison and intervention groups received the follow-up questionnaire, which was used to demonstrate whether the conversation starter tool improved adherence to an agreed-upon health habit goal. Success was measured by parent report of adherence to the agreed-upon health habit goal.
Change in weight status was not evaluated in this study as follow-up occurred four-to-six weeks after the intervention, and children of all weight statuses were included. Change in health habits is a desirable outcome for all children, as these health habits improve health throughout the lifespan, regardless of the effect on BMI (
Of the 91 participants enrolled in the study, 80 (88%) completed the follow-up. One questionnaire in the intervention group was inaccurately completed by the pediatrician and was removed from the analysis for 79 completed questionnaires (87%). There were 45 participants enrolled in the comparison group, with 39 participants completing the follow-up survey for an attrition rate of 13%. There were 46 participants enrolled in the intervention group with 40 accurately completed surveys for an attrition rate of 13%. The attrition rate is comparable to a similar health habit survey study (
Health habits needed for improvement were totaled for all participants. In all, there were 96 unhealthy habits needed for improvement among the 79 participants. There were 46 unhealthy habits in the comparison group and 50 unhealthy habits in the intervention group. Nine participants in the intervention group identified that they were already adhering to all of the health habits, so no goal was selected, meaning that 31 participants had 50 unhealthy habits needed for improvement. The intervention group was further separated into two categories: intervention and goal. The goal category included the 31 health habits selected as a goal among the 31 remaining participants in the intervention group who were not adhering to all of the health habits. The intervention group category consisted of all health habits needed for improvement but were not selected by the parent as the primary goal for improvement (n=19).
Crosstabulation was completed on all health habits and is shown in Table 2. The comparison group demonstrated a 30.4% improvement in overall health habits. The intervention group showed a 15.8% improvement in health habits. The goal group demonstrated a 41.9% improvement in health habits.
Table 2Comparing improvement among all health habits with group assignment.
Group
Outcome
1→1
1→0
Total
Comparison
32 (70%)
14 (30%)
46
Intervention
16 (84%)
3 (16%)
19
Goal
18 (58%)
13 (42%)
31
Total
66
30
96
1→1 indicates nonadherence to health habit at baseline and follow-up.
1→0 indicates nonadherence to health habit at baseline and adherence at follow-up.
Each health habit was then analyzed separately to demonstrate change in that particular habit (Table 3). All 79 parents reported that their child gets at least one hour of physical activity per day. Additionally, most parents reported that their child gets at least nine hours of sleep per night, and no parent chose this goal to work on. Because there was little to no room for improvement, physical activity and sleep were not analyzed further. Due to the small sample size, a Fisher’s exact test was used to determine the association between group (comparison versus goal group) and adherence (non-adhering at baseline to non-adhering at follow-up and non-adhering at baseline to adhering at follow-up) for screen time, sugar-sweetened beverages, and fruit and vegetable intake. Participants who were adhering to the health habit before and after intervention and participants who were adhering before and were not adhering after the intervention were removed, as these groups did not address the primary research question on improving health habits. The results are demonstrated in Table 4. Study personnel could not reject the null hypothesis that there is no association between the assigned group (comparison or intervention chosen goal) and adherence of habit at the .05 significance level. The Fisher’s exact values for sugar-sweetened beverages, fruits and vegetables, and screen time were p = .607, p = .102, and p = .459, respectively.
Table 3Comparing health habit adherence outcomes to participant group.
Sugar Sweetened Beverages
Group
Outcome
0→0
1→1
1→0
0→1
Total
Comparison
21 (54%)
10 (26%)
7 (18%)
1 (3%)
39
Intervention
18 (56%)
4 (13%)
1 (3%)
9 (28%)
32
Goal
0 (0%)
5 (63%)
3 (38%)
0 (0%)
8
Total
39
19
11
10
79
Fruit and Vegetable Intake
Group
Outcome
0→0
1→1
1→0
0→1
Total
Comparison
28 (72%)
9 (23%)
2 (5%)
0 (0%)
39
Intervention
21 (68%)
6 (19%)
1 (3%)
3 (10%)
31
Goal
0 (0%)
4 (44%)
5 (56%)
0 (0%)
9
Total
49
19
8
3
79
Screen Time
Group
Outcome
0→0
1→1
1→0
0→1
Total
Comparison
21 (54%)
13 (33%)
5 (13%)
0 (0%)
39
Intervention
17 (65%)
6 (23%)
1 (4%)
2 (8%)
26
Goal
0 (0%)
9 (64%)
5 (36%)
0 (0%)
14
Total
38
28
11
2
79
Physical Activity
Group
Outcome
0→0
Total
Comparison
39 (100%)
39
Intervention
40 (100%)
32
Goal
0 (0%)
8
Total
79
79
Sleep
Group
Outcome
0→0
1→1
1→0
0→1
Total
Comparison
37 (95%)
2 (5%)
0 (0%)
0 (0%)
39
Intervention
37 (93%)
0 (0%)
0 (0%)
3 (8%)
40
Goal
0 (0%)
0 (0%)
0 (0%)
0 (0%)
0
Total
74
2
0
3
79
0→0 indicates adherence to health habit at baseline and follow-up.
1→1 indicates nonadherence to health habit at baseline and follow-up.
1→0 indicates nonadherence to health habit at baseline and adherence at follow-up.
0→1 indicates adherence to health habit at baseline and nonadherence at follow-up.
Perception of children’s weight status was assessed pre-and-post survey to determine if the intervention affected parental perception of children’s weight status. No parent in either group changed their perception of their child’s weight status at the follow-up survey. For this reason, the results were analyzed together (Table 5). There were four underweight children identified in this study. Three parents (75%) accurately identified their child as “underweight,” while one parent (25%) overestimated their child as “healthy weight.” There were 48 children identified as “healthy weight,” and 46 parents (95.8%) correctly identified their child as “healthy weight,” whereas two parents (4.2%) underestimated their child’s weight as “underweight.” There were 27 children identified as “overweight,” and only five parents (18.5%) correctly identified their child as “overweight,” while 22 parents (81.5%) underestimated their child’s weight status as “healthy weight.”
Table 5Parental perception of children's weight compared to actual weight.
The Expert Committee on the treatment of childhood and adolescent obesity advises providers to complete behavior assessments and work with parents on identifying reasonable goals that families can work on (
). This study evaluated the use of a newly created conversation starter tool to improve health habits in young children. A handout on health habits identifying benefits to children’s health was created following recommendations from the Expert Committee (
). The pediatricians worked with parents to select a goal to work on. Overall, 42% of the selected goals were met, according to the parent report at the follow-up survey; however, use of the conversation starter tool did not demonstrate statistically significant improvement in health habits.
Some parents in the intervention group commented that they had made improvements and were continuing to work on their selected goal but responded that they had not reached the goal completely. While specifically comparing the comparison group to the intervention chosen goal group, study personnel could not demonstrate a statistically significant association between the outcomes and the group. This may be a result of the small sample size. Future studies may alter recruitment design to ensure that there are enough participants for each chosen goal.
Pediatricians seeing children in the intervention group were made aware of the parent’s perception of their child’s weight status before entering the room, but this did not affect the parent’s perception at follow-up. Some parents mentioned that the pediatrician said their child was overweight, but they still identified their child as “healthy weight.” In all, we found that 81.5% of parents of overweight children underestimated their child’s weight status as “healthy weight,” and this did not change at follow-up despite the pediatrician knowing the parent’s perception prior to starting their education.
In this study, 100% of parents answered that their child gets at least one hour of physical activity per day, which is much more than the reported objective measurement in previous studies (
). This suggests the need to define physical activity to parents. Other studies have assessed the accuracy of parental perception of physical activity and concluded that inaccuracy might be based on misclassifying busyness as physical activity, being unaware of activity level when the child is not with the parent, and social comparisons (
). Distinguishing between moderately vigorous physical activity and routine activity is an important concept for future study and for providers to be aware of.
Practice implications
The conversation starter tool was designed to be implemented into practice without the need for any specific training. The tool can be used on all four-to eight-year-old children to promote improved health habits. While this study addressed weight status, it also moved beyond that to identify health benefits apart from weight to motivate parents who may not perceive their child’s weight status as a motivator for improved habits. The findings support
, who identified that many parents misperceive and prefer a heavier body size, and working too hard to correct the misperception may affect overall rapport with the parent. The authors recommended that pediatric health care providers focus on overall health habit improvements.
Limitations
As with all studies, several limitations were identified. First, providers have different styles and communication methods, which can alter the outcomes of educational tools. For example, the standard of care was used in the comparison group, but not all standard of care is equal. Similarly, pediatricians may have spent varying amounts of time on the intervention, changing the overall effectiveness. Another limitation is that this study used a convenience sample of pediatricians at a local pediatric clinic. There were no nurse practitioners or family physicians included in this study.
There were also some limitations with the survey method. The comparison group did fill out a questionnaire on health habits. This is not typical standard care. At least one parent remarked that completing the survey helped her realize that they needed to make a change in the home, so they did improve their health habits. This could have affected the overall results and inflated the improvement demonstrated in the comparison group to make the difference between the comparison and the intervention groups smaller. Additionally, parent report of child behaviors on a survey may vary from direct measurement.
Parents in the comparison group were told that their answers on the questionnaire would remain anonymous. In contrast, parents in the intervention group were told that the pediatrician would see the results. This could have created social desirability bias in the intervention group which may have lowered the effect of the intervention, as demonstrated in the analysis. Finally, while there were 79 participants included in the study, the analysis would have been more robust if there had been a larger number of participants in the intervention group. Separating each health habit resulted in very small samples for analysis. This can be remedied with future studies.
Conclusion
The American Academy of Pediatrics has advocated for interventions to prevent obesity in children by improving health habits through primary care interventions (
). This study introduced a simple intervention to improve health habits in young children that is very feasible for use in the primary care setting. The conversation starter tool is an example of a primary care intervention that guides pediatric health care providers through various motivating factors for improved health habits to improve parent motivation for change. Furthermore, it can help parents make a specific health improvement goal for their child. Future research is needed to develop longitudinal studies of health habits and correlate with weight status in children.
Funding
Helene Johnson Fund Purdue University.
Declaration of Competing Interest
We have no conflicts of interest to disclose.
This study was approved by Beacon Health System and Purdue University Institutional Review Boards.
Acknowledgements
The late Dr. Diane Berry, Yujie Chen, Dr. Zachary Hass, Jena Bontrager.
References
American Academy of Pediatrics
Kids need fiber: Here's why and how. healthychildren.org.
The use of measures of obesity in childhood for predicting obesity and the development of obesity-related diseases in adulthood: A systematic review and meta-analysis.
00245-7&id=gr1.jpg){kind=link}
00245-7&id=gr2a.jpg){kind=link}
00245-7&id=gr2b.jpg){kind=link}