Summary and recommendations for practice
- The current evidence base for childhood obesity prevention in primary care is poor, and no clear effective approach can be advocated from the literature.
- Evidence from the wider literature suggests that multi-component interventions (e.g., including combinations of diet and physical activity advice, behavior change approaches) are the most effective approach in the clinical setting, although there is limited evidence on which intervention components are essential.
- Most national guidelines recommend the use of “BMI percentiles for age” for assessment and monitoring of overweight in children.
- There is little research on the differential impacts of different primary care practitioners in obesity prevention.
- Parental involvement is recommended by many national guidelines, although there is little conclusive evidence for the role of parents in primary care.
- There are a number of barriers for primary care providers implementing obesity prevention and management interventions. Future research should not only tackle the evidence for effective primary care interventions, but also the challenges of translating evidence-based guidelines into primary care practice.
The majority of research into childhood obesity interventions, including prevention, has focused on school and community prevention, or tertiary care. This chapter explores the evidence for preventive approaches in primary care settings.
What is primary care?
Since the Alma Alta conference in 1978, there has been worldwide acceptance of the importance of primary health care (PHC) as the key factor for attainment of the goal of “health for all”.1 The World Health Organization defines primary health care as “essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the overall social and economic development of the community.”2
In more developed countries, PHC is the term for the health services that play a central role in the local community; including general practitioners, pharmacists, dentists and midwives. It provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practising in the context of family and community.3
Besides appropriate treatment of common diseases and injuries, provision of essential drugs, maternal and child health, and prevention and control of locally endemic diseases and immunization, it should ideally include measures to promote public health, including education of the community on prevalent health problems and delivering approaches to prevent them. In this chapter we aim to take a broad approach to defining PHC including general practice, community pediatrics and other community health services and primary-care led public health.
Is childhood overweight and obesity seen as an important issue for primary care?
Only two settings, schools and primary care, see children regularly enough to offer an effective secondary prevention program for obesity.4 However, in most countries worldwide the involvement of primary care has been limited.
Studies by general practitioner s (GP s) in the UK, USA and Australia have found that childhood over-weight and obesity was recognized as an important health problem.5–9 However, a number of barriers were perceived in tackling the issue in primary care including lack of time and resources, and a lack of practical, effective approaches. In the UK, GPs and practice nurses felt that their role in obesity management was centered on raising the issue of a child’s weight, and providing basic diet and exercise advice.5 There was concern that the clinician–patient relationship could be adversely affected by discussing what was often seen as a sensitive topic. GPs and practice nurses felt ill-equipped to tackle childhood obesity, given a lack of evidence for effective interventions, and many were skeptical that providing diet and exercise advice would have any impact upon a child’s weight.
What is prevention of obesity in children?
There is some ambiguity in the terminology for obesity prevention. Are we concerned with the prevention of increased incidence of obesity? Or is the goal preventing weight gain among those overweight to prevent progression to more severe levels of obesity?
The traditional public health classification system designates three types of prevention: primary, secondary and tertiary.10 The goal of primary prevention is to decrease the number of new cases (incidence) of a disorder. In secondary prevention, the goal is to lower the rate of established cases of the disorder in the population (prevalence). Tertiary prevention seeks to reduce the amount of disability associated with an existing disorder. For obesity, tertiary prevention could refer to decreasing the likelihood of associated diseases (e.g., diabetes).
When this prevention classification system was introduced, the implicit disease model was one of an acute condition with a uni-factorial cause. It was assumed that mechanisms linking the cause of a specific disease to its subsequent occurrence could be identified. However, obesity is recognized as having multi-factorial etiologies and research is still identifying high-risk and protective factors for the development of obesity, and determining which key factors can be effectively targeted by preventive interventions. This had led to greater emphasis on risk reduction in disease prevention.
The US Institute of Medicine (IOM) has recommended an alternative terminology for disease prevention, which identifies three types of prevention: universal, selective and indicated prevention.11 Universal preventive measures or interventions are designed for everyone in the eligible population. Selective preventive measures are directed toward a subgroup of the population who have a higher risk of developing the disorder. Indicated preventive interventions are targeted to high-risk individuals identified as having minimal but detectable signs or symptoms of the disorder, or exhibiting biological markers indicating predisposition.
Universal prevention programs are aimed at the general public. Such programs can have advantages particularly as they are usually cost-effective and the intervention is acceptable and of low risk for the population involved. Universal obesity programs can be classified into two broad categories: (1) preventive education and skills for all individuals (e.g., programs in various settings designed to improve diet and increase physical activity in a population); and (2) modification of social, environmental and economic policies in an attempt to reduce the population’s exposure to the environmental causes of obesity (e.g., regulating food marketing). Programs in the first category are often based on a model of individual behavior change, which for obesity are usually delivered in a range of non-clinical settings, including schools. There is currently little evidence for the effectiveness of universal childhood obesity prevention programs or policies.12
Selective prevention programs are designed for groups at high risk of obesity or who are already over-weight but not yet obese. Personal high-risk factors for obesity include individual level factors, such as a family history of obesity or non-insulin-dependent diabetes mellitus and low resting metabolic rate: personal eating habits and physical activity (e.g., a high-fat diet, a sedentary lifestyle), developmental periods associated with weight gain (e.g., pre-puberty), and critical life events (e.g., illness). A recent systematic review showed that such high-risk prevention strategies have been poorly tested and have no currently confirmed beneficial effects.13
In the past, indicated prevention has sometimes been referred to as secondary prevention or early interventions. These can be designed for individuals (in contrast to entire groups) who show biological markers for obesity, or who are already overweight but do not meet the diagnostic criteria for obesity. Risk factors for such individuals include a family history of obesity as well as biological markers and the development of early symptoms. Although research is still in the preliminary stages of identifying reliable biological markers for obesity, interventions that target individuals who are already overweight (or whose health risks are increased owing to their weight and/or a sedentary lifestyle) have proved to be effective in a number of settings, including primary care.
Many approaches to prevent obesity have been proposed, although as discussions in other chapters show, few studies have shown long-term, sustained reductions in weight. The emphasis on working with high-risk individuals with interventions that are matched or targeted to specific risk factors (as in selective and indicated prevention strategies) appears to have considerable value, and is a particular focus of interventions in primary care.
In this chapter, we consider that the primary aim of obesity prevention in primary care is to reduce the number of new cases. An important secondary aim is to delay the onset of obesity in those who are over-weight. Consistent with the IOM definition of prevention (i.e., interventions that occur before onset), we do not include a discussion of weight maintenance to prevent the exacerbation of obesity or its complications in those in whom the condition is established. Neither do we cover the treatment of obesity, although it is worth mentioning that there are research trials and national guidelines for use of drugs and surgery in obese adolescents. At least four national guidelines have already issued recommendations with regard to bariatric surgery in adolescents: National Health and Medical Research Council (NHMRC) Australian guidelines for the management of overweight and obese children and adolescents,14 the Singapore Ministry of Health clinical guidelines,15 and guidelines from the Institute for Clinical Systems Improvement (ICSI),16 and the UK Institute for Health and Clinical Excellence (NICE).17
This chapter is based on a literature review of published and unpublished studies in English, conducted in June 2008, of obesity prevention and treatment interventions based in primary care settings worldwide. The review considered the impact of interventions in children of all main age-groups: preschool (0–4), early school years (5–11) and adolescents (12–18). We included clinical and non-clinical services provided by health professionals, or associated primary care staff, who may or may not have received special training to manage obese children. In some clinical programs, an individual professional provider may work alone; in others, a multi-disciplinary group of professional providers works together and systematically coordinates their efforts.
Evidence and guidelines for obesity prevention interventions in primary care
Evidence from all clinical settings
There is limited evidence on the essential components of effective health sector interventions for childhood obesity. However, throughout the literature it appears that a multi-disciplinary approach is most commonly advocated. Programs normally include one or several of the following components:
- nutritional and physical activity advice
- behavioral treatment components
- decreasing sedentary activities and increasing lifestyle-related physical activity
- social and/or psychological support involving families.
There have been several extensive literature reviews of the evidence for management and treatment of childhood obesity including a 2003 Cochrane review,18 which was updated in 2006 for the UK NICE guidelines.17 Other reviews for national guidance include the Australian Clinical Practice Guidelines for the Management of Overweight and Obesity in Children and Adolescents (NHMRC),14 the Scottish Intercollegiate Guidelines Network (SIGN),19 recommendations of a US expert committee convened by the American Medical Association, Department of Health and Human Services and the CDC,20 as well as a large number of other academic literature reviews.13,21–32
The 2006 NICE review resulted in evidence-based guidance on obesity prevention and management for a range of sectors in the UK. Its main conclusions for the health sector, which are echoed in several national guidelines (see Table 12.1), were that multi-component interventions were the “treatment of choice”, and that weight management strategies should include behavior change to increase children’s physical activity and improve eating behavior or quality of the diet.17 These conclusions were based on a review of 42 randomized and non-randomized controlled trials of more than six months follow-up in clinical settings. However, only one of these studies was based in primary care, with the majority of study findings from tertiary care consisting of specialist out-patient weight reduction programs in university obesity research clinics (mostly in the USA). The review also commented on the poor methodological quality of the studies, including high drop-out rates, which would have impacted on the robustness of the evidence.
Table 12.1 Recommendations on the prevention and management of childhood overweight and obesity from selected national guidelines.
NB: all BMI reference values cited are percentiles for age and sex unless stated.
| Guideline reference | Target audience | Recommendations |
| National Health and Medical Research Council (NHMRC), Australia 2003 (6) | Health care providers | • Recommends that BMI should be used as the standard measure of overweight and obesity for 2–18-year-olds in Australia, making use of CDC BMI for age percentile charts (BMI > 85th percentile = overweight; BMI > 95th percentile = obese). |
| • Advocates breastfeeding promotion as infant feeding method of choice for prevention. | ||
| • In young children weight maintenance is an acceptable goal. | ||
| • Recommends multi-component intervention approach until further evidence is gained (states that relative contributions of diet, exercise and behavioral modification are unknown). Approaches to include assessment of physical activity and television viewing levels and family eating styles. | ||
| • Recommends medium- to long-term intervention. | ||
| • Recommends the involvement of parents in the management of overweight and obesity in children and adolescents, especially in primary school age. | ||
| Registered Nurses Association of Ontario (RNAO), Canada 2005 (74) | Aimed at advanced practice nurses | • No specific primary care recommendations. |
| • Recommends monitoring BMI changes over time using US CDC percentiles (BMI 85th–95th percentile = overweight; BMI > 95th percentile = obese). | ||
| • Recommends general promotion of healthy eating and physical activity at all levels of society. | ||
| Canadian Clinical Practice Guidelines, Obesity Canada (NFP organization),Canada 2007 (27) | Designed to provide evidence-basedrecommendations to health care providers involved in obesity prevention and management | • Recommends the creation of a national surveillance system incorporating measurement of BMI in all children and adolescents aged 2 years and over. |
| • Discussion of prevention of childhood obesity with the pregnant mother and encouragement of exclusive breastfeeding until 6 months. | ||
| • General childhood obesity prevention advice: reduction of sedentary pursuits, with a reduction in TV viewing time to <2 hours per day; a recreational approach to activity, appropriate to the family context; limiting energy-dense snack foods high in sugar and fat. | ||
| • For overweight and obese children recommends comprehensive multi-component healthy lifestyle interventions with a focus on lifestyle, diet and physical activity and incorporating an element of family oriented behavior therapy. | ||
| • Recommends ongoing follow up by a health professional for 3 months. | ||
| • Advocates a multi-sectoral and multi-professional approach and specifically recommends involvement of dietary specialist aiming towards the reduction of energy intake within the context of a balanced diet. | ||
| National Institute for Health and Clinical Excellence (NICE), England and Wales 2006 (9) | The first national guidance for England and Wales on prevention, identification, assessment and management of overweight and obesity. | • Recommends use of BMI at the clinician’s discretion as an identification and assessment tool (not advocating universal monitoring or screening). Advises caution in interpretation in children. Recommends to consider tailored intervention if BMI at 91st percentile or above. |
| • Recommends targeting of at risk children with one or both parents obese. | ||
| • Encourages health professionals to reinforce messages regarding regular family meals, reducing sedentary behaviors and encouraging active games and sports within daily lives and as structured activities. | ||
| Aimed at all health professionals who provide interventions in primary or secondary care | • Recommends multi-component, tailored interventions in both children and young adults, aiming to address lifestyle within the family and in social settings with a focus on dietary improvement and increasing physical activity. Recommends the inclusion of behavior change techniques. | |
| • Recommends long term rather than brief interventions with ongoing regular support from a trained professional. | ||
| • Recommends involvement of the parents in interventions with family based as well as individual level programs depending on the age and maturity of the child. Encourage parental responsibility for lifestyle changes in children under 12 years. | ||
| Scottish Intercollegiate Guidelines Network (SIGN) 2003 (12) | Aimed at all health professionals who provide interventions in primary or secondary care | Recommendations for weight maintenance |
| • In most obese children (BMI > 98th percentile) weight maintenance is an acceptable goal (recommendation grade: D). | ||
| • Weight maintenance and/or weight loss can only be achieved by sustained behavioral changes, for example healthier eating, increasing physical activity. In healthy children, 60 minutes of moderate vigorous physical activity/day has been recommended. | ||
| • Reducing physical inactivity (for example, watching television, playing computer games) to < 2 hours/day on average or the equivalent of 14 hours/week (recommendation grade: D). | ||
| • In overweight children (BMI > 91st percentile) weight maintenance is an acceptable goal. Annual monitoring of BMI percentile may be appropriate to help reinforce weight maintenance and reduce the risk of children becoming obese. | ||
| Singapore Ministry of Health 2004 (7) | Aimed at all health professionals who provide interventions in primary or secondary care | • Focus on increasing physical activity, decreasing sedentary time and dietary change (although comments that less restrictive diets should be used compared with adults). |
| • Behavior treatment programs recommended for weight loss. | ||
| • Interventions for obesity in children should be directed at both parents and the child, rather than the child alone. | ||
| US Preventive Services Task Force (USPSTF), USA 2005 (59) | Aimed at all health professionals who provide interventions in primary or secondary care | • Insufficient evidence is available on the effectiveness of interventions for overweight children and adolescents that can be conducted in primary care settings or to which primary care clinicians can make referrals. |
| • No specific recommendations are given concerning management of overweight and obesity. | ||
| American Academy of Pediatrics (AAP), USA 2003 (75) | Aimed at health care providers, physicians | • Calculating and plotting BMI once a year in all children and adolescents (BMI 85th–95th percentile considered at risk of overweight. BMI > 95th percentile is considered overweight or obese). |
| Targets all children | • Health care providers advised to encourage breastfeeding, healthy eating, physical activity in multiple settings and the limitation of television viewing to <2 hrs per day. | |
| • Combination of dietary and physical activity interventions for an optimal approach. Families to be educated with regards to the impact they can have on their children’s development of physical activity and eating habits. | ||
| American Medical Association (AMA), USA 2007 (13) | Aimed at clinicians to offer practical guidance and recommendations in all areas of childhood obesity care | • Recommends documentation of BMI at each well child visit (In children over 2 years BMI 85th–94th percentile = overweight; BMI > 95th percentile = obese. In youths obesity defined as BMI > 30 kg/m2. In children <2 years weight for height values >95th percentile categorized as overweight). |
| • Recommends targeting of at risk children with one or both obese parents. | ||
| • Role of universal assessment and evidence-based preventive recommendations including limited consumption of sugary drinks, appropriate levels of fruit and vegetables in diet, no television before 2 years of age and thereafter <2 hrs per day, breakfast, limiting portion size and regular family meals. | ||
| • Three treatment stages according to BMI and other risk factors: (i) prevention; (ii) prevention plus structured weight management; (iii) comprehensive multi-disciplinary intervention with a consistent focus on dietary factors and eating and physical activity behaviors. | ||
| • Emphasizses the importance of parental involvement, relevant to the age and level of independence of the child. | ||
| American Heart Association (AHA), USA 2005 (76) | Aimed at health care providers, physicians | • Recommends yearly screening of BMI percentiles (BMI 85th–95th percentile considered at risk of overweight; BMI > 95th percentile considered overweight or obese). |
| • Recommends age specific prevention advice including breast feeding, healthy home environments, 5-a-day fruit and vegetables, family meals, 1 hour of active play per day, <2 hrs television per day. | ||
| • The principal intervention strategies for children are similar to those for adults (dietary modification and increased physical activity), but stress that family involvement was critical and the interventions had to be age-specific and tailored to degree of overweight. |
Summarizing the evidence of obesity management from specialist weight management programs, the review suggests that physical activity and diet combined are more effective in weight management in children aged 4–16 years, than diet alone.33
There was no evidence of effectiveness for physical activity interventions alone, and no clear evidence of which dietary interventions are most effective. Targeting sedentary behavior, including TV viewing, was shown to be as effective as promoting physical activity in managing weight in obese children.34–36 Lifestyle-related activity was shown to be more effective than organized aerobic exercise in maintaining weight loss in obese children aged 8–12 years.37 In specialist weight management programs, behavioral treatment combined with physical activity and/or diet is also effective in the treatment of obese children and adolescents aged 3–18 years. Behavioral treatment can be more effective if parents, rather than children (aged 6 to 16 years), are given the main responsibility for behavior change. However, there is no evidence on which components of behavioral treatment are the most effective for childhood and adolescent obesity.
Despite the lack of robust research evidence, many countries have published national guidelines for the prevention and management of childhood obesity. In September 2005, the National Guideline Clearinghouse synthesized the recommendations on the assessment and management of obesity and overweight in children from six published guidelines. This information has been summarized in Table 12.1, with the addition of more recent guidelines. Most of the guidelines do not make specific recommendations for primary care providers.
Evidence from primary care interventions
Since many of the guidelines were published, four childhood obesity intervention trials in primary care have been completed.
The Live, Eat and Play (LEAP) RCT was a secondary prevention intervention nested within a baseline cross-sectional study of 2112 overweight children aged 5–10 years attending 29 general practices in Melbourne, Australia. A total of 82 children and their parents were randomized to receive the intervention of four standard GP consultations over 12 weeks targeting nutrition, physical activity and sedentary behaviors with supplementary personalized family materials. The control group families were notified of BMI status by letter but with no further follow-up, although GP attendances in this group were audited. There were no statistically significant differences between the two groups at nine and 15 month follow-up, although there was some evidence of an increase in nutrition measures and daily physical activity in the intervention group.38,39
One US trial also involved a multi-component primary care intervention for overweight adolescents: 44 overweight adolescents were randomized either to a four-month behavioral weight control program, which was initiated in a primary care setting and extended through telephone and mail contact, or to the control group, which received a single session of physician weight counseling. At end of intervention and at three-month follow up, the intervention group had greater improved BMI scores than controls.40
The patient-centered assessment and counseling for exercise and nutrition (PACE+) is a RCT of a joint primary care and home-based intervention of 878 adolescent boys and girls aged 11–15 years, recruited through primary care providers in California, USA.41 This was a primary prevention intervention focused on improving physical activity and dietary behaviors. It had two stages: primary care based computer-assisted diet and physical activity assessment and goal setting followed by brief counseling, and then 12 months of monthly mail and telephone counseling at home. The comparison group received an intervention addressing sun exposure protection, which followed the same approach and intensity as the intervention. The intervention group significantly reduced sedentary behaviors, and showed some improvements in daily physical activity (boys) and dietary saturated fat intake (girls), but there were no differences between the two groups in BMI.
An Italian controlled trial investigated the management of children age 3–12 years in family pediatric practices,42 where 186 obese children were recruited from the 18 practices that agreed to participate. The children were randomized to two different treatment groups: routine counseling approach (group A) and enhanced counseling approach (group B), and followed for 12 months. A reduction in overweight in both groups resulted but the enhanced intervention group showed significantly greater decrease in BMI as well as changes in dietary behavior and higher parental involvement.
Thus, the evidence base for primary care based interventions is currently extremely poor, and there is no clear effective approach that can be advocated from the literature. Although many interventions are occurring in primary care practice, most have not been formally evaluated in terms of effectiveness and cost–effectiveness. This paucity of evidence from both research and practice is extremely surprising, given the primary care obesity workload.
Is there evidence for the role of other primary care practitioners?
Although primary care and professional health care literature discusses the roles of primary care practitioners in obesity management, there have been few studies comparing differences between the different professional groups, or interventions focusing on specific practitioners other than GPs.
Health visitors and child care nurses perceive that childhood obesity is an important issue and that they have a role in prevention including giving physical activity advice,43 although one study reported that they devote less clinical activity to childhood obesity than practice nurses.44 A pilot study showed that a specialist health-visitor-led weight management clinic in primary care can reduce BMI and improve dietary behavior in adults. 45 We have found two ongoing cluster randomized trials of early childhood interventions that may prove promising for health visitors or community nurses—one targeting parents during the first 18 months of a child’s life based in the community child health centres,46 and a second using specially trained community nurses undertaking multiple home visits to prevent overweight.47
The role of nurses in public health is well recognized. Several studies show that practice nurses are comfortable about routinely giving lifestyle advice on diet and physical activity, but many are not necessarily aware of the correct recommendations.43 Although nurses also recognize childhood obesity as an important health issue, one study found that primary care nurses were not necessarily clear or happy with their roles, feeling that GPs were offloading the obesity workload onto nurses.48 One US study found that although family nurse and pediatric nurse practitioners recognized the seriousness of being overweight and were educating parents, they were not consistently using BMI age index. Those aware of BMI and health lifestyle guidelines were more likely to do preventive work with families.49
Why involve parents in obesity prevention?
Many reviews of obesity interventions highlight the role of the family and the importance of parental involvement in preventing childhood obesity.20,21,50–52 Inevitably, with a paucity of trial data focused on primary care interventions, much of the evidence is drawn from school and community-based programs. Even then, authors note that relatively few and often poor quality studies exist, which look at the effectiveness of obesity preventions with a parental focus.21,50
Golan et al demonstrated in a US-based behavioral change study of 6 to 11-year-olds that a focus on parents as exclusive agents of change significantly improved the outcome of mean percentile weight reduction in children.51 A seven-year follow-up of this study showed that mean reduction of overweight was still significantly improved in the parent-only, compared to the children-only, group.52
Four ten year follow-up studies conducted by Epstein et al, again in the USA, targeted children aged 6–12 years with family-based behavioral obesity interventions. They demonstrated that the direct involvement of at least one parent as a participant improved short- and long-term outcomes as regards weight regulation in the children.53,54
Further supporting the involvement of parents in obesity interventions, there is a growing body of evidence from studies on child nutrition and growth detailing the impact that parent choices and behaviors can have on child nutrition and physical activity habits.50
A recent meta-analysis, however, has found conflicting evidence regarding the benefits of parental involvement in obesity interventions. When interventions of all age groups were considered together, there was no significant difference comparing those with and without parental involvement.55
What barriers may exist to parental involvement in primary care interventions?
In primary care, an effective universal approach will rely on the motivation of the health care provider. Although perhaps not the view of most primary care providers, several UK based qualitative studies have demonstrated that primary health care professionals, including GPs and practice nurses, felt that obesity prevention was an inappropriate use of their time and was a problem of the family and child. 5,7,48
A more targeted approach, however, perhaps aimed at secondary prevention of obesity in already over-weight children, starts to rely more on parental involvement for successful initiation and implementation. It is the parent who might initiate contact with primary care services in this situation, even if initially prompted through BMI measurement in other settings such as schools. Evidence suggests that an important barrier in this scenario is parents ’ inability to recognize overweight or obesity in their children, or see it as a problem.56,57 Health professionals (pediatricians, nurse practitioners and dieticians) felt that lack of parental involvement was a major barrier.8
Parenting styles are discussed in some obesity intervention reviews,58 focusing on the authoritative parenting style as having been shown to be the most successful in effecting behavioral change in relation to smoking behaviors, and also in increasing physical activity in adolescent girls.59,60 Some behavior change research has also focused on the parents, rather than the children’s, stage of readiness to accomplish lifestyle changes,61 particularly given that parents can influence the outcome of obesity interventions in different ways, according to their child’s developmental stage, though parental involvement seems to have most impact in younger children.55
How are primary care interventions involving parents?
We see several levels of parental involvement in child obesity interventions. The parent may simply be required to offer a supportive role at home, for example, getting children to activities; or they they may receive education during clinic attendance, participate in education sessions without the specific aim of getting them to to adopt a behavioralist role, or receive information packs.38,39,41 The parent may be trained in behavioral techniques and required to take a very active role in the intervention. The parent may be a subject themselves in family intervention programs where nutrition and activity behaviors or parent BMI may be a trial outcome.
The role of primary care will be expected to increase in the coming years as the incidence and prevalence of overweight and obesity in children prevails, and programs are introduced that highlight the issue for parents, schools and the health care system.
Most effective obesity prevention programs have been carried out through comprehensive approaches that include a combination of dietary and behavioral modification, physical activity and parental involvement. They have mostly been based in preschool, school, community, family or tertiary care settings. It is clear that virtually no evidence of effectiveness and cost–effectiveness exists about interventions tackling overweight and obesity in primary care. The continued identification of effective prevention and weight reduction strategies for children, and the clarification of the role of primary care in this, must be research priorities.
It is clear that there are many barriers for GPs, nurses and other primary care professionals in addressing childhood overweight and obesity, many of which relate to lack of time, resources, appropriate skills and training. However, the challenges of translating evidence-based guidelines into health systems practice must also be addressed.62 The evidence base for future obesity prevention interventions can be improved by reporting of contextual environmental, cultural and other issues,63 which may be useful in both helping explain variability in outcomes of different approaches, but also for practitioners in adopting future research into practice.
1 World Health Organization, UNICEF: Primary Health Care: Report of the International Conference on Primary Health Care. Alma-Ata USSR: Geneva: WHO. 1978.
2 World Health Organization: Primary Health Care. In: www.who.int/topics/primary_health_care/en/ed. World Health Organization, Geneva, 2008.
3 Vanselow N, Donaldson M, Yordy K: From the Institute of medicine. JAMA 1995; 273 (3):192.
4 Wake M, McCallum Z: Secondary prevention of overweight in primary school children: what place for general practice? Med J Aust 2004; 181 (2):82.
5 Walker O, Strong M, Atchinson R, Saunders J, Abbott J: A qualitative study of primary care clinicians ’ views of treating childhood obesity. BMC Fam Pract 2007; 8 (50):Published online 3 September 2007. doi: 10.1186/1471-2296-8
6 Waters E, Haby M, Wake M, Salmon L: Public health and preventative healthcare in children: current practices of Victorian GPs and barriers to participation. Med J Aust 2000; 173:68–71.
7 Epstein L, Ogden J: A qualitative study of GPs’ views of treating obesity. Br J Gen Pract 2005; 55 (519):750–754.
8 Story MT, Neumark-Stzainer DR, Sherwood NE et al: Management of child and adolescent obesity: Attitudes, barriers, skills, and training needs among health care professionals. Pediatrics 2002; 110 (1):210–214.
9 King LA, Loss JH, Wilkenfeld RL, Pagnini DL, Booth ML, Booth SL: Australian GPs ’ perceptions about child and adolescent overweight and obesity: the Weight of Opinion study. Br J Gen Pract 2007; 57 (535):124–129.
10 Commission on Chronic Illness: Chronic Illness in the United States, vol. 1. Cambridge: MA Harvard University Press, 1957.
11 Thomas P, ed. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington: Institute of Medicine, 1995; pp. 152–162.
12 Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ: Interventions for preventing obesity in children. Cochrane Database Syst Rev: Reviews 2005, Issue 3 John Wiley & Sons, Ltd Chichester, UK, 2005; 3. doi: 10.1002/14651858.CD001871.pub2
13 Flodmark CE, Marcus C, Britton M: Interventions to prevent obesity in children and adolescents: a systematic literature review. Int J Obes (Lond) 2006; 30 (4):579–589.
14 National Health and Medical Research Council: Clinical practice guidelines for the management of overweight and obesity in children and adolescents. 2003. www.health.gov.au/internet/wcms/publiching.nsf/content/obesityguidelines-guidelines-children.htm.
15 Singapore Ministry of Health: Obesity. Singapore: Agency for Healthcare Research and Qulaity, 2004.
16 Institute for Clinical Systems Improvement: Prevention and Management of Obesity (Mature Adolescents and Adults). ICSI, 2005.
17 Institute for Health and Clinical Excellence: CG43 Obesity: Full Guideline, Section 5a—Management of Obesity in Clinical Settings (Children): Evidence Statements and Reviews. London: NIHCE, 2006.
18 Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E: Interventions for treating obesity in children. Cochrane Database Syst Rev 2003; 3 (Art. No. CD001872).
19 Scottish Intercollegiate Guidelines Network: Management of Obesity in Children and Young People: A National Clinical Guideline. Edinburgh: SIGN, 2003.
20 Barlow SE: Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007; 120 (Suppl. 4)S164–S192.
21 McLean N, Griffin S, Toney K, Hardeman W: Family involvement in weight control, weight maintenance and weight-loss interventions: a systematic review of randomised trials. Int J Obes Relat Metab Disord 2003; 27 (9):987–1005.
22 Jelalian E, Saelens BE: Empirically supported treatments in pediatric psychology: pediatric obesity (structured abstract). J Pediatr Psychol 1999; 24 (3):223–248.
23 Fulton JE, McGuire M, Caspersen C: Interventions for weight loss and weight gain prevention among youth: current issues. Sports Med 2001; 31:153–165.
24 Reilly JJ: Obesity in childhood and adolescence: Evidence based clinical and public health perspectives. Postgrad Med J 2006; 82 (969):429–437.
25 Haddock CK, Shadish WR, Klesges RC, Stein RJ: Treatments for childhood and adolescent obesity. Ann Behav Med 1994; 16:235–244.
26 Epstein L, Myers MD, Raynor HA, Saelens BE: Treatment of pediatric obesity. Pediatrics 1998; 101:554–570.
27 Epstein L, Goldfield GS: Physical activity in the treatment of childhood overweight and obesity: current evidence and research issues. Med Sci Sports Exerc 1999; 31:S553–S559.
28 Maziekas M, LeMura LM, Stoddard NM et al: Follow up exercise studies in paediatric obesity: implications for long term effectiveness. Br J Sports Med 2003; 37:425–429.
29 Berry D, Sheehan R,. Heschel R, KnaflK, Melkus G, Grey M: Family-based interventions for childhood obesity: a review (Structured abstract). J Fam Nurs 2004; 10 (4):429–449.
30 Herrera E, Johnston CA, Steele RG: A comparison of cognitive and behavioral treatments for pediatric obesity. Child Health Care 2004; 33:151–167.
31 Bautista-Castano I, Doreste J, Serra-Majem L: Effectiveness of interventions in the prevention of childhood obesity. Eur J Epidemiol 2004; 19 (7):617–622.
32 Connelly JB, Duaso MJ, Butler G: A systematic review of controlled trials of interventions to prevent childhood obesity and overweight: a realistic synthesis of the evidence. Public Health 2007; 121 (7):510–517.
33 Woo KS, Chook P, Yu CW: Effects of diet and exercise on obesity-related vascular dysfunction in children. Circulation 2004; 109 (16):1981–1986.
34 Robinson TN: Reducing children’s television viewing to prevent obesity: a randomized controlled trial. JAMA 1999; 282 (16):1561–1567.
35 Epstein L, Valoski AM, Vara LS et al: Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychol 1995; 14:109–115.
36 Epstein L, Paluch RA, Gordy CC et al: Decreasing sedentary behaviors in treating pediatric obesity. Arch Pediatr Adolesc Med 2000; 154:220–226.
37 Epstein L, Wing RR, Koeske R et al: A comparison of lifestyle exercise, aerobic exercise and calisthenics on weight loss in obese children. Behav Ther 1985; 16:345.
38 McCallum Z, Wake M, Gerner B et al: Can Australian general practitioners tackle childhood overweight/obesity? Methods and processes from the LEAP (Live, Eat and Play) randomized controlled trial. J Paediatr Child Health 2005; 41 (9–10):488–494.
39 McCallum Z, Wake M, Gerner B et al: Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood over-weight/mild obesity. Int J Obes (Lond) 2007; 31 (4):630–636.
40 Saelens BE, Sallis JF, Wilfley DE, Patrick K, Cella JA, Buchta R : Behavioral weight control for overweight adolescents initiated in primary care. Obes Res 2002; 10 (1):22–32.
41 Patrick K, Calfas KJ, Norman GJ et al: Randomized controlled trial of a primary care and home-based intervention for physical activity and nutrition behaviors: PACE+ for adolescents. Arch Pediatr Adolesc Med 2006; 160 (2):128–136.
42 Nova ARASE: Long-term management of obesity in paediatric office practice: experimental evaluation of two different types of intervention. Ambul Child Health 2001; 7 (3–4):239–247.
43 Douglas F, van Teijlingen E, Torrance N, Frearn P, Kerr A, Melonia S : Promoting physical activity in primary care settings: health visitors ’ and practice nurses ’ views and experiences. J Adv Nurs 2006; 55 (2):159–168.
44 Brown I, Stride C, Psarou A, Brewins L, Thompson J: Management of obesity in primary care: nurses ’ practices, beliefs and attitudes. J Adv Nurs 2007; 59 (4):329–341.
45 Jackson C, Coe A, Cheater FM, Wroe S: Specialist health visitor-led weight management intervention in primary care: Exploratory evaluation. J Adv Nurs 2007; 58 (1):23–34.
46 Campbell K et al: The infant feeding activity and nutrition trial (INFANT) an early intervention to prevent childhood obesity: cluster randomised controlled trial. BMC Public Health 2008; 8:103.
47 Wen L, Baur LA, Rissel C, Wardle K, Alperstein G, Simpson JM : Early intervention of multiple home visits to prevent childhood obesity in a disadvantaged population: a home-based randomised controlled trial (Healthy Beginnings Trial). BMC Public Health 2007; 7(76).
48 Mercer SW, Tessier S: A qualitative study of general practitioners ’ and practice nurses ’ attitudes to obesity management in primary care. Health Bull (Edinb) 2001; 59 (4):248–253.
49 Larsen L, Mandleco B, Williams M, Tiedeman M: Childhood obesity: prevention practices of nurse practitioners. J Am Acad Nurse Pract 2006; 18 (2):70–79.
50 Lindsay AC, Sussner KM, Kim J, Gortmaker S: The role of parents in preventing childhood obesity. Future Child 2006; 16 (1):169–186.
51 Golan M, Weizman A, Apter A, Fainaru M: Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nutr 1998; 67 (6):1130–1135.
52 Golan M, Crow S: Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obes Res 2004; 12 (2):357–361.
53 Epstein LH, Valoski A, Koeske R, Wing RR: Family-based behavioral weight control in obese young children. J Am Diet Assoc 1986; 86 (4):481–484.
54 Epstein LH, Valoski A, Wing RR, McCurley J: Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA 1990; 264 (19):2519–2523.
55 Stice E, Shaw H, Marti CN: A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work. Psychol Bull 2006; 132 (5):667–691.
56 Etelson D, Brand DA, Patrick PA, Shirali A: Childhood obesity: do parents recognize this health risk? Obes Res 2003; 11 (11):1362–1368.
57 Wake M, Salmon L, Waters E, Wright M, Hesketh K: Parent-reported health status of overweight and obese Australian primary school children: a cross-sectional population survey. Int J Obes Relat Metab Disord 2002; 26 (5):717–724.
58 Davis MM, Gance-Cleveland B, Hassink S, Johnson R, Paradis G, Resnicow K: Recommendations for prevention of childhood obesity. Pediatrics 2007; 120 (Suppl. 4):S229–S253.
59 Jackson C, Bee-Gates DJ, Henriksen L: Authoritative parenting, child competencies, and initiation of cigarette smoking. Health Educ Q 1994; 21 (1):103–116.
60 Schmitz KH, Lytle LA, Phillips GA, Murray DM, Birnbaum AS, Kubik MY: Psychosocial correlates of physical activity and sedentary leisure habits in young adolescents: the Teens Eating for Energy and Nutrition at School study. Prev Med 2002; 34 (2): 266–278.
61 Rhee KE, De Lago CW, Arscott-Mills T, Mehta SD, Davis RK: Factors associated with parental readiness to make changes for overweight children. Pediatrics 2005; 116 (1):e94–e101.
62 Saelens BE, Liu L: Clinician’s comment on treatment of childhood overweight meta-analysis. Health Psychol 2007; 26 (5):533–536.
63 Klesges LM, Dzewaltowski DA, Glasgow RE: Review of external validity reporting in childhood obesity prevention research. Am J Prev Med 2008; 34 (3):216–223.
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