ORIGINAL RESEARCH
A primary care intervention to improve weight in obese children: A feasibility study Diane O. Tyler, PhD, APRN, FNP, FAAN, FAANP (Director and Professor of Clinical Nursing)1,2 & Sharon D. Horner, PhD, RN, FAAN (Professor and Associate Dean of Research)2 1 2
American Academy of Nurse Practitioners Certification Program, Austin, Texas The University of Texas at Austin School of Nursing, Austin, Texas
Keywords Obesity; weight management; primary care; family; children; motivational interviewing; rural. Correspondence Diane O. Tyler, PhD, APRN, FNP, FAAN, FAANP, American Academy of Nurse Practitioners Certification Program, The University of Texas at Austin School of Nursing, 1700 Red River, Austin, TX 78701; Tel: 512-471-7913; Fax: 512-471-4910; E-mail: [email protected] Received: 4 July 2014; accepted: 20 January 2015 doi: 10.1002/2327-6924.12246
Abstract Purpose: Examine the effects of a primary care weight management program, which used a parent–child–provider collaborative negotiation intervention, among rural-dwelling families with obese children. Data sources: Health histories, physical examinations, fasting blood samples, interviews, and questionnaires. Conclusions: Feasibility of implementing a family weight management intervention in a rural primary care setting was demonstrated. Few differences between the treatment and comparison groups were found; however, more favorable trends and outcomes occurred in those who received the intervention. Implications for practice: Positive provider–patient communication in helping families with obese children make difficult lifestyle changes should be encouraged in primary care clinics as small changes in behavior can result in reducing risk and improving health outcomes.
Introduction Childhood obesity continues to be at epidemic levels. In the past 50 years, obesity prevalence has grown from 5% to 16.9% among children aged 2–19 (Ogden, Carroll, Kit, & Flegal, 2012). Although the previous decades of rapid increases may be stabilizing among some populations, no significant change in overall prevalence was detected between the 2007–2008 and 2009–2010 National Health and Nutrition Examination Survey (NHANES) data (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Furthermore, the prevalence and severity continues to worsen among those who have low income, are members of ethnic and racial minority groups, and geographical regions, most especially in the southern states. Obesity at any age is highly complex and its etiology multifactorial. Predisposing conditions and risk factors for obesity in children include interactions of prenatal and genetic factors, health status, eating patterns, physical activity, family routines, and socioeconomic status (Guyer et al., 2009; Ogden, Yanovski, Carroll, & Flegal, 2007). Thus, interventions that target the unique situations of children and families are highly recommended in weight management programs. The purpose of this pilot study was to examine the effects and feasibility of a primary care weight management 98
program, which used collaborative negotiation, among rural-dwelling families with obese children. Families living in rural areas are particularly challenged to establish healthy lifestyles. Several reports cite increased risk for obesity among rural-dwelling children (Broyles et al., 2010; Lui et al., 2007; McMuray, Harrell, Bangdiwala, & Deng, 1999). Liu et al. (2007) examined weight status of school-aged children aged 10–17 across the United States and found obesity prevalence in rural areas was 16.5% compared to 14.4% for children in urban areas. McMurray et al. (1999), after controlling for race, socioeconomic status, and gender, reported rural children had a 54.7% increased risk for obesity compared to urban children. The wide disparity between city and rural environments regarding obesity risk in children is largely attributed to better access to healthier foods, such as fresh fruits and vegetables and whole grains, and physical activity opportunities (Broyles et al., 2010; Larson, Story, & Nelson, 2009). Access to healthcare professionals is also significantly different, and school-based health centers in rural communities are often the only source for pediatric health services making them unique providers of opportunities to engage families in obesity prevention and treatment. Journal of the American Association of Nurse Practitioners 28 (2016) 98–106 C 2015 American Association of Nurse Practitioners
Primary care intervention
D. O. Tyler & S. D. Horner
In addition to access to health care, desire and ability to initiate lifestyle changes are necessary components of weight management. However, motivation to make behavior change is particularly problematic as motivation is often cited as the most common barrier to initiating weight loss (Courtney & Dickson, 2010). Motivational interviewing (MI) is a well-established, evidenced-based approach for facilitating behavior change (Miller & Rollnick, 2002). It has been effective among a wide variety of populations and with numerous targeted health behaviors (e.g., smoking, alcohol and other substance use, medication adherence, diet, and physical activity). MI strategies have been found to be effective in families with overweight children (Gance-Cleveland & Oetzel, 2010); however, no studies were found that employed MI with parent–child dyads. Most research in healthcare settings uses a modified MI approach, originally referred to as brief negotiation and later titled brief MI (Rollnick, Heather, & Bell, 1992). This approach was adapted for the present study by incorporating components of child development and methods to promote positive parent–child relationships consistent with the Touchpoints model of care (Brazelton, 1992, 1998). The modified method, called a collaborative negotiation, has been described previously (Tyler & Horner, 2008a, 2008b).
Methods This pilot study used a two-group repeated measures design to examine the effects of providing a negotiated weight-management (NWM) intervention. It was conducted at two nurse-managed, school-based health clinics that provide primary care to children who reside in the primarily rural, medically underserved areas of central Texas. The clinics were located in adjacent school districts, with participant randomization by clinic sites (i.e., dependent upon the district families resided). One clinic served as the intervention site and the other was the comparison site. Pediatric nurse practitioners provided the majority of care at both clinics, and the clinics had active caseloads of approximately 3500 children annually at the intervention site and 2350 at the comparison clinic. Families served were predominately Hispanic (greater than 60% at the intervention site and over 50% at the comparison clinic) and over 50% of students qualified for free or reduced lunch at both sites. Data were collected to answer the following hypotheses: Hypothesis 1:
Children who participate in the NWM program will have greater improvements in weight-related health indicators (body mass index [BMI], waist circumference, systolic BP, diastolic BP, and fasting blood
work [triglyceride; low-density lipoprotein (LDL), high-density lipoprotein (HDL), and total cholesterol; glucose; insulin]) than the comparison group. Hypothesis 2: Children who participate in the NWM program will have greater improvements in health behavior knowledge, attitudes about eating, and quality of life than the comparison group.
Sampling procedures Eligibility criteria were weight status (BMI ࣙ 95th percentile), child age between 8 and 12 years, ability to speak and read English (both parent and child), have transportation to the clinic, and willing to participate. Exclusion criteria included health conditions that would prohibit participation in the intervention either because of the nature of the child’s health problem (e.g., severe mental retardation, metabolic or genetic conditions, such as diabetes or Prader–Willi syndrome) that would require highly specialized care, or the inability to participate (e.g., severe conduct disorder). The a priori sample size of 30 per group was determined by a power analysis using an effect size of .72, based on BMI percentile data from a systematic review (Dunn, Deroo, & Rivara, 2001) and a previous study (Tyler, 2004), for a two-tailed t-test with 80% power. The sample size was chosen to provide an adequate sample to determine feasibility of the intervention protocol. The study was approved by the university’s Institutional Review Board and by administrators (i.e., school superintendent, school principals) for both participating school districts. All research personnel were trained in human subjects’ protection. Participant recruitment occurred through referrals by the school-based clinics’ advanced practice nurses and by elementary school nurses in the participating school districts. Contact with the potential participants occurred only after parent permissions were granted. Parents signed a referral-release card indicating that their contact information could be given to the researchers. Announcements were also placed in the school districts’ newsletters and in local newspapers with information about the study and how to contact the researchers (i.e., self-nomination). For those families who gave permission, a member of the research team contacted the family. Participant enrollment involved contacting families, verifying that the child met the inclusion criteria and none of the exclusion criteria, and scheduling an appointment. At the first appointment the study was explained, parents’ and children’s questions were answered, and signed informed consent and assent was obtained from those who agreed to participate. 99
Primary care intervention
D. O. Tyler & S. D. Horner
Intervention
Data collection
Participants in both clinics received the same weight management information from a nurse, which included diet and physical activity counseling plus supporting written materials available from the U.S. Department of Agriculture and Centers for Disease Control and Prevention (e.g., Surgeon General’s Call to Action, Nutrition and Food Labels, Food Groups and Serving Sizes, Fruits and Vegetables by Color, and Activity Tips). The intervention group made seven clinic visits (baseline visit with provision of weight management information, five intervention visits, and one follow-up/termination visit). The comparison group made four clinic visits: one at baseline for data collection and weight management information and then three subsequent visits for data collection only. The participants at the intervention clinic received the five NWM intervention visits, which consisted of nurse-delivered counseling that focused on weight-related behaviors. The nurse intervener used brief negotiation techniques based on MI principles and strategies (Emmons & Rollnick, 2001; Miller & Rollnick, 2002). This approach focuses on offering supportive guidance rather than prescriptive “expert advice” that can readily induce resistance. In brief negotiations, strategies are designed to elicit motivation to change behaviors from the parent and child (Rollnick, 1996; Rollnick & Miller, 1995). Conversations with the parent and child also incorporated Touchpoints principles (Brazelton, 1992, 1998) focusing on family strengths to establish healthy routines and develop strategies for overcoming difficulties that interrupt health promoting behaviors. All visits were held at the clinics. At each of the five intervention visits (weeks 2, 4, 8, 12, and booster week 25) the intervener engaged in a dialogue with the parent and child about their feelings and experiences related to changing family routines that involve eating and activity behaviors. All discussions were conducted with parents and children together. The parent who attended the visits was the one who managed the after school meals. In some families this was the father and in others it was the mother, as it depended on their work schedules. Consistent with the MI approach each visit was structured to address four tasks, including (a) setting the agenda for the visit, (b) assessing parents’ and children’s motivation and confidence, (c) making decisions and setting targets, and (d) exchanging information (Rollnick, 1996). This approach enables parents and children to become active participants in planning for and encouraging in healthy behaviors. During the encounters, the parent and child were asked to rate on a scale of 0–10 both their motivation (e.g., “how willing”) and confidence (e.g., “how able”) for making their identified behavior change (Tyler & Horner, 2008a, 2008b). The intervention sessions lasted approximately 30 min each.
Data were collected for both groups during visits to the clinics at four time points over 9 months. Baseline data were collected at the time of study enrollment (Time 1) which was denoted as week 1, and then every 3 months, that is, at 13 weeks (Time 2), 25 weeks (Time 3), and at 37 weeks (Time 4). Data collection took about 40 min to complete at each visit. Additionally, at each data collection period, all participants received an activity promotion gift, such as a pedometer, a wrist watch, and jump ropes as incentive items for completing study measures and to encourage activity (totaling approximately a $100 value).
100
Measures Demographics. Demographic and health history data were provided by the parents at baseline. Demographic data included child’s age, sex, and race/ethnicity. Health history data included family medical history and child medical history. Physical activity (e.g., activity log) and eating patterns (e.g., food frequency) data tools were provided to participants; however, these data could not be statistically analyzed because of the amount of missing data. The remaining measures listed below were provided by the children at each of the four data time points. Health behavior knowledge. The Child Health Behavior Knowledge Scale (Knowledge) is a 9-item measure that assesses diet and exercise knowledge, such as identifying foods high and low in dietary sodium and fat and amount of recommended exercise for children. A sample item is, “A good low sodium snack is: fresh fruit, pickles, tortilla chips, or I don’t know.” Responses on the scale are multiple-choice options with only one correct answer. The scale has acceptable reliability (α = .51, test–retest r = .73) in assessing knowledge among 68 ethnically diverse fifth and sixth graders (58% Mexican American, 12% white, 12% Asian, 6% African American) living in a low-income area (Vega et al., 1987). The Knowledge scale had similar reliability (α = .57) in the current study. Attitudes about eating. The Children’s Eating Attitudes Test (C-EAT) is a 26-item self-report measure that assesses eating attitudes, food preoccupation, and dieting behaviors in children. It discriminates between normal dieters and individuals with obesity, anorexia, and bulimia (Garner, Olmsted, & Garfinkle, 1985). The C-EAT had good reliability (α = .76, test–retest r = .81) in a sample of 318 children between 8 and 13 years of age (Maloney, McGuire, & Daniels, 1988). A score of >20 is considered to be consistent with an eating disorder diagnosis. The C-EAT scale had similar reliability (α = .81) in the current study. Sample items from the C-EAT include “I think about food a lot of the time” and “I take longer than others to eat my
Primary care intervention
D. O. Tyler & S. D. Horner
meals.” Likert responses range from always, very often, often, sometimes, rarely, and never. Quality of life. The Kid-KINDL questionnaire is a 24-item scale with six dimensions: physical well-being, emotional well-being, self-esteem, family, friends, and everyday functioning. The Kid-KINDL is a self-report tool for use with 8- to 12-year-old children. It has good reliability (α > .70 in studies with over 5000 children: Rajmil et al., 2004; Ravens-Sieberer & Bullinger, 1998). The Kid-KINDL scale had similar reliability (α = .65) in the current study. The questionnaire has been able to distinguish between children with different physical disorders (obesity, asthma, bronchitis, cancer, and atopic dermatitis) and under different types of strain. Two items from the family dimension are “During the past week, I got on well with my parents” and “My parents stopped me from doing certain things.” Responses on a five-option Likert scale range from “never” to “all the time.” Weight-related health indicators. Weight indicators in this study include the physical measures of BMI, waist circumference, and blood pressure (BP), and the clinical measures of lipid, insulin, and glucose. The BMI is the child’s weight (kilogram) divided by the square of height (meters) and interpreted using the CDC ageand sex-specific BMI standard percentile growth curves. Weight was obtained from the child wearing light-weight indoor clothing and no shoes or belts with a balance beam standing scale to the nearest .1 kg (obtained three times and then averaged). Height was obtained with a stadiometer to the nearest .5 cm. Waist circumference is a measure of central obesity and is associated with insulin resistance and cardiovascular risk factors (Buiten & Metzger, 2000; Higgins, Gower, Hunter, & Goran, 2001). A flexible, nonstretchable tape measure with millimeter markings was placed around the waist at 1 cm level above the umbilicus and measured to nearest .5 cm (Higgins et al., 2001). BP measures were obtained after the child was sitting quietly for 5 min with a cuff sized to the child’s arm length and circumference, and the arm supported at heart level. Two readings were taken with a 2-min rest between measurements for a reliability check and a third reading was taken when there was ࣙ5 mmHg difference in either systolic or diastolic BP. In the latter instance, the average of the three readings was obtained and used as the child’s recorded BP. If variance in the first two BP readings was
A primary care intervention to improve weight in obese children: A feasibility study Diane O. Tyler, PhD, APRN, FNP, FAAN, FAANP (Director and Professor of Clinical Nursing)1,2 & Sharon D. Horner, PhD, RN, FAAN (Professor and Associate Dean of Research)2 1 2
American Academy of Nurse Practitioners Certification Program, Austin, Texas The University of Texas at Austin School of Nursing, Austin, Texas
Keywords Obesity; weight management; primary care; family; children; motivational interviewing; rural. Correspondence Diane O. Tyler, PhD, APRN, FNP, FAAN, FAANP, American Academy of Nurse Practitioners Certification Program, The University of Texas at Austin School of Nursing, 1700 Red River, Austin, TX 78701; Tel: 512-471-7913; Fax: 512-471-4910; E-mail: [email protected] Received: 4 July 2014; accepted: 20 January 2015 doi: 10.1002/2327-6924.12246
Abstract Purpose: Examine the effects of a primary care weight management program, which used a parent–child–provider collaborative negotiation intervention, among rural-dwelling families with obese children. Data sources: Health histories, physical examinations, fasting blood samples, interviews, and questionnaires. Conclusions: Feasibility of implementing a family weight management intervention in a rural primary care setting was demonstrated. Few differences between the treatment and comparison groups were found; however, more favorable trends and outcomes occurred in those who received the intervention. Implications for practice: Positive provider–patient communication in helping families with obese children make difficult lifestyle changes should be encouraged in primary care clinics as small changes in behavior can result in reducing risk and improving health outcomes.
Introduction Childhood obesity continues to be at epidemic levels. In the past 50 years, obesity prevalence has grown from 5% to 16.9% among children aged 2–19 (Ogden, Carroll, Kit, & Flegal, 2012). Although the previous decades of rapid increases may be stabilizing among some populations, no significant change in overall prevalence was detected between the 2007–2008 and 2009–2010 National Health and Nutrition Examination Survey (NHANES) data (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Furthermore, the prevalence and severity continues to worsen among those who have low income, are members of ethnic and racial minority groups, and geographical regions, most especially in the southern states. Obesity at any age is highly complex and its etiology multifactorial. Predisposing conditions and risk factors for obesity in children include interactions of prenatal and genetic factors, health status, eating patterns, physical activity, family routines, and socioeconomic status (Guyer et al., 2009; Ogden, Yanovski, Carroll, & Flegal, 2007). Thus, interventions that target the unique situations of children and families are highly recommended in weight management programs. The purpose of this pilot study was to examine the effects and feasibility of a primary care weight management 98
program, which used collaborative negotiation, among rural-dwelling families with obese children. Families living in rural areas are particularly challenged to establish healthy lifestyles. Several reports cite increased risk for obesity among rural-dwelling children (Broyles et al., 2010; Lui et al., 2007; McMuray, Harrell, Bangdiwala, & Deng, 1999). Liu et al. (2007) examined weight status of school-aged children aged 10–17 across the United States and found obesity prevalence in rural areas was 16.5% compared to 14.4% for children in urban areas. McMurray et al. (1999), after controlling for race, socioeconomic status, and gender, reported rural children had a 54.7% increased risk for obesity compared to urban children. The wide disparity between city and rural environments regarding obesity risk in children is largely attributed to better access to healthier foods, such as fresh fruits and vegetables and whole grains, and physical activity opportunities (Broyles et al., 2010; Larson, Story, & Nelson, 2009). Access to healthcare professionals is also significantly different, and school-based health centers in rural communities are often the only source for pediatric health services making them unique providers of opportunities to engage families in obesity prevention and treatment. Journal of the American Association of Nurse Practitioners 28 (2016) 98–106 C 2015 American Association of Nurse Practitioners
Primary care intervention
D. O. Tyler & S. D. Horner
In addition to access to health care, desire and ability to initiate lifestyle changes are necessary components of weight management. However, motivation to make behavior change is particularly problematic as motivation is often cited as the most common barrier to initiating weight loss (Courtney & Dickson, 2010). Motivational interviewing (MI) is a well-established, evidenced-based approach for facilitating behavior change (Miller & Rollnick, 2002). It has been effective among a wide variety of populations and with numerous targeted health behaviors (e.g., smoking, alcohol and other substance use, medication adherence, diet, and physical activity). MI strategies have been found to be effective in families with overweight children (Gance-Cleveland & Oetzel, 2010); however, no studies were found that employed MI with parent–child dyads. Most research in healthcare settings uses a modified MI approach, originally referred to as brief negotiation and later titled brief MI (Rollnick, Heather, & Bell, 1992). This approach was adapted for the present study by incorporating components of child development and methods to promote positive parent–child relationships consistent with the Touchpoints model of care (Brazelton, 1992, 1998). The modified method, called a collaborative negotiation, has been described previously (Tyler & Horner, 2008a, 2008b).
Methods This pilot study used a two-group repeated measures design to examine the effects of providing a negotiated weight-management (NWM) intervention. It was conducted at two nurse-managed, school-based health clinics that provide primary care to children who reside in the primarily rural, medically underserved areas of central Texas. The clinics were located in adjacent school districts, with participant randomization by clinic sites (i.e., dependent upon the district families resided). One clinic served as the intervention site and the other was the comparison site. Pediatric nurse practitioners provided the majority of care at both clinics, and the clinics had active caseloads of approximately 3500 children annually at the intervention site and 2350 at the comparison clinic. Families served were predominately Hispanic (greater than 60% at the intervention site and over 50% at the comparison clinic) and over 50% of students qualified for free or reduced lunch at both sites. Data were collected to answer the following hypotheses: Hypothesis 1:
Children who participate in the NWM program will have greater improvements in weight-related health indicators (body mass index [BMI], waist circumference, systolic BP, diastolic BP, and fasting blood
work [triglyceride; low-density lipoprotein (LDL), high-density lipoprotein (HDL), and total cholesterol; glucose; insulin]) than the comparison group. Hypothesis 2: Children who participate in the NWM program will have greater improvements in health behavior knowledge, attitudes about eating, and quality of life than the comparison group.
Sampling procedures Eligibility criteria were weight status (BMI ࣙ 95th percentile), child age between 8 and 12 years, ability to speak and read English (both parent and child), have transportation to the clinic, and willing to participate. Exclusion criteria included health conditions that would prohibit participation in the intervention either because of the nature of the child’s health problem (e.g., severe mental retardation, metabolic or genetic conditions, such as diabetes or Prader–Willi syndrome) that would require highly specialized care, or the inability to participate (e.g., severe conduct disorder). The a priori sample size of 30 per group was determined by a power analysis using an effect size of .72, based on BMI percentile data from a systematic review (Dunn, Deroo, & Rivara, 2001) and a previous study (Tyler, 2004), for a two-tailed t-test with 80% power. The sample size was chosen to provide an adequate sample to determine feasibility of the intervention protocol. The study was approved by the university’s Institutional Review Board and by administrators (i.e., school superintendent, school principals) for both participating school districts. All research personnel were trained in human subjects’ protection. Participant recruitment occurred through referrals by the school-based clinics’ advanced practice nurses and by elementary school nurses in the participating school districts. Contact with the potential participants occurred only after parent permissions were granted. Parents signed a referral-release card indicating that their contact information could be given to the researchers. Announcements were also placed in the school districts’ newsletters and in local newspapers with information about the study and how to contact the researchers (i.e., self-nomination). For those families who gave permission, a member of the research team contacted the family. Participant enrollment involved contacting families, verifying that the child met the inclusion criteria and none of the exclusion criteria, and scheduling an appointment. At the first appointment the study was explained, parents’ and children’s questions were answered, and signed informed consent and assent was obtained from those who agreed to participate. 99
Primary care intervention
D. O. Tyler & S. D. Horner
Intervention
Data collection
Participants in both clinics received the same weight management information from a nurse, which included diet and physical activity counseling plus supporting written materials available from the U.S. Department of Agriculture and Centers for Disease Control and Prevention (e.g., Surgeon General’s Call to Action, Nutrition and Food Labels, Food Groups and Serving Sizes, Fruits and Vegetables by Color, and Activity Tips). The intervention group made seven clinic visits (baseline visit with provision of weight management information, five intervention visits, and one follow-up/termination visit). The comparison group made four clinic visits: one at baseline for data collection and weight management information and then three subsequent visits for data collection only. The participants at the intervention clinic received the five NWM intervention visits, which consisted of nurse-delivered counseling that focused on weight-related behaviors. The nurse intervener used brief negotiation techniques based on MI principles and strategies (Emmons & Rollnick, 2001; Miller & Rollnick, 2002). This approach focuses on offering supportive guidance rather than prescriptive “expert advice” that can readily induce resistance. In brief negotiations, strategies are designed to elicit motivation to change behaviors from the parent and child (Rollnick, 1996; Rollnick & Miller, 1995). Conversations with the parent and child also incorporated Touchpoints principles (Brazelton, 1992, 1998) focusing on family strengths to establish healthy routines and develop strategies for overcoming difficulties that interrupt health promoting behaviors. All visits were held at the clinics. At each of the five intervention visits (weeks 2, 4, 8, 12, and booster week 25) the intervener engaged in a dialogue with the parent and child about their feelings and experiences related to changing family routines that involve eating and activity behaviors. All discussions were conducted with parents and children together. The parent who attended the visits was the one who managed the after school meals. In some families this was the father and in others it was the mother, as it depended on their work schedules. Consistent with the MI approach each visit was structured to address four tasks, including (a) setting the agenda for the visit, (b) assessing parents’ and children’s motivation and confidence, (c) making decisions and setting targets, and (d) exchanging information (Rollnick, 1996). This approach enables parents and children to become active participants in planning for and encouraging in healthy behaviors. During the encounters, the parent and child were asked to rate on a scale of 0–10 both their motivation (e.g., “how willing”) and confidence (e.g., “how able”) for making their identified behavior change (Tyler & Horner, 2008a, 2008b). The intervention sessions lasted approximately 30 min each.
Data were collected for both groups during visits to the clinics at four time points over 9 months. Baseline data were collected at the time of study enrollment (Time 1) which was denoted as week 1, and then every 3 months, that is, at 13 weeks (Time 2), 25 weeks (Time 3), and at 37 weeks (Time 4). Data collection took about 40 min to complete at each visit. Additionally, at each data collection period, all participants received an activity promotion gift, such as a pedometer, a wrist watch, and jump ropes as incentive items for completing study measures and to encourage activity (totaling approximately a $100 value).
100
Measures Demographics. Demographic and health history data were provided by the parents at baseline. Demographic data included child’s age, sex, and race/ethnicity. Health history data included family medical history and child medical history. Physical activity (e.g., activity log) and eating patterns (e.g., food frequency) data tools were provided to participants; however, these data could not be statistically analyzed because of the amount of missing data. The remaining measures listed below were provided by the children at each of the four data time points. Health behavior knowledge. The Child Health Behavior Knowledge Scale (Knowledge) is a 9-item measure that assesses diet and exercise knowledge, such as identifying foods high and low in dietary sodium and fat and amount of recommended exercise for children. A sample item is, “A good low sodium snack is: fresh fruit, pickles, tortilla chips, or I don’t know.” Responses on the scale are multiple-choice options with only one correct answer. The scale has acceptable reliability (α = .51, test–retest r = .73) in assessing knowledge among 68 ethnically diverse fifth and sixth graders (58% Mexican American, 12% white, 12% Asian, 6% African American) living in a low-income area (Vega et al., 1987). The Knowledge scale had similar reliability (α = .57) in the current study. Attitudes about eating. The Children’s Eating Attitudes Test (C-EAT) is a 26-item self-report measure that assesses eating attitudes, food preoccupation, and dieting behaviors in children. It discriminates between normal dieters and individuals with obesity, anorexia, and bulimia (Garner, Olmsted, & Garfinkle, 1985). The C-EAT had good reliability (α = .76, test–retest r = .81) in a sample of 318 children between 8 and 13 years of age (Maloney, McGuire, & Daniels, 1988). A score of >20 is considered to be consistent with an eating disorder diagnosis. The C-EAT scale had similar reliability (α = .81) in the current study. Sample items from the C-EAT include “I think about food a lot of the time” and “I take longer than others to eat my
Primary care intervention
D. O. Tyler & S. D. Horner
meals.” Likert responses range from always, very often, often, sometimes, rarely, and never. Quality of life. The Kid-KINDL questionnaire is a 24-item scale with six dimensions: physical well-being, emotional well-being, self-esteem, family, friends, and everyday functioning. The Kid-KINDL is a self-report tool for use with 8- to 12-year-old children. It has good reliability (α > .70 in studies with over 5000 children: Rajmil et al., 2004; Ravens-Sieberer & Bullinger, 1998). The Kid-KINDL scale had similar reliability (α = .65) in the current study. The questionnaire has been able to distinguish between children with different physical disorders (obesity, asthma, bronchitis, cancer, and atopic dermatitis) and under different types of strain. Two items from the family dimension are “During the past week, I got on well with my parents” and “My parents stopped me from doing certain things.” Responses on a five-option Likert scale range from “never” to “all the time.” Weight-related health indicators. Weight indicators in this study include the physical measures of BMI, waist circumference, and blood pressure (BP), and the clinical measures of lipid, insulin, and glucose. The BMI is the child’s weight (kilogram) divided by the square of height (meters) and interpreted using the CDC ageand sex-specific BMI standard percentile growth curves. Weight was obtained from the child wearing light-weight indoor clothing and no shoes or belts with a balance beam standing scale to the nearest .1 kg (obtained three times and then averaged). Height was obtained with a stadiometer to the nearest .5 cm. Waist circumference is a measure of central obesity and is associated with insulin resistance and cardiovascular risk factors (Buiten & Metzger, 2000; Higgins, Gower, Hunter, & Goran, 2001). A flexible, nonstretchable tape measure with millimeter markings was placed around the waist at 1 cm level above the umbilicus and measured to nearest .5 cm (Higgins et al., 2001). BP measures were obtained after the child was sitting quietly for 5 min with a cuff sized to the child’s arm length and circumference, and the arm supported at heart level. Two readings were taken with a 2-min rest between measurements for a reliability check and a third reading was taken when there was ࣙ5 mmHg difference in either systolic or diastolic BP. In the latter instance, the average of the three readings was obtained and used as the child’s recorded BP. If variance in the first two BP readings was
