Stemming the tide: Obesity prevention
and treatment in primary care pediatrics
Eliana M. Perrin, MD, MPH
Associate Professor of Pediatrics
Department of Pediatrics
Division of General Pediatrics and Adolescent Medicine
University of North Carolina at Chapel Hill
Road Map for Today
• My background
• My focus: obesity
prevention in primary care
practice
• Earlier project results that
form the building blocks for
current projects
• Current projects
• Conclusions and future
research directions
My background
Swarthmore- liberal arts
Rochester- biopsychosocial
Stanford- academic medicine
and weight related disorders
UNC- RWJ and faculty and the switch to
obesity as a public health problem
Six degrees of separation from
Indiana
How about just two!
I love the Tar Heels
Hansbrough played for the Tar Heels
Now he plays for the Pacers
But I digress….
• Right now I spend most of my work time on
research
– K23 award
– R01 award
– 2 R03s and AHRQ contract under review
• Rest of time I work in primary care pediatrics
• Lots of mentorship of medical students,
residents, fellows, and junior faculty
SCOOPT Lab
Possible research focus areas in
childhood obesity
DOCTOR’S OFFICE
CORPORATIONS/POLICY
BUILT ENVIRONMENT
SCHOOLS
BIOLOGY/GENETICS
COMMUNITY/
CULTURAL
National buy in
Primary care prevention involves at least a
pediatric provider and a patient (parent
and child or family)
My research attempts to understand both perspectives
and provide interventions that impact both.
Primary Care Providers’ Plight
• “Healthy People 2010” charged primary care
providers with task of curbing the epidemic.
• Diagnosis of overweight or trends toward overweight
considered one of the 1st steps.
• Multiple studies show physicians under-diagnose
overweight and obesity in both adults and children.
(McArtor RE, et al, Intern’l J of Obesity 1992; Denen ME, Hennessey JV, Markert
RJ., J of Gen Int Med. 1993; Eck LH, et al Intern’l J of Obesity 1994; Stafford RS, et al
Arch Family Med, 2000, Benson, et al, Pediatrics, 2009)
Primary Care Providers’ Plight
• Much expected to do with limited time:
BP, DBP (toilet training, temper tantrums, discipline, school,
ADHD), vision and hearing, immunizations, hct/hgb, lead
screening, TB screening, cholesterol, sexuality and STD
prevention, injury prevention, violence prevention, sleep
positioning, and sleep disturbances, to say nothing of the
physical exam, chronic problems, etc.
Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice:
pediatricians and American Academy of Pediatrics policy statements.
Pediatrics. Oct 2006;118(4):e964-978.
• Even obesity screening is complicated…
Screening for overweight always involves
determining weight for height
First complicated aspect of screening…
BMI=weight/height2= kg/m2
• In adults:
– Definitions for overweight and obesity are static and easy
• However, in children:
– BMI is a dynamic process that varies as child grows.
– BMI values need to be plotted on standardized charts.
– A reasonable proxy for weight status.
(Dietz WH & Robinson TN, J Pediatrics,1998; Dietz WH & Bellizzi MC,
American J Clin Nutr,1999)
Second complicated aspect: terminology changes
≥95th %
“Obese”
previously “overweight”
85th to < 95th %
“Overweight”
previously “at risk”
5th-85th %
Healthy Weight
< 5th %
Underweight
(2007, Expert Committee on Assessment, Prevention, and Treatment
of Child and Adolescent Overweight and Obesity, Pediatrics)
Overweight
Age 4, 93rd Age 4, 87th
BMI=17.6 BMI=17.1
Age 5, 94th
BMI=17.7
Obese
>99th
Age 6,
BMI=23
Age 12, >99th
BMI=29.8
“Visual impression”- how good is it?
“Visual impression”- how good is it?
BMI ~98th Obese
BMI ~93rd Overweight
BMI ~12th Healthy
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...
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BMI vs. Height and Weight Study
(Journal of Pediatrics, 2004)
CONCLUSIONS:
• BMI charting compared to height and weight charting
• More effective at demonstrating obesity.
• Prompted greater concern.
• Rarely being used.
IMPLICATIONS:
• Pediatricians need to detect concerning weight trends.
• Further efforts needed to adopt BMI charting.
Self-Efficacy Survey Study
(Ambulatory Pediatrics, 2005)
CONCLUSIONS:
• Pediatricians don’t feel effective in treatment/prevention of
obesity.
• Environmental barriers (like fast food or lack of parks) are most
frequently encountered.
• Low self-efficacy is associated with practice-based barriers (like
lack of EMR to calculate BMI).
• Pediatricians want resources including better counseling tools and
better ways of communicating weight status to parents.
IMPLICATIONS:
• Interventions in office-based setting  increase self-efficacy 
increase counseling?
Pediatrician Weight Self-Perception Study
(Obesity Research, 2005)
CONCLUSIONS:
• Nearly half of overweight pediatricians did not classify
themselves as such and misperception of overweight was
worse than in non-doctor US samples.
• Those identifying themselves as “thin” & those identifying
themselves as “overweight” reported more difficulty
counseling regardless of actual weight status.
IMPLICATIONS:
• Physicians’ own weight self-perceptions may be one barrier
to appropriate screening and counseling.
Pediatrician self-efficacy with a counseling toolkit
(Patient Education & Counseling, 2008)
CONCLUSIONS:
Pre-/post• Confidence to interpret BMI, identify concerning dietary and PA
behaviors and counsel during well child checks improved.
• Ease of counseling about healthy eating, PA, and healthy weight
improved from less than 10% reporting ease of counseling to
nearly 40%.
IMPLICATION:
• If a very simple toolkit improves self-efficacy and ease, perhaps
similar toolkits might help boost counseling rates.
Barriers & facilitators of using BMI
Pediatrician focus group study
(Flower, Perrin, et al, Ambulatory Pediatrics, 2007)
CONCLUSIONS:
• There are many systems’ barriers to using BMI but it can
be a useful diagnostic and even counseling tool.
IMPLICATIONS:
• Practice-level changes such as incorporating BMI into
office systems and EMRs may be needed to support
pediatric primary care providers in using BMI routinely.
• More research on whether parents understand the
concept of BMI or it serves as a communication tool.
Do parents understand color-coded BMI
charts better than standard charts?
What is the relationship of literacy and/or
numeracy to that understanding?
Oettinger MD, Finkle JP, Esserman D, Whitehead L, Spain TK, Pattishall SR, Rothman RL,
Perrin EM. “Color-coding improves parental understanding of body mass index
charting.” Acad Pediatr. 2009; 9(5):330-8.
Stop-light color coded
(à la asthma action plan) vs. standard BMI
Methods
•N=163 parents (children aged 2-8 yrs)
•Two academic pediatric clinics
•Parents given:
–Demographics, color blindness test, WRAT-3R, S-TOFHLA
–“Understanding BMI” questionnaire
•Parallel questions -- compare understanding of standard vs.
color-coded BMI charting
•“Control” questions-- independent of color-coding.
Comparison of correctness on parallel
questions for B&W vs. color-coded
questions (N=163)
Question #
AOR (95% CI)
P value
1
6.5 (3.3-12.6)
<0.0001
2
3.5 (2.18-5.53) <0.0001
3
2.0 (1.25-3.14) <0.0005
4
8.8 (5.0-15.4)
<0.0001
pooled
4.3 (3.1-6.0)
<0.0001
Mean Correct on Questionnaire
Performance by numeracy level
Numeracy level (WRAT)
Summary: Understanding BMI and
Numeracy
• Many parents reported understanding BMI (60%) but only
33% could explain it correctly.
• Parents had greater odds of answering BMI chart questions
correctly using color-coded vs. standard charts.
• Lower numeracy parents benefited more from color charts
than did higher numeracy parents, who performed well
using both charts.
• “NNT”= 2 to 6 (K-5 numeracy)
= 3 to 23 (middle school numeracy)
= 5 to 13 (high school numeracy)
Use of a Pediatrician Toolkit
(Perrin EM, et al, Academic Pediatrics, 2010)
CONCLUSIONS:
Post toolkit use in an academic clinic:
Children had healthier behaviors
Parents developed greater accuracy in children’s
weight status
IMPLICATIONS:
Further RCT research needs to be done, but it
looks like our toolkit helps change parental
perception!
These studies have been the building blocks
for my current and future research…
Now my research is focused on the parent
perspective and primary prevention
• What do parents find sensitive and motivating? What is their
advice for doctors?
-K 23 grant in progress
• What health effects are there of obesity at young ages and as
predictors for the future that parents might find motivating?
-Asheley has presented
• How can pediatricians best help prevent obesity from the
beginning?
-R01 grant in progress
Context: Parents don’t see the problem of
overweight
Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. Maternal
perceptions of overweight preschool children. Pediatrics 2000;106:1380-6.
Etelson D, Brand DA, Patrick PA, Shirali A. Childhood obesity: do parents recognize this
health risk? Obes Res 2003;11:1362-8.
Goodman E, Hinden BR, Khandelwal S. Accuracy of teen and parental reports of
obesity and body mass index. Pediatrics 2000;106:52-8.
Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, Whitaker RC. Why don't lowincome mothers worry about their preschoolers being overweight? Pediatrics
2001;107:1138-46.
Maynard LM, Galuska DA, Blanck HM, Serdula MK. Maternal perceptions of weight
status of children. Pediatrics 2003;111:1226-31.
Crawford PB, Gosliner W, Anderson C et al. Counseling Latina mothers of preschool
children about weight issues: suggestions for a new framework. J Am Diet Assoc
2004;104:387-94.
Jeffery AN, Voss LD, Metcalf BS, Alba S, Wilkin TJ. Parents' awareness of overweight in
themselves and their children: cross sectional study within a cohort (EarlyBird 21).
BMJ 2005;330:23-4.
Lampard AM, Byrne SM, Zubric SR, Davis EA, Parents’ concern about their children’s
weight., Int J of Pediatr Obesity 2008; 3 (2): 84-92.
In my CLINCAL experience, this is how this
plays out
If child is healthy weight, parent thinks child is skinny
parents try to get the child to GAIN weight
If the child is overweight, parents think the child is at a
healthy weight
no motivation to change dietary or PA behaviors
Both groups of parents need education
about weight status
healthy recommendations
Can we teach parents about their children’s weight
status in a way that is sensitive and motivating?
Theory is….
Communication of
BMI
Understanding the child
is an unhealthy weight
Intention to change
behaviors
Behavior change
Understanding
health
consequences
Healthier weight
trajectory
How to do this quickly, effectively, and sensitively???
Interviews with parents
Semi-structured interviews
• 24 parents of children (12 AA and 12 white)
• 4 each of healthy weight, overweight, obese
• 1.5 hours; 25 pages of transcript each
• Coded themes with Atlas ti software
Broad concept of ideal visit and what would be
sensitive and motivating
Reactions to:
• “Ideal” video
• Color-coded charts and other tools
Interviews with parents study:
Demographics
Education
16
14
12
10
8
6
4
2
0
8th-11th grade
High
school/GED
Some college
Two year
degree
Graduate
degree
Interviews with parents study:
Demographics
Insurance
18
16
14
12
10
8
6
4
2
0
Medicaid
Private
Among 20 actually overweight parents,
self-report:
16
14
12
10
8
6
4
2
0
Healthy Weight
Overweight
Obese
14
Among 16 overweight children, parents report:
12
10
8
6
4
2
0
Overweight
Healthy Weight
Interviews with parents study
Body Mass Index
Previous knowledge and chart preference
12/24 parents indicated they had not heard of the term body mass
index.
7/12 indicated they had heard of the term BMI, but incorrectly defined
the term when asked.
23/24 parents preferred the color coded BMI chart over the standard
chart.
Advice From Parents
• Give me charts to help explain recommendations
• Give me the color-coded chart
• Give it to me straight, but be sensitive in your
language
• Get to know me & make tailored and realistic
recommendations
• Listen and know me as a person before making
recommendations
• Tell me more about health than weight
Give me charts
Yesterday, I went to the doctor with my youngest son who is
the middle boy and they weighed him. … And I was
concerned that he weighs very, very little. … And I did ask
the doctor what about his weight …I don't know what to do.
Does he need vitamins? ‘Oh, no. He looks good. He is
healthy. He is not bones, bones, bones like he is not eating
well.’ For him it was normal. And I still didn't quite
understand him because he didn't show me a paper okay….
Like he is at this age, he should weigh this much, he should
be tall this size, you know like that. I wasn’t very happy
because I wanted to hear something else… He could show
me a paper saying this is the age of certain kids, and this is
what they weigh….
Charts help explain recommendations
The doctor came in and he didn’t say nothing to me about him
being overweight or anything like that. He just said we need to
talk about a nutrition plan and get him on this and that, and,
well, I’m looking at him like I don’t understand why you are
telling me this….I think laying it out what you are going to talk
about before you decide to talk about it is something that I think
is going to help me to not feel like I need to be defensive….
Give me the color-coded chart
This one is better (pointing to the color coded chart)…. I
am looking at this (the non-color coded chart) and all I
see is numbers versus I can look at this and I see the
colors and I know yellow is high risk, red is just
completely overweight, green is she is doing well and
below the green she is underweight, so this helps me to
specify where I am….
Give it to me straight!
Well, I like the way the lady showed her the chart and
explained it to her and came straight out with it and told
her that her child was overweight for her age. Instead of
just hiding it and not telling her. We are going to try to get
her back in the green area where she needs to be at. I see
the woman (mother in the video) didn't like it as much, but
wow, you know you got to take the bitter with the sweet…..
The woman (doctor) is just doing her job letting you know. I
like that, I want somebody to tell me something about
mine. Well, you think she is overweight, well ok, I am going
to work on it. When I come back I guarantee you going to
say, ‘Oh, she is fine!’
But be sensitive in your language
The doctor should say, “Okay we're a little bit
concerned, he looks like he's bigger than most
kids his age or something of that sort, then it
would've probably been okay, but I don't know,
the ‘obese’ word, I, I don't like it.”
Get to know me & make tailored and
realistic recommendations
You have to look at your socioeconomic stuff … You know you
have to bring all of that in before you can sit down and make
these high hat recommendations like you should take your child to
the park more often. Well we don’t have a park in the inner city,
not one that is not run by the gangs. So, in order to make the
recommendations that the doctors are wanting to make, they are
going to need more personal information, and they are going to
need a way to get it without offending people. We live on $459
dollars a month and my disability check. Forty fifty nine a month
for three people. It is not feasible to recommend fresh vegetables
when I can get ‘three-for-a-dollar’ cans, and the cans with the
dents for a quarter. And that is the reality.
Get to know me & make tailored and
realistic recommendations
They never really said anything about exercise.
Only thing they really say is to water their juice
down and try to portion out their foods but they
don't really tell you how to manage the foods,
what types of foods you should give 'em, you
know what kind of exercises you should have
them doing you know to make it fun obviously,
'cause a five and a four year-old ain’t gonna just
sit there and exercise.
Get to know me & make tailored and
realistic recommendations
They (doctors) usually start saying, ‘OK, your child is overweight. I
think you need to make sure they are eating vegetables or getting
exercise.’ I’d rather they’d say, you know, ‘tell me about the
average day. What is this child eating? How are they exercising?’
And make some real suggestions based on that lifestyle, because,
you know, to say to me, ‘Add in vegetables.’ Well, maybe that’s not
in my budget. Maybe there is a reason why there aren’t
vegetables. You know, to say ‘add in physical activity,’ maybe I
work two jobs… and so, you know, to get to a park isn’t as feasible.
So, to have that conversation and ask what you are currently
doing, and why, and ‘have you thought of this as an option?’
versus ‘do this,’ but throw out different things, because different
things are going to work for different families.
Listen and know me as a person before
making recommendations
Because if you listen to me and you get to know me as a person
and the things that are going on in my life then I will be more
receptive to take what you are saying versus the doctor coming
and saying, ‘Hey, you know I heard your child is overweight. Y’all
watch a lot of TV? Yeah? Ok, now you need to cut that off.’
Tell me more about health than weight!
I would listen to advice on how, you know, I can make them
healthier, not help them lose weight, 'cause I don't want to help
them lose weight. It's like putting a child on a diet, which I don't
think my child needs, either one of them.
Another approach: primary
prevention
Greenlight Study to Prevent Obesity
•NIH-funded (NICHD) multiple PI R01
•4 sites: Vanderbilt, NYU, UNC, and UM
•Will discuss:
–Background
–Objectives and Principles
–Methods
–Measures
–Time line
Background: Obesogenic behaviors start young
By 4 months:
• 66% regularly had juice/sugary drink in the bottle
• 20% were fed solid food
• 18% were fed whenever s/he cried
• 29% of formula-feeding babies fed "until s/he finished the
bottle"
• 33% were fed solid food until the jar was finished
At 6 months
• Mean media exposure= 159 minutes/day
Objectives and Principles
• Prevent obesity as measured by % overweight or
obese by BMI% at age 2.
• Obesity prevention RCT study targeting children at 2
mo of age and following them through age 2 years.
– Low literacy educational materials for parents
– Addresses cultural challenges, language barriers
– Health communication ,teach back, goal setting,
motivational interviewing training for residents
Methods: RCT with following structure
250 2 mo. olds @ NYU
250 2 mo. olds @ Vanderbilt
Obesity
Prevention
Baseline measures at 2 months
250 2 mo. olds @ UNC
250 2 mo. olds @ U. Miami
Attention
placebo
f/u
measures
and BMI
status at 24
months
Measures
•BMI% at age 2
•Demographics including very good SES
•Dietary and PA measures at every well child
check
•WRAT and S-TOFLA
•PHLAT
•Food insufficiency, maternal depression,
satisfaction with visit, locus of control, etc.
Timeline
•
•
•
•
Started January, ‘09
Enrolling cohort now- 18 month process
Follow cohort for 2 years
Cross sectional analyses throughout and
cohort analyses at end
Conclusions of my research
• Parents and doctors do not visualize early concerning
weight trajectories, but there ways that doctors and
parents can have helpful conversations together.
• Providers would benefit from tools that help their selfefficacy, screening, and ways to motivate families to adopt
healthy lifestyles.
• Color coded BMI charts may help doctors communicate
weight status, particularly to those of lower numeracy.
• Parents would appreciate sensitive, yet straightforward,
tailored communication from providers who know them
well.
• We anticipate learning a lot about prevention of
overweight and injury from our R01 research
Future Directions and Goals
•Testing a BMI screening communication and early
intervention that builds from both parent and
pediatrician perspectives.
•Further work on the relationships between obesity
and health in young children.
–Teasing apart vitamin D, PA, and inflammation
•R01 has a reverse RCT that helps me learn a new
discipline- injury prevention!
•Continue mentorship and collaborations.
Thank you. I’d like to especially acknowledge
many mentors and collaborators:
Cynthia Bulik, PhD
Alice Ammerman, RD, DrPH
Jacob Lohr, MD
Michael Simmons, MD
Tom Robinson, MD
Matt Gillman, MD
Joanne Finkle, RN, JD
Michael Steiner, MD
Asheley Skinner, PhD
Kori Flower, MD, MPH
Russell Rothman, MD, MPP
Shonna Yin, MD, MPH
Lee Sanders, MD, MPH
Research Assistants: Brenda Calderon and Alison Mendoza
Why is parent literacy important for child obesity?
• “Health literacy” includes understanding …
– Connection between obesity and disease
– How to interact with medical system
– How to set health-behavior goals
• “Health numeracy” includes understanding
– Weight status (percentiles)
– Food labels
– Portion sizes
• 3. A pediatrician points to a mark on the BMI chart (point to the X
marked on the standard BMI chart indicating a 6 year old boy with a
BMI of 20) and tells you that your 6 year old boy falls above the 95th
percentile line on the BMI chart. On this chart, below the 5%ile
indicates underweight, between the 5%ile and 85%ile indicates
healthy weight, between the 85%ile and 95%ile indicates at risk for
overweight and above the 95%ile indicates overweight. What does
the BMI chart tell you about the weight status of your child?Answer
choices: The child is underweight; The child is a healthy weight; The
child is at risk for overweight; The child is overweight
• 3. The pediatrician points to a mark on the BMI chart (point to the X
marked on the color-coded BMI chart indicating a 6 year old boy with
a BMI of 20) and tells you that your 6 year old boy falls above the 95th
percentile line on the BMI chart. On this chart, green indicates
healthy weight, yellow indicates at risk for overweight and red
indicates underweight (below) or overweight (above).What does the
BMI chart tell you about the weight status of your child? Answer
choices: The child is underweight; The child is a healthy weight; The
child is at risk for overweight; The child is overweight.
NICHD K23 (Perrin, PI)
Keep TABS (Talking about BMI Screening): Phase 1,
developing the intervention
Aim 1. Determine how parents of children ages 3-8 in different
BMI risk category groups (“healthy weight,” “at risk for
overweight,” and “overweight”) understand and experience
communication of BMI screening results via semi-structured
and structured interviews.
Aim 2. Assess pediatricians’ current knowledge, attitudes, and
beliefs regarding communication of BMI weight status
screening results to parents of young children via focus
groups.
Aim 3. Develop and refine theory- and evidence-based
intervention tools and strategies to build the Keep TABS
(Talking About BMI Screening) intervention that is efficient
for pediatricians and potentially motivating to parents,
based on qualitative investigation outlined by Specific Aims
1 and 2.
Keep TABS
Phase II. Perform a Feasibility Study of the
Keep TABS Intervention
Specific Aim 4. Conduct a feasibility study of
our Keep TABS intervention at pediatric
practices (N=4; n=2 intervention, n=2 control;
80 parent-child pairs to allow for attrition) to
provide essential data to inform a later large
multi-site, randomized controlled trial with
regard to the following outcomes:
Specific Aim 4 Outcomes
A. Process outcomes:
1. Determine our ability to recruit patients in different BMI risk
profiles.
2. Determine our ability to deliver the Keep TABS intervention
(training, implementation, data collection) in busy practice
settings.
3. Determine our ability to measure study outcomes, including
parental accuracy of assessment of their children’s weight.
B. Study outcomes:
1. Determine the effect size, intraclass correlations, and receiver
characteristics that will form the basis for the larger
effectiveness trial for the intervention, particularly on the
primary effect size of interest (parental accuracy of children’s
weight status).
Ineligible-subspecialty,
retired, deceased
n=86
NCPS/AAP
Members
n=824
Allocated
respondents
n=738
Ht/Wt Vignette
Completed
n=173
BMI Vignette
Completed
n=183
Did not return
questionnaire
n=214
Returned
survey but
screened out
no routine care
n=168
Response rate=71%
An interesting finding:
In one study, while 2 in 5 children whose BMIs
were ≥50% by age 3 years were overweight at
age 12, none of the children whose BMIs were
<50% were overweight at age 12 .
(Nader PR, O'Brien M, Houts R, et al. Identifying risk for obesity in early
childhood. Pediatrics 2006, 118:e594-601)
Career Development- gaps needed to fill to
get to where I’m going
• Qualitative methodology (class work and CHAI
CORE-behavioral/social interventions training)
• How culture intersects with health behavior (class
work and observational)
• Risk communication and health behavior (private
tutorials)
• Motivational interviewing (seminars)
• Obesity epidemiology (class work and project
work)
• Randomized trials (summer institute work)
• Grant writing (seminars), responsible conduct of
research (serve on IRB), manuscript preparation
Percentage Difference in CRP
Compared to Healthy Weight
1600
1400
1200
Very obese, p<0.01
age 3+
Obese, p<0.01 age
6+
Overweight, p<0.01
age 6+
1000
800
600
400
200
ye
ar
s
s
ar
15
-1
7
Ye
-1
4
12
9-
11
Y
ea
rs
ar
s
6-
8
Ye
s
ye
ar
5
3-
1-
2
Ye
ar
s
0
Percentage Difference in ANC Compared to
Healthy Weight
60
50
Very obese, p<0.05 age
1+
Obese, p<0.01 age 6+
40
30
Overweight, p<0.01 age
9+
20
10
ye
ar
s
15
-1
7
Ye
ar
s
12
-1
4
ea
rs
911
Y
rs
Ye
a
68
ye
ar
s
35
12
Ye
a
rs
0
Percentage Difference in Ferritin/Transferrin
Compared to Healthy Weight
160
140
120
Very obese, p<0.05 age
3+
Obese, p<0.01 age 6+
100
80
60
Overweight, p<0.01 age
9+
40
20
ye
ar
s
15
-1
7
Ye
ar
s
12
-1
4
ea
rs
911
Y
rs
Ye
a
68
ye
ar
s
35
Ye
a
12
-20
rs
0
Methodology and Aims of K23
#1-Interviews with parents- what’s motivating and
understandable?
#2-Focus groups with pediatricians-how do they
respond to what parents tell us?
#3-Use theory and what is learned from #1 and #2 to
develop the communication intervention.
#4-Test the intervention: a) process outcomes of
feasibility; and; 2) study outcomes-determination of
change in parental perception of child’s weight
status.
Results: Demographic Characteristics
% Race/Ethnicity
American Indian
Asian
Black/African American
Native Hawaiian/Pacific
Islander
White/Caucasian
Hispanic/Latino
Combined centers
(N=163)
1
3
48
1
38
9
Results: Characteristics
HOUSEHOLD INCOME
Combined (163)
<$10,000
26%
$10,000-19,999
13%
20,000-39,999
32%
40,000-59,999
8%
60,000+
17%
Medicaid or Tenncare
66%
Private
33%
None
1%
INSURANCE
MEAN YRS OF EDUCATION
13.5
DOCTOR DISCUSSED BMI AT LAST VISIT
27%