Expanding the Role of Primary Care in the Prevention and Treatment of Childhood Obesity: A Review of Clinic- and Community-Based Recommendations and Interventions

Table 1

Recommendations for primary care providers for the prevention and treatment of obesity and selected citations.

Recommendation types (source)	Desired outcome					Citations for promising evidence-based interventions
	Active living	Healthy eating	Other health behaviors	Clinical practice	Community policy
Weight status assessment and monitoring
Primary care providers (PCPs) should screen children aged 6 and older for obesity (USPSTF 2010) [28].				×		Ewing et al., 2009^1 [33]; Kopp and Hornberger, 2008 [30]; Kubik et al., 2008 [15]; Mckee et al., 2010 [17]; Perrin et al., 2007^2 [20]; Perrin et al., 2008 [31]; Polacsek et al., 2009 [32]; Savinon et al., 2012 [29]; Van Gerwen et al., 2009^2 [19]
PCPs should inquire about nutritional intake, calculate and plot BMI, and identify obesity-related comorbidities (AAP 2003) [9].		×		×
PCPs should routinely track BMI and offer relevant evidence-based counseling and guidance about obesity prevention (IOM 2005) [2].				×
PCPs should encourage parents to discuss weight status with their child’s health care provider and monitor age- and gender-specific body mass index (BMI) percentiles (IOM 2005) [2].				×
PCPs should calculate and plot BMI once a year in all children and adolescents and use change in BMI to identify rate of excessive weight gain relative to linear growth (AAP 2003) [9].				×
PCPs should identify and track patients at risk by virtue of family history; birth weight; or socioeconomic, ethnic, cultural, or environmental factors. Recognize and monitor changes in obesity-associated risk factors for adult chronic disease, such as hypertension, dyslipidemia, hyperinsulinemia, impaired glucose tolerance, and symptoms of obstructive sleep apnea syndrome (AAP 2003) [9].				×
Healthy lifestyle promotion
PCPs should make AAP guidelines on screen time more available to parents, and young children should be encouraged to spend less time using digital media and more time being physically active (WH 2010) [7].	×					Kubik et al., 2008 [15]; Perrin et al., 2007^2 [20]; Plourde, 2006 [39]; Pomietto et al., 2009 [38]; Waldrop and Ferguson, 2008 [21]
PCPs should inform pregnant women and women planning a pregnancy of the importance of conceiving at a healthy weight and having a healthy weight gain during pregnancy, based on the relevant recommendations of IOM (WH 2010) [7].				×
PCPs should provide information to pregnant women and new mothers on breastfeeding, including the availability of educational classes, and connect pregnant women and new mothers to breastfeeding support programs to help them make an informed infant feeding decision (WH 2010) [7].			×
PCPs should use behavioral interventions aimed at reducing screen time based on sufficient evidence of effectiveness for reducing measured screen time and improving weight-related outcomes. Interventions can be single component or multicomponent and focus on changing screen time through classes aimed at improving children’s or parents’ knowledge, attitudes, or skills (Community Guide 2011) [12].	×
PCPs should promote healthy eating (AAP 2006) [8].		×
PCPs should encourage parents to limit sedentary activity and make physical activity and sport recommendations to parents and caregivers that are consistent with the developmental level of the child (AAP 2006) [8].	×
PCPs should recommend parent, guardian, and caregiver responsibilities for children's nutrition: (1) control when food is available, (2) provide social context for eating, (3) teach about food and nutrition when cooking and at the grocery store, (4) counteract inaccurate information from the media and other influences, (5) teach other caregivers what parents want their child to eat, (6) serve as role models and lead by example, and (7) promote and participate in regular daily physical activity (AHA 2006) [36].	×	×	×
PCPs should promote guidelines for improving nutrition in young children: (1) parents choose mealtimes, not children; (2) provide a wide variety of foods; (3) pay attention to portion sizes; (4) use nonfat or low-fat dairy products; (5) limit snacking; (6) limit sedentary behaviors; (7) allow self-regulation of total caloric intake in the presence of normal BMI; and (8) have regular family mealtimes (AHA 2006) [36].		×
PCPs should promote guidelines for nutritional quality after weaning: (1) delay the introduction of juice until at least 6 months of age, (2) respond to satiety cues and do not overfeed, and (3) include healthy foods and continue offering if initially refused (AHA 2006) [36].		×
PCPs should promote breastfeeding for first nutrition and try to maintain it for 12 months (AHA 2006) [36].			×
PCPs should support and promote healthful dietary patterns among diverse ethnic groups, taking into consideration regional and cultural differences (ADA 2004) [34].		×
PCPs should support and promote (1) Dietary Guidelines for Americans for healthy children after the age of 2 years; (2) use of the US Department of Agriculture’s Food Guide Pyramid as a guide for meeting dietary recommendations with use of the Food Guide Pyramid for Young Children aged 2 to 6; and (3) use of the Fitness Pyramid for Kids to encourage physical activity among children (ADA 2004) [34].	×	×
PCPs should encourage parents and caregivers to promote healthy eating patterns by offering nutritious snacks, such as vegetables and fruits, low-fat dairy foods, and whole grains; encouraging children’s autonomy in self-regulation of food intake and setting appropriate limits on choices; and modeling healthy food choices (AAP 2003) [9].		×
PCPs should encourage, support, and protect breastfeeding (AAP 2003) [9].			×
Patient treatment
PCPs should offer or refer children aged 6 and older to intensive counseling and behavioral interventions to promote improvements in weight status (USPSTF 2010) [28].				×		Dalton et al., 2011 [48]; Henes et al., 2010^1 [44]; Jacobson and Melnyk,2011^1 [90]; Jacobson and Gance-Cleveland, 2011^2 [24]; Kubik et al., 2008 [15]; Kwapiszewski and Lee Wallace, 2011^1 [43]; Mcclaskey, 2010^1 [49]; Siegel et al., 2009^1 [45]; Stahl et al., 2011 [40]; Taveras et al., 2011 [41]
PCPs should use technology-supported multicomponent coaching or counseling interventions intended to reduce weight on the basis of sufficient evidence that they are effective in improving weight-related behaviors or weight-related outcomes. The Task Force on Community Preventive Services recommends technology-supported multicomponent weight coaching or counseling interventions intended to maintain weight loss on the basis of sufficient evidence that they are effective in maintaining weight-related behaviors or weight-related outcomes. These interventions often also include other components, which can be technological or nontechnological (e.g., computers; videoconferencing; in-person counseling; written feedback; or computerized telephone system interventions that target physical activity, nutrition, or weight) (Community Guide 2011) [12].			×
PCPs should offer pregnant women counseling, such as guidance on dietary intake and physical activity that is tailored to their life circumstances (IOM 2009) [22].	×	×		×
PCPs should routinely offer relevant evidence-based counseling and guidance about obesity prevention (IOM 2005) [2].				×
Clinician skill development
PCPs should provide education and training in breastfeeding for all health professionals who care for women and children (SG 2011) [91].			×			Cluss et al., 2010 [56]; Cronk et al., 2011^1 [54]; Haemer et al., 2011 [50]; Holt et al., 2011 [51]; Jacobson and Melnyk,2011^1 [90]; Maher et al., 2010 [57]; McGaffey et al., 2011 [52]; Perrin et al., 2008 [31]; Polacsek et al., 2009 [32]; Pomietto et al., 2009 [38]; Stahl et al., 2011 [40]; Schwartz et al., 2007^1 [53]; Savoye et al., 2011 [55]
Medical and other health professional schools, health professional associations, and health care systems should ensure that health care providers have the necessary training and education to effectively prevent, diagnose, and treat obese and overweight children (WH 2010) [7].				×	×
Medical student, resident, and continuing medical education programs should consider and periodically review basic community pediatric competencies to be included in training and maintenance of certification efforts for pediatricians (AAP 2005) [35].					×
Training programs and certifying entities should require obesity prevention knowledge and skills in their curricula and examinations (IOM 2005) [2].					×
PCPs should foster communication by building partnerships across health-related disciplines and professional organizations and conduct effective nutrition education training programs for physicians, child nutrition personnel, and other health care providers on strategies that can be used with children to promote healthier eating habits (ADA 2004) [34].		×			×
Clinical infrastructure development
Hospitals and PCPs should use maternity care practices that empower new mothers to breastfeed, such as baby-friendly hospital standards (WH 2010) [7].			×		×	Anand et al., 2010 [58]; Ariza et al., 2009 [59]; Ariza et al., 2012 [60]; Pomietto et al., 2009 [38]; Polacsek et al., 2009 [32]; Whitlock et al., 2008 [92]
PCPs should use interventions during pregnancy and after birth to promote and support breastfeeding (USPSTF 2010) [28].				×
Insurers and accrediting organizations should provide incentives for maintaining healthy body weight and include screening and obesity prevention services in routine clinical practice and quality assessment measures (IOM 2005) [2].					×
Referrals to community programs
PCPs should educate themselves concerning the availability of community resources that affect the health and well-being of the children they serve (AAP 2005) [35].					×	Dreimane et al., 2007^1 [62]; Estabrooks et al., 2009^1 [67]; Foster et al., 2012^1 [68]; Heinberg et al., 2010^1 [63]; Paul et al., 2011^1 [64]; Pinard et al., 2012^1 [65]; Quattrin et al., 2012^1 [69]; Stark et al., 2011^1 [70]; Taylor et al., 2005^1 [71]
PCPs and insurance companies should provide information to pregnant women and new mothers on breastfeeding, including the availability of educational classes, and connect pregnant women and new mothers to breastfeeding support programs to help them make informed infant feeding decisions (WH 2010) [7].			×
Community health education
PCPs should make AAP guidelines on screen time more available to parents, and young children should be encouraged to spend less time using digital media and more time being physically active (WH 2010) [7].	×					Agrawal et al., 2012 [77]; Eisenmann et al., 2008 [74]; Gombosi et al., 2007 [75]; Moore et al., 2009 [76]
Education and outreach efforts about prenatal care should be enhanced through creative approaches that take into account the latest in technology and communications (WH 2010) [7].				×
PCPs should become involved in the education of residents and medical students in community settings. Pediatricians have the unique opportunity to model roles outside the traditional clinical roles that students and residents encounter. Pediatric academicians should use resources from the AAP and the Ambulatory Pediatric Association to engage community pediatrician as educators, both in the care of individual patients in community-based practice and in roles related to promotion of the well-being of all children in the community. Community-based resources outside the bounds of the traditional hospital and outpatient office setting should be used to instruct residents on the effect of the community on child health status and the positive effect of interdependent collaboration of community agencies with health professionals on child health (AAP 2005) [35].					×
Multisector community initiatives
Local health departments and community-based organizations, working with health care providers, insurance companies, and others should develop peer support programs that empower pregnant women and mothers to get help and support from other mothers who breastfeed (WH 2010) [7].			×		×	Multi-sector: Chang et al., 2010 [78]; Chomitz et al., 2010^1 [83]; Cousins et al., 2011 [80]; Economos et al., 2007^1 [82]; Karanja et al., 2010^1 [79]; Samuels et al., 2010 [81]; School-PCP: Edwards, 2005 [87]; Stephens et al., 2011 [85]; Tyler and Horner, 2008 [86]; Whaley et al., 2010 [14]
PCPs should ensure that maternity care practices throughout the United States are fully supportive of breastfeeding and develop systems to guarantee continuity of skilled support for lactation between hospitals and health care settings in the community (SG 2011) [91].			×
PCPs and other members of the community should interact and advocate to improve all settings and organizations where children spend time (e.g., child care facilities, schools, and youth programs). School and community resources should be considered as assets in developing strategies for the problems that children will face now and throughout their lives (AAP 2005) [35].					×
PCPs should become comfortable with an interdisciplinary collaborative approach and advocacy effort to child health. Pediatricians can play an important role in coordinating and focusing new and existing services to realize maximum benefit for all children (AAP 2005) [35].					×
PCPs should work collaboratively with public health departments and colleagues in related professions to identify and decrease barriers to the health and well-being of children in the communities they serve (AAP 2005) [35].					×
PCPs should foster communication by building partnerships across health-related disciplines and professional organizations. Conduct effective nutrition education training programs for physicians, child nutrition personnel, and other health care providers on strategies that can be used with children that promote healthier eating habits (ADA 2004) [34].		×			×
Policy advocacy
PCPs should use community data (epidemiologic, demographic, and economic) to increase their understanding of the health and social risks on child outcomes and of the opportunities for successful collaboration with other child advocates (AAP 2005) [35].					×
Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians, and ensure access to services provided by International Board Certified Lactation Consultants (SG 2011) [91].			×
PCPs should advocate for the appropriate allocation of funding for quality research in the prevention of childhood obesity (AAP 2006) [8].					×
PCPs should advocate for (1) a school curriculum that teaches children and youth the health benefits of regular physical activity; (2) comprehensive community sport and recreation programs; (3) reinstatement of compulsory, quality, and daily physical education (PE) classes in all schools taught by qualified, trained educators; (4) provision of a variety of physical activity opportunities in addition to PE; and (5) development and implementation of a school wellness counsel on which local physician representation is encouraged (AAP 2006) [8].	×				×	Mayer, 2009^2 [88]; McPherson et al., 2012 [89]
PCPs should advocate the AHA 2006 Diet and Lifestyle Goals for Cardiovascular Disease Risk Reduction: consume an overall healthy diet, aim for healthy body weight, and encourage regular physical activity (AHA 2006) [8].	×	×			×
PCPs should advocate for the development and implementation of a school wellness counsel on which local physician representation is encouraged (AAP 2006) [8].					×
PCPs should work with local governments to change their planning and capital improvement practices to give higher priority to opportunities for physical activity (IOM 2005) [2].	×				×
PCPs and other members of the community should interact and advocate to improve all settings and organizations in which children spend time (e.g., child care facilities, schools, and youth programs). School and community resources should be considered as assets in developing strategies for the problems that children will face now and throughout their lives (AAP 2005) [35].					×
PCPs should become comfortable with an interdisciplinary collaborative approach and advocacy effort to child health. Pediatricians can play an important role in coordinating and focusing new and existing services to realize maximum benefit for all children (AAP 2005) [35].					×
PCPs should support and advocate for social marketing intended to promote healthful food choices and increased physical activity (AAP 2003) [9].	×	×			×

AAP: American Academy of Pediatrics; ADA: American Dietetic Association; AHA: American Heart Association; Community Guide: The Community Guide to Preventive Services; IOM: Institute of Medicine; SG: Surgeon General’s Call to Action to Support Breastfeeding; USPSTF: United States Preventive Services Task Force; WH: White House Task Force on Childhood Obesity; see the list of references for complete citation.
¹Indicates article describing an intervention that had a statistically significant effect on participants’ weight or weight status.
²Indicates review article.