This chapter will address the following American College of Graduate Medical Education competencies: professionalism and systems-based practice.

Professionalism: Professionalism is important in working with communities just as it is in clinical care. This chapter will review an approach to community engagement that emphasizes commitment to professional responsibilities, acting on ethical principles, and sensitivity to diversity and values of respect.

Systems-Based Practice: Engagement in community work demonstrates that the pediatric health care provider has an awareness of the larger system of health care delivery, and this chapter will help the provider learn to interact with the system to optimize patient outcomes.

According to the socioecological model (see Chapters 20 and 21), addressing health problems like obesity requires approaches at multiple levels.¹ Given the widespread prevalence of obesity and its multifactorial etiology, the need to address obesity prevention in community settings is evident. The Chronic Care Model as applied to obesity (see Chapter 12) highlights the importance of linking clinical and community resources.²

While the optimal program models are still emerging, sufficient evidence has demonstrated that community-based programs engaging families can make a difference both in primary prevention and secondary prevention or treatment of obesity.^3,4 While these programs may exist, pediatric health care providers may not know about them or where to look for them. Even in the current information age, this can be a challenge! Programs are sometimes developed or adapted locally and may have limited marketing resources. What exists in each community is rapidly evolving because more resources are directed to the obesity problem, and yet substantial gaps in availability remain. Therefore, health care providers are especially needed as advocates for obesity prevention and intervention in their communities.

In order to find and access community-based programs for obesity prevention and intervention, pediatric health care providers should “think globally, act locally.” In other words, health care providers should be knowledgeable about evidence for effective programs—now being developed globally—and then apply that evidence locally to their community and patient population. A few “go-to” program sites are suggested, many of which have distilled the evidence in tools that can be used clinically, to find repositories of program information and educational materials (Table 19-1).^{5, 6, 7, 8, 9}

For children younger than 5 years, home and child care or preschool environments are most important, so programs should prioritize parents and child care providers. For older children, important settings include home, school, and neighborhood or community programs, and there are a number of programs and resources developed for those settings. Successful programs for overweight youth showing improvement in body mass index (BMI) and weight-related outcomes include those with moderate-to-high intensity (> 25 contact hours), parent participation, and multicomponent approaches that focus on long-term change through behavioral skills.^3,4 A bigger challenge can be finding local programs, and that is where local partnerships are critical (see Cases discussed later).

While national efforts are bringing awareness to the obesity epidemic and empowering families and communities to engage in healthy eating and active living, pediatric health care providers have the opportunity to expand their role by participating in locally implemented prevention and intervention programs. Obesity experts recognize that primary care physicians can feel frustrated by efforts that feel futile given the scope of the obesity problem.^10,11 However, pediatricians’ impact can extend beyond the clinic setting. Advocacy work complements the important screening and counseling clinicians provide (see Chapter 18). Health care providers can bring their medical expertise to local programs and foster discussions about how this complex issue can be addressed in each community. Providers can share patients’ experiences and cultural beliefs so that the design and delivery of community programs can better overcome barriers to participation. Collaboration between health care providers and community programs represents a win-win, because providers and programs can both better serve families.

Successful and sustainable models build upon ongoing partnerships with community groups. Community partners often include local schools, public health departments, recreation centers, and advocacy groups for nutrition and activity. Bringing diverse stakeholders to the table for program planning and implementation allows for broader audience reach, stimulates discussions of how families are supported in different settings, and can create champions for projects in different sectors of the community. The American Academy of Pediatrics (AAP) provides general principles around building effective partnerships, and examples can be found in the Chapter 20.¹²

The AAP also provides Community Access to Child Health (CATCH) grants to pediatricians interested in planning and implementing community projects that help children access needed health services and a medical home.¹³ Recent CATCH grantees have tackled issues ranging from oral health to community violence and have used a diversity of models that rely on existing clinics, local health educators, and/or social media outlets. Specific examples can be found on the AAP CATCH Web site (http://www2.aap.org/catch/). Based on lessons learned in the field by CATCH grantees, an AAP brief provides information on how to identify, recruit, engage, and work with community partners.¹⁴ The brief notes that “successful partnerships [can] be a source of great learning, growth and joy in the expansion and provision of services to children and families,” and can result in permanent services for children.¹⁴

Obesity prevention programs should be designed to serve high-risk populations within their communities, including diverse racial and economic groups. Data from the National Health and Nutrition Examination Survey have consistently demonstrated disparities in obesity among racial groups, with higher rates among Hispanic, black, and Native American populations.¹⁵ Differing patterns among population subgroups highlight the necessity of serving diverse socioeconomic groups at the community level. In planning programs, community partners should especially consider racial disparities, equity in access to services, and cultural and language barriers.¹⁶

Many obesity programs have been tested in more affluent and educated populations. Additional research is needed to determine which programs best support diverse families. When available, community-based programs are ideal because they are more tailored to engage families close to where they live. Several approaches can be used in offering community programs to better meet the needs of diverse families (Table 19-2), including sliding scale fees, incorporating the entire family, creating flexible schedules, and providing child care. Ultimately, programs are needed that create effective policy changes and overcome the environmental barriers in low-income and diverse communities, such as limited access to safe physical activity options and lack of healthy food options.¹⁶