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Description

weigh and make health-related decisions based on an understanding of the value and limits of scientific knowledge and the scientific method

Choose and research a topic related to human biology. The term paper should be educational and evidence-based. You may select one topic that relates to either homeostatic mechanisms or to a disease that may interest you because of your own health or family history. You will find a list of suggested topics below, or you may come up with your own. If you select a topic that is not listed below, discuss your topic with your instructor before beginning work.

The Topic is childhood obesity

Assignment criteria

Select one of the suggested topics above (you may also choose a topic not listed above).

Find articles related to the topic. You can find assistance with searching for articles at the UMUC Library Subject Guides at

http://libguides.umuc.edu/science

.

Write a paper of 1800-2000 words (double-spaced), excluding references. You may include pictures, tables and other material but please include all references. You should cite information in the text from at least five sources (including books, journals, and the Internet). You may not use online encyclopedias. Use APA style for citing references (see

http://www.umuc.edu/library/guides/apa.html

). All source material should be paraphrased or summarized in your own words. You should have no more than one direct short quote (less than 40 words) and no long quotes (more than 40 words) in your paper.

The sections of your Term Paper should include a title; an introduction that defines/describes your topic and what current/ongoing research has discovered about this topic; background information on what healthy organ system(s) is/are affected by the topic; the mechanism of action (e.g., how does the topic disrupt homeostasis? how does a disease spread and infect a person?); its symptoms and how it is diagnosed; current treatment options; prevalence/any other relevant statistics  and your references. You may include additional sections as necessary to cover your particular topic.

Your explanations and uses of evidence, illustrations, or other definitive details should be appropriate for a science class: explanatory and well supported by research; your language should aid the reader’s understanding of the subject (including definitions where appropriate); you should use information logically, and provide conflicting evidence and research where appropriate.

What Parents Need to Know about Childhood Obesity – Johns Hopkins All Children’s Hospital

Childhood Obesity Facts | Overweight & Obesity | CDC

Defining Childhood Obesity | Overweight & Obesity | CDC

Childhood Obesity Causes & Consequences | Overweight & Obesity | CDC

Data & Statistics | Overweight & Obesity | CDC

American Psychologist
© 2020 American Psychological Association
ISSN: 0003-066X
2020, Vol. 75, No. 2, 178 –188
http://dx.doi.org/10.1037/amp0000530
Summary of the Clinical Practice Guideline for Multicomponent
Behavioral Treatment of Obesity and Overweight in Children
and Adolescents
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Guideline Development Panel for Treatment of Obesity, American Psychological Association, Washington, DC
The purpose of this clinical practice guideline developed by the American Psychological
Association (APA) is to provide recommendations concerning multicomponent behavioral treatment of obesity and overweight in children and adolescents. Intended users of
the guideline include psychologists, other health and mental health professionals, patients, families, and policymakers. The guideline development panel (GDP) used a
systematic review conducted by the Kaiser Permanente Research Affiliates EvidenceBased Practice Center as its primary evidence base (O’Connor, Burda, Eder, Walsh, &
Evans, 2016). The GDP consisted of researchers and clinicians in psychology, medicine,
nursing, and nutrition as well as adult community members who had childhood and adolescent
experience with obesity. Critical outcomes used in rating evidence and formulating recommendations were change in body mass index (BMI or zBMI) and serious adverse events. For
child and adolescent patients aged 2 to 18 years with obesity or overweight, the GDP
strongly recommends the provision of family-based multicomponent behavioral interventions, with a minimum of 26 contact hours, initiated at the earliest age possible.
Due to insufficient evidence, the GDP was not able to make recommendations about
specific forms of family-based multicomponent behavioral interventions with respect
to their comparative effectiveness; associations with adherence, engagement, or retention
Editor’s note. This article is part of a special issue, “Obesity: Psychological and Behavioral Aspects of a Modern Epidemic,” published in the
February–March, 2020 issue of American Psychologist. David B. Sarwer
and Carlos M. Grilo served as editors of the special issue, with Anne E.
Kazak as advisory editor.
chological Association guidelines staff were Lynn F. Bufka, Raquel Halfond, and Howard S. Kurtzman.
This guideline was developed with financial support from the American
Psychological Association. The Guideline Development Panel for Treatment of Obesity functioned as an independent panel of the association.
Final recommendations were reviewed by the APA Council of Representatives for approval as APA policy. However, the Council had no influence
on the content of the recommendations.
The panel members and staff express their appreciation to Katherine
Nordal (former APA Executive Director of Practice) and APA’s Board of
Directors, Board of Professional Affairs, Board of Scientific Affairs, and
Council of Representatives for their support of the effort; the members of
the APA Advisory Steering Committee for the Development of Clinical
Practice Guidelines, who provided ongoing guidance and feedback; APA
staff members C. Vaile Wright and Shannon Beattie for their support and
assistance; and scientists at Kaiser Permanente Research Affiliates
Evidence-Based Practice Center for their work on the systematic review
and methodological guidance. The panel and staff also appreciate the work
of two initial panel members, Leonard Epstein and Caroline Jhingory.
The guideline is not intended to create a requirement for practice but
rather to be a general guide and facilitate decision-making for both provider and patient. It is not intended to limit scope of practice in licensing
laws for psychologists or for other independently licensed professionals,
nor limit coverage for reimbursement by third party payers. For guidance
on using this guideline please refer to https://www.apa.org/about/offices/
directorates/guidelines/context.aspx.
Correspondence concerning this article should be addressed to Practice
Directorate, American Psychological Association, 750 First Street NE,
Washington, DC 20002-4242. E-mail: cpg@apa.org
Authors’ note. Guideline Development Panel for Treatment of Obesity,
American Psychological Association, Washington, DC.
The present article is a summary of the full guideline document that was
adopted as APA policy by the APA Council of Representatives at its
meeting of March 9 –10, 2018, and which will be reviewed within five
years of that date (by 2023). A decision to sunset, update, or revise the
document will be made at that time. The full document is available online
at https://www.apa.org/obesity-guideline/clinical-practice-guideline.pdf.
Members of the Guideline Development Panel for Treatment of Obesity
were Maria M. Llabre (chair), Department of Psychology, University of
Miami; Jamy D. Ard (vice-chair), Department of Epidemiology and Prevention, Department of Medicine, Wake Forest University Baptist Medical
Center; Gary Bennett, Duke Global Health Institute, Duke University;
Phillip J. Brantley, Department of Behavioral Medicine, Pennington Biomedical Research Center, Louisiana State University; Barbara Fiese, Department of Human Development and Family Studies, University of Illinois at Urbana-Champaign; Jane Gray, Texas Center for the Prevention and
Treatment of Childhood Obesity, Dell Children’s Medical Center; Patty
Nece, Washington, District of Columbia; Michele Polfuss, College of
Nursing, University of Wisconsin-Milwaukee; Hollie Raynor, Department
of Nutrition, University of Tennessee; Delia Smith West, Department of
Exercise Science, Arnold School of Public Health, University of South
Carolina; and Denise E. Wilfley, Center for Healthy Weight and Wellness,
Washington University School of Medicine in St. Louis. American Psy178
CLINICAL PRACTICE GUIDELINE FOR OBESITY
179
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
in treatment; or specific effectiveness with patients or families with particular characteristics. Considerations and challenges related to implementing the recommended interventions are discussed, and areas in which additional research is needed are identified.
Public Significance Statement
The purpose of this article is to summarize the clinical practice guideline developed by the
American Psychological Association to provide recommendations concerning multicomponent
behavioral treatment of obesity and overweight in children and adolescents. Almost one third of
youth aged 2 to 19 years in the United States are overweight or obese, which is concerning given
the connection between obesity and multiple immediate as well as longer term health risks. The
guideline recommends at least 26 contact hours of family-based multicomponent behavioral
interventions for child and adolescent patients aged 2 to 18 with obesity or overweight, initiated
at the earliest age possible.
Keywords: obesity, clinical practice guideline, overweight, children, adolescents
Obesity in childhood is defined as body mass index
(BMI) greater than or equal to the 95th percentile, whereas
overweight is defined as BMI greater than or equal to 85th
percentile based on the Centers for Disease Control and
Prevention (CDC) growth curves for age and gender (CDC,
2018). Childhood obesity rates have increased in the United
States in the past five decades (Ogden, Carroll, Kit, &
Flegal, 2014). In the 1960s, the prevalence of obesity was
approximately 4% in 6- to 11-year-olds and 5% in 12- to
19-year-olds; however, by 1994, the prevalence had increased to 11% for both age groups (Ogden, Flegal, Carroll,
& Johnson, 2002). As of 2014, 17% of youth (aged 2–19
years) had obesity (Ogden et al., 2016). The prevalence of
obesity increases with age. Preschool-age children (2–5
years) have the lowest prevalence at 9.4%, increasing to
17.4% for children 6 to 11 years old and 20.6% for adolescents (12–19 years; Ogden et al., 2016). Recently, when
including overweight statistics, 31.8% of youth (aged 2–19
years) have overweight or obesity (Ogden et al., 2014). The
percentage of youth who meet criteria for severe obesity
(BMI greater than or equal to the 35 or 120% of the 95th
percentile in weight; Kelly et al., 2013) is 6% (Ogden et al.,
2016).
The burden of obesity poses some immediate and longer
term health risks for children. There are a number of immediate negative medical consequences due to obesity—
many of which increase as a function of the severity of
obesity. These health effects include Type 2 diabetes, hypertension, hyperlipidemia, metabolic syndrome, asthma,
polycystic ovarian syndrome, and nonalcoholic fatty liver
disease (Pulgarón, 2013). In children, more severe obesity
can lead to obstructive sleep apnea and musculoskeletal and
joint dysfunction (Bass & Eneli, 2015). In the longer term,
children with obesity have a higher probability of having
obesity as adults, and many of the adult comorbid conditions are more likely to occur with a prolonged history of
obesity (Goldhaber-Fiebert, Rubinfeld, Bhattacharya, Rob-
inson, & Wise, 2013; Singh, Mulder, Twisk, van Mechelen,
& Chinapaw, 2008). As children reach adolescence, an
elevated BMI becomes increasingly predictive of risk of
obesity (BMI greater than or equal to the 30 kg/m2) in
adulthood (Singh et al., 2008). For Black and White males
who have a BMI at or above the 85th percentile (overweight) at the age of 15, 56.6% and 59.2%, respectively, are
predicted to have obesity in their early 40s (GoldhaberFiebert et al., 2013). For Black and White females who have
a BMI at or above the 85th percentile at the age of 15,
89.4% and 78.3%, respectively, are predicted to have obesity in their early 40s (Goldhaber-Fiebert et al., 2013). The
higher probability of obesity in adulthood portends worse
health outcomes later in life. For instance, it is estimated
that over the next 40 years, those younger than 20 years old
with obesity may experience an increase in the prevalence
of Type 2 diabetes of 49% (Imperatore et al., 2012).
Obesity can also have deleterious effects on mental
health and psychosocial development in children. Compared with children who have a healthy weight, those
with obesity have higher rates of depression, social isolation, low self-esteem, and poorer quality of life (Small
& Aplasca, 2016). Weight-based stigmatization may play
an important role in these outcomes. Children with overweight or obesity experience pervasive and often unrelenting weight stigmatization from an early age (Harrist
et al., 2016; Puhl & Latner, 2007). Indeed, weight-based
bullying is more prevalent than bullying based on race,
sexual orientation, and religion (Puhl et al., 2016). Youth
with overweight experience significantly more bullying
than their peers who are of a healthy weight (van Geel,
Vedder, & Tanilon, 2014), with the severity of bullying
and stigmatization increasing as weight increases (Puhl,
Luedicke, & Grilo, 2014). Sources of stigmatization include peers, parents, teachers, coaches, and strangers
(Puhl et al., 2014).
180
CLINICAL PRACTICE GUIDELINE FOR OBESITY
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Previous Guidelines for Treatment of
Childhood Obesity
The need for evidence-based recommendations for the
treatment of obesity and overweight in children and adolescents has been recognized for over two decades. The first
expert panel was convened in 1997 and issued recommendations on the assessment and treatment of childhood obesity (Barlow & Dietz, 1998). However, their recommendations were predominantly developed from consensus
reached by the expert committee; few, if any, of the recommendations for assessment and intervention were based on
a systematic review of evidence, due to a lack of published
research in the area. As the evidence base has grown,
subsequent panels have been formed and now multiple
organizations provide guidance in this area.
Based on the results of systematic review (e.g., Whitlock,
O’Connor, Williams, Beil, & Lutz, 2010, and a more current
review used by the United States Preventative Services Task
Force [USPSTF]), in 2010, the USPSTF recommended that
clinicians screen children aged 6 to 18 years for obesity and
offer or refer these children to intensive counseling and
behavioral interventions to promote improvements in
weight status (Grade B recommendation; USPSTF, 2010)
and reconfirmed that recommendation in 2017 (USPSTF,
2017). These recommendations were endorsed by the
American Academy of Family Physicians (AAFP, 2017),
the American Heart Association (Kelly et al., 2013) and the
Academy of Nutrition and Dietetics (Hoelscher, Kirk,
Ritchie, Cunningham-Sabo, & Academy Positions Committee, 2013) both issued intervention recommendations to
focus on lifestyle changes. In 2013, the AHA recognized
limitations of initial lifestyle modifications and pharmacotherapy for children and adolescents with severe obesity and
recommended bariatric surgery as the most efficacious
treatment for severe obesity in adolescents (Kelly et al.,
2013). The 2013 AHA recommendations were endorsed by
the Obesity Society. Lifestyle intervention programs are
accepted as initial interventions due to the perceived reluctance of families and providers to begin weight management
with children and adolescents with either medication or
surgery, given the limited information about long-term impact and potential for adverse events.
Although the strength of the evidence in support of the
recommendations proposed by these health organizations is
variable, a common consensus is the requirement that interventions for the management of weight in children and
adolescents with overweight or obesity include four key
components. These components are following a healthy
diet, increasing physical activity and/or reducing sedentary
time, incorporating behavioral practices in support of the
required changes in behavior, and parental1/caretaker involvement (particularly for young children).
Scope of the Guideline
Earlier reviews and guidelines did not specify factors that
may be important for understanding how to implement an
intervention successfully, who may benefit most from intervention, what strategies are most efficacious, or areas of
patient engagement needed for successful outcomes. Therefore, in addition to examining the efficacy of family-based,
multicomponent behavioral interventions, the scope of the
American Psychological Association (APA) clinical practice guideline development panel’s effort included an examination of evidence addressing these other factors. Specifically, this included comparative effectiveness studies
that addressed implementation characteristics, child/family
moderators, intervention strategies, and patient engagement
to provide recommendations important for clinical implementation of the intervention. The panel commissioned the
Kaiser Permanente Research Affiliates Evidence-Based
Practice Center (hereafter, “Kaiser Permanente”) to conduct
a systematic review of the evidence to address these questions and based this guideline on that review (O’Connor,
Burda, Eder, Walsh, & Evans, 2016). The guideline does
not address other possible interventions (i.e., pharmacotherapy, bariatric surgery). The intended users of the guideline
include psychologists, other health and mental health professionals, students/training programs, patients, families of
patients, policymakers, and the public.
Process and Methods
Panel Formation
APA’s Advisory Steering Committee for the Development of Clinical Practice Guidelines (hereafter, “ASC”;
ASC, 2017) put out a call for the nomination (including
self-nomination) of both researchers and clinicians across
various professional disciplines (psychology, nursing, nutrition, general medicine) who had content expertise in the
topic area of obesity treatment as well as in biostatistics
or methodology. Individuals with knowledge of obesity
across age groups, sex, populations, and treatment settings
were sought in order to seat a diverse panel with a variety
of perspectives on obesity and its treatment that could
discuss the research evidence and its applicability to those
seeking treatment. Additionally, community members, selfidentified as having had obesity as children or adolescents,
who were active in the leadership of groups that sought to
enhance public awareness and access to services were
sought.
1
The panel recognizes that children live in many arrangements, typically with parents but sometimes with guardians or other carers. The panel
generally uses parents for simplicity in the text but periodically adds other
terms to underscore that appropriate adults may be engaged in care.
Furthermore, the research literature regularly refers to “parental” behavior
but again that is relevant to all adults raising children.
CLINICAL PRACTICE GUIDELINE FOR OBESITY
Conflicts of Interest
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Before final appointment to the panel, nominees provided
information regarding possible conflicts of interest (COIs).
COIs were defined as
a divergence between an individual’s private interests and his
or her professional obligations such that an independent observer might reasonably question whether the individual’s
professional actions or decisions are motivated by personal
gain, such as financial, academic advancement, clinical revenue streams, or community standing. (Schünemann et al.,
2009, p. 565; see also Institute of Medicine [IOM], 2011a, p.
78).
The IOM report additionally discusses intellectual COIs
relevant to clinical practice guidelines, which are defined as
“academic activities that create the potential for an attachment to a specific point of view that could unduly affect an
individual’s judgment about a specific recommendation”
(Guyatt et al., 2010, p. 739; see also IOM, 2011a, p. 78).
Although intellectual affiliations were expected, panel
members were not to be singularly identified with particular
interventions, nor were they to have significant known
financial conflicts that would compromise their ability (or
appearance thereof) to weigh evidence fairly. It was understood, however, that some “adversarial collaboration” representing different points of view was to be expected and
encouraged as part of the process. Upon successful completion of the reviews, the ASC made the final membership
recommendations to the APA Board of Directors for confirmation.
Scoping and Key Questions of Systematic Review
The panel used a “PICOTS” (Population, Intervention,
Comparator, Outcomes, Timing, and Setting; Samson &
Schoelles, 2012) approach to scoping the systematic review.
With this approach, the panel used each of these elements as
a framework to guide decisions about scope. First, regarding
the population component, based on the existence of a
recently released guideline focusing on treatment of obesity
in adults, including lifestyle/behavioral interventions (Jensen et al., 2013), the panel decided to focus its work on
children and adolescents. For the intervention and comparator components, the panel decided to focus on familybased multicomponent interventions based on expert knowledge of the intervention literature and an initial literature
scoping conducted by Kaiser scientists. Based on the outcome prioritization survey in which panel members rated
outcomes from 1 (not important) to 9 (critical) for making
a decision about what treatment to recommend, the panel
decided to focus on BMI/zBMI and serious adverse events
as the most critical outcomes. Finally, based on an initial
literature scoping conducted by Kaiser scientists, along with
panel member expertise, the panel made decisions about the
181
timing and setting of the interventions (assessment of outcome 12 or more months after initial assessment, outpatient
settings).
Clinical limitations notwithstanding, BMI is considered
an indirect measure of body fat that is meant to screen for
overweight or obesity. In children, it is recommended that a
BMI be calculated and plotted on the CDC BMI-for-age and
sex-specific growth curve at a minimum annually. A BMI
could also be standardized (zBMI) so that each score represents an individual’s standing relative to his or her specific age and sex group. BMI has demonstrated acceptable
clinical validity and can guide weight management in children (Barlow & Expert Committee, 2007; Styne et al.,
2017).
The panel’s decisions about which PICOTS to focus on
(based on the scoping review of existing guidelines and
reviews on obesity conducted by Kaiser scientists, outcomes prioritization survey, and panel member expertise)
led directly to the formulation of the key questions. The key
questions articulate the PICOTS of interest in a form that is
conducive to guiding the systematic review undertaken to
address the panel’s questions. The five key questions identified by the panel were the following:
Key Question 1: In children and adolescents with overweight
or obesity, do family-based multicomponent behavioral interventions reduce and maintain change in age/sex- standardized
BMI?
Key Question 2: What is the impact of selected characteristics
of family-based multicomponent behavioral interventions
(dosage of contact, setting, interventionist qualifications,
mode of delivery, use of multidisciplinary team, involvement
of psychologist, cultural tailoring) in the management of age/
sex-standardized BMI? Specifically,
Key Question 2a: Are these characteristics associated with the
efficacy of the interventions?
Key Question 2b: What is the comparative effectiveness of
these characteristics?
Key Question 3: How do selected patient and family sociodemographic characteristics (child’s age, severity of adiposity,
parental obesity, race, socioeconomic status) affect familybased multicomponent behavioral interventions? Specifically,
are different strategies used or needed for families with different sociodemographic characteristics?
Key Question 4: What is the impact of selected strategies of
family-based behavioral interventions (goals and planning,
comparison of outcomes, self-monitoring of behavior, selfmonitoring of outcome, reward and threat, stimulus control,
modeling of healthy lifestyle behaviors by parents, motivational interviewing, general parenting skills [e.g., positive
parenting] or family conflict management) in the management
of age/sex-standardized BMI? Specifically,
Key Question 4a: Are these strategies associated with the
efficacy of the interventions?
182
CLINICAL PRACTICE GUIDELINE FOR OBESITY
Key Question 4b: What is the comparative effectiveness of
these strategies?
Key Question 5: What is the effect of patient adherence (e.g.,
percentage of homework completed, percentage of sessions
attended), engagement, and retention on BMI outcomes?
Specifically,
Key Question 5a: What interventions or intervention characteristics and strategies are associated with these factors?
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Key Question 5b: What levels of patient adherence, engagement, and retention are associated with improved efficacy of
the interventions?
The systematic review and guideline do not address any
of the following: (1) screening for overweight or obesity,
treatments other than family-based multicomponent interventions, assessment of associated conditions, or follow-up
after treatment; (2) prevention of overweight or obesity; (3)
costs of treatments; or (4) availability of care.
Specific scoping decisions about which populations, interventions, comparators, outcomes, timing, and settings to
include are detailed in Figure 1 of the full guideline document.
Comprehensive Search of the Scientific
Literature
As the name implies, a systematic review involves a
methodical and organized search for studies and evidence of
efficacy (and comparative effectiveness) regarding the treatment under consideration (IOM, 2011b). For the systematic
review conducted by the Kaiser Permanente scientists
(O’Connor et al., 2016), a variety of scientific databases
were searched using selective search terms to identify relevant studies (see Appendix A [pp. A1–A15] of the systematic review). The identified individual studies were then
assessed to determine whether they met inclusion criteria
(e.g., were aged 2–18 years) and rated, using predefined
criteria, to establish quality. Studies were included if they
met inclusion criteria and were randomized controlled trials
or nonrandomized controlled clinical trials that were of fair
or good quality. In brief, after an exhaustive search strategy,
screening of 9,491 records, review by researchers of the
full-text of 577 articles, 119 articles (65 studies—i.e., more
than one published article resulted from some studies) were
included in the systematic review.
Of the 65 included trials, 36 were “efficacy trials” that
evaluated the family-based multicomponent behavioral intervention against a control group. Two trials were
maintenance-only interventions (“maintenance trials”) that
participants engaged in after finishing the weight reduction
intervention. Thirty-four of the trials were classified as
“comparative effectiveness” due to the inclusion of at least
two active intervention arms. However, six of these were
also classified as efficacy trials due to the inclusion of a
control group. Table 2 in the full guideline document2
provides details of the effect sizes.
The settings for all studies were outpatient and included
such places as primary care medical, specialty care medical,
or other (i.e., community; school, such as an after-school
program but not classroom-based; research clinic at a university) settings (O’Connor et al., 2016). Forty-four percent
of the 36 efficacy trials were conducted in the United States,
with the remainder being conducted in various countries
outside the United States. Seventy-two percent of efficacy
trials were conducted in health care settings, with the remainder being conducted in a community setting. Twentyeight percent of the efficacy trials included multiple age
groups, 17% concentrated on preschoolers, 47% concentrated on elementary-aged children, and 8% concentrated on
adolescents. Females comprised 58% of the children, and
many efficacy studies did not report race/ethnicity
(O’Connor et al., 2016). Table 3 of the underlying systematic review (O’Connor et al., 20163) provides additional
details about each included study.
Development of Evidence Tables
Evidence tables (summaries of data in available studies)
were created by the Kaiser Permanente scientists from evidence collected for the systematic review regarding the
efficacy or comparative effectiveness of treatments. These
tables contain the foundational evidence on which current
recommendations were made and generated some of the
information included in the grid (described below).
The evidence tables (see Appendix D of the systematic
review; O’Connor et al., 20164) were abstracts of data in the
systematic review and include, as available for each body of
evidence, the number of studies, effect sizes, confidence
intervals (when available), and quality ratings.
Development and Use of Evidence Grid
The evidence grid is a document developed and used by
panel members to summarize and evaluate the evidence
generated in the systematic review, along with any supplemental information. Panel ratings and judgments were documented on the grid to assist in the formulation of recommendations. This grid allowed panel members to document
decisions, compare consistency across decisions, and provide transparency to reviewers and users of the guideline
document.
2
The full document is available online at https://www.apa.org/obesityguideline/clinical-practice-guideline.pdf.
3
The full systematic review is available online at https://www.apa.org/
obesity-guideline/systematic-evidence-review.pdf.
4
The appendix of the systematic review is available online at https://
www.apa.org/obesity-guideline/systematic-evidence-review-appendixes
.pdf.
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CLINICAL PRACTICE GUIDELINE FOR OBESITY
Four domains of information— overall strength of the
evidence, balance of benefits versus harms/burdens, patient
values and preferences, and applicability— constituted the
basis on which each treatment recommendation and its
strength was determined.
Rating of aggregate/global strength of evidence (SOE).
For each column of the grid (which corresponds to a key
question and/or specific intervention [i.e., number of contact hours]), aggregate/global SOE was based on the SOE
from the systematic review for the two critical outcomes,
namely, response to treatment (measured as BMI/zBMI as
an absolute response, as well as a response of ⱖ⫺0.25
zBMI, which may provide significant improvements in cardiometabolic health in children [Ford, Hunt, Cooper, &
Shield, 2010; Kalavainen, Utriainen, Vanninen, Korppi, &
Nuutinen, 2012]) and serious adverse events. In accordance
with the GRADE consortium system, the panel adhered to
the rule that the aggregate SOE could be no higher than the
lowest individual SOE for each of the critical outcomes
(Guyatt et al., 2013). For example, if one critical outcome
had “high” SOE but the other critical outcome had “low”
SOE, the global quality of evidence for that particular
column in the grid would be “low,” as that is the lowest
SOE for an individual critical outcome. The SOE for serious
adverse events, one of the panel’s critical outcomes, was
insufficient/very low for all interventions for which grid
columns were completed. This explains why the global SOE
was insufficient/very low for all interventions, despite low,
moderate, or high SOE for the critical outcome of BMI/
zBMI. Thus, the application of the rule of aggregate SOE is
a limitation in the case of behavioral interventions in which
reporting of serious adverse events is limited yet the harms
are considered minimal. The panel rated each component
separately to highlight the higher SOE for BMI/zBMI.
Assessing magnitude of benefits. One of the key components of the decision-making process for the panel was
assessment of the balance between benefits and harms. This
required that both benefits and harms be quantified. Magnitude of benefits was rated as large, medium, or small
benefit of treatment or no difference in effect or unable to
rate.
Assessing magnitude of harms/burdens. Because “serious adverse events” was one of the two critical outcomes
of treatment decided upon by the panel, these needed more
precise specification and definition. Ultimately, panel members defined events such as medical problems (e.g., stunted
growth) as a serious adverse event. Harms were differentiated from burdens, with harms identified as negative events
resulting from treatment (e.g., symptom worsening) and
burdens as disruptions associated with treatment (e.g., time
spent, convenience). The systematic review of the treatment
literature did not generate sufficient data on harms and
burdens of interventions because this information is not
routinely reported in studies.
183
In response to this deficit, the panel commissioned APA
staff to examine articles in the systematic review to extract
data regarding harms and burdens, such as dropout/attrition,
symptom worsening, and so forth. Further, clinicians as
well as the community member on the panel reported on
their as well as peers’ experiences with the interventions.
This information was considered together when evaluating
harms and burdens.
Assessing patient values and preferences. In addition
to assessing the benefits and the harms/burdens associated
with specific interventions, the panel attempted to ascertain
patient values and preferences. As described above, to ascertain this information, the panel relied on a search of the
literature as well as on clinicians and community members
on the panel who voiced their perspectives about preferences for different interventions and the value that patients
might place on different outcomes or harms/burdens associated with particular treatments. The SOE for the sources
of information assessing patients’ values and preferences
for different interventions was very low because it included
observational studies and “expert” (i.e., panel member)
opinion.
Applicability of evidence. The final determinant that
panel members considered before making recommendations
was the applicability (generalizability) of the evidence to
various populations and settings. To organize information
on applicability, panel members again applied the PICOTS
framework. The panel reviewed specific information from
the studies to determine whether there were any concerns
about applicability pertaining to specific patient populations
that needed to be included on the grid.
Decision Making Regarding Treatment
Recommendations
On the basis of the ratings of these four factors (SOE,
balance of benefits vs. harms/burdens, patient values and
preferences, and applicability), the panel then made a decision regarding its recommendation for a particular treatment
or comparison of treatments. The options included a strong
(“the panel recommends”) or conditional (“the panel suggests”) recommendation either in support of or against a
particular treatment on the basis of the combination of these
factors. Panel members could also decide that there was
insufficient evidence to be able to make a recommendation
about a particular treatment. Panel members were able to
reach consensus regarding the strength of each recommendation.
External Review Process
This document was submitted to the ASC for feedback.
The document was posted on the APA website and public
feedback was solicited for 60 days. Panel members reviewed all comments and further revised the document.
184
CLINICAL PRACTICE GUIDELINE FOR OBESITY
Recommendations and Statement of Evidence
The panel recommends the following:
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Recommendation
For child and adolescent patients aged 2 to 18 with
obesity or overweight, the panel strongly recommends the
provision of family-based multicomponent behavioral interventions, with a minimum of 26 contact hours, initiated at
the earliest age possible.
Each of the family-based multicomponent behavioral interventions included at a minimum of three components:
physical activity (increase physical or decrease sedentary
activity), dietary change, behavioral component that supports the physical activity and/or dietary change components. There was insufficient evidence for the panel to make
a specific recommendation about the content of the intervention (intervention strategies, characteristics) beyond
these three components. However, as an illustrative example, one of the included interventions (Coppins et al., 2011)
involved approximately 48 contact hours delivered and designed by a team including a psychologist (clinical or educational), dietician, health promotion officer for physical
activity, and two or three instructors for physical activity.
The intervention consisted of two workshops (8 total hours)
and two weekly sessions of physical activity over the school
year. The physical activity sessions were led by the physical
activity instructors, whereas the workshops involved the
whole team of professionals. The workshops involved the
child/adolescent participant plus his or her parent/guardian
and similar-aged siblings and included content on psychological well-being, behavior change, physical activity, decreasing sedentary behavior, and healthy eating. Among the
psychological well-being topics covered were self-esteem,
bullying, building resiliency in children, and the important
role of family support (Coppins et al., 2011). Additional
detailed descriptions of included interventions are available
in the appendixes of O’Connor et al. (2016).
Statement of evidence rationale. Of 36 efficacy trials
for children or adolescents with overweight or obesity, familybased multicomponent behavioral interventions showed an
average reduction of ⫺0.16 zBMI (95% confidence interval
[⫺0.24, ⫺0.07]) relative to nonactive controls. Of 24 efficacy and comparative effectiveness trials for children or
adolescents with overweight or obesity, family-based multicomponent behavioral interventions with 26 or more contact hours achieved a zBMI reduction greater than or equal
to ⫺0.25 in 58.3% of the trials. Of these 24, 12 were
efficacy trials that provided moderate quality of evidence of
a medium effect, and 12 were comparative effectiveness
trials that provided low quality evidence of a medium effect.
Of 25 efficacy or comparative effectiveness5 trials for
children or adolescents with overweight or obesity using
family-based multicomponent behavioral interventions with
26 or more hours of contact, there was a significant association (p ⫽ .03) between age and whether the trial met the
clinically significant reduction in zBMI greater than 0.25.
Among the 14 trials showing a clinically significant reduction, 10 (71%) targeted preschool or elementary-aged children. All trials targeting preschool children showed a benefit. Pages 21 to 23 of the full guideline document provides
additional details of the evidence rationale underlying the
recommendations.
The panel was unable to make recommendations on the
following:
Comparative Effectiveness of Strategies
There was insufficient evidence to determine the comparative effectiveness of selected strategies of family-based
multicomponent behavioral interventions, including goals
and planning, comparison of outcomes, self-monitoring of
behavior, self-monitoring of outcome, contingent reward or
threat, stimulus control, modeling of healthy lifestyle behaviors by parents/caregivers, motivational interviewing, or
parenting skills training.
Adherence, Engagement, or Retention in
Treatment
There was insufficient evidence to determine whether
specific intervention characteristics or strategies were associated with adherence, engagement, or retention. Higher
attendance was associated with greater efficacy but there
was insufficient evidence to determine whether adherence
(beyond attendance) was associated with efficacy.
Applicability to Specific Patient/Family
Characteristics
There was insufficient evidence to determine whether
specific intervention strategies were more effective with
patients or families having specific characteristics. Other
than age, there was either no association or insufficient
evidence to determine whether population characteristics
were associated with outcome.
Potential Harms and Burdens of Treatment
Potential Harms
No medical harms for the recommended treatment were
reported in studies included in the systematic review. The
panel recognizes that family conflict could arise during
treatment. Children could develop psychological issues related to the success or failure of the recommended interven5
This includes one comparative effectiveness trial that was a maintenance trial.
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CLINICAL PRACTICE GUIDELINE FOR OBESITY
tion. Few studies assessed psychological well-being but 11
did report on quality of life and only one study suggested a
possible negative impact from the intervention; all others
reported no difference or suggested the higher intensity
intervention may result in slightly improved quality of life.
It was rare for any of the included studies to report on
harms, and generally if there was a statement on harms, it
simply indicated that adverse events did not occur
(O’Connor et al., 2016). Thus, the low SOE is a function of
the nature of the evidence the panel used to make determinations about harms (observational study data, patient and
clinician input), not a statement regarding whether or not
harms occurred in these interventions. It will be important
for future trials to include information on possible adverse
events.
Potential Burdens
The panel noted potential burdens, such as extra effort
needed to access treatment (recommended treatment is more
often available in specialty clinics, but specialty clinics are
not in every geographical area and not always easily accessed) and lack of access to safe physical activity and
healthy foods. Another potential burden is that treatment
typically requires at least two family members, a parent and
a child, to be engaged (relatively few interventions are
parent only). Another potential burden is the amount of time
required (for meeting with providers and at home), which
can be inconvenient, difficult, and costly. These burdens
may be greater for families of lower socioeconomic status.
Discussion
Implementation
Although there was no direct evidence to support a specific dietary intervention or physical activity regimen over
another, the findings support the use of family-based multicomponent behavioral interventions that address behavior
change, diet, and physical activity with sufficient intensity.
Sufficient intensity was operationalized as having at least 26
contact hours. As no single strategy emerged as superior to
others, providers have flexibility in selecting an efficacious
family-based multicomponent behavioral intervention program and utilize strategies to accomplish change appropriate for particular patients and local implementation needs.
Treatment should focus not solely on weight but on overall
health and the development of healthful behaviors in the
family and target change in physical activity, eating, and
sedentary behaviors (energy-balance behaviors). Based on
the synthesis of the literature, this section highlights program components and potential barriers and strategies to be
considered for successful program implementation.6
It is important to note that these multicomponent behavioral interventions are not solely provided to the child or
185
adolescent but, importantly, also involve the parents and
potentially other family members as active participants, and
the level of their involvement can vary according to the
developmental age of the child. The emphasis is on equipping caregivers with tools (problem solving, providing contingent rewards, etc.) that can be used to manage energybalance behaviors and are helpful to support positive
parenting. Both parents and children are targeted for increases in healthy physical activity and eating behavior and
decreases in sedentary behavior. Family-based behavioral
treatments typically do not promote extreme dietary restrictions but instead focus on changes such as an increase in
consumption of fruits and vegetables and a decrease in
consumption of sugar-sweetened beverages to enhance diet
quality. Activity changes may include reducing the amount
of time spent in screen-based behaviors, such as TV watching. In successful interventions, families learn how to focus
on energy-balance behaviors in their actions and conversations rather than on weight, as that can be stigmatizing and
disheartening. Practitioners have a fair amount of flexibility
regarding the energy-balance behaviors when tailoring specific elements to participating families, taking into consideration such characteristics as child gender, age, ability
status, and family culture. The following points should be
considered for successful implementation.
First, it is unknown whether all of the strategies of successful trials noted previously are necessary or how each
affects individual outcomes. There was no direct evidence
to support a specific strategy or mode of delivery of dietary
intervention or physical activity regimen over another.
Thus, until further research compares strategies directly,
practitioners have a fair amount of flexibility when choosing specific elements or mode of delivery within the areas of
physical activity, nutrition, and behavioral change when
providing care or establishing new programs, especially in
order to match specific characteristics of the family or
situation.
Second, flexibility in treatment setting together with
problem solving are needed to address location and other
practical concerns that are potential barriers to treatment.
Because there was insufficient evidence to recommend a
specific program venue, offering care in the variety of
settings available in rural and urban areas, such as schools,
medical settings, community centers, and faith-based settings, would be important to increase accessibility.
Third, the age of the child is a consideration. Evidence
suggested treatment may work especially well for young
children, supporting the importance of intervening as early
as possible. As programs are developed for different groups,
the child’s developmental age as well as the participants’
6
Providers are encouraged to access the following webpage for specific
intervention resources and program material: https://www.apa.org/obesityguideline/for-clinicians.
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186
CLINICAL PRACTICE GUIDELINE FOR OBESITY
culture, values, and preferences should be integrated into
the interventions (e.g., see Falbe, Cadiz, Tantoco, Thompson, & Madsen, 2015; Hammons, Wiley, Fiese, & TeranGarcia, 2013).
Fourth, practitioners should develop knowledge, skills,
and awareness related to weight bias and stigma (differential and negative treatment and attitudes experienced by
people who have overweight or obesity). Health professionals and family members have been identified as the most
frequent sources of weight stigma for individuals with obesity (Puhl & Brownell, 2006; Puhl & Latner, 2007; Puhl et
al., 2014). Consequences of weight stigma reported in children include psychosocial concerns of lower self-esteem,
depression, body dissatisfaction, and a negative impact on
their interpersonal relationships (Puhl & Latner, 2007). Furthermore, the panel encourages providers to work with
children and parents to address stigma that may be occurring within the family (e.g., name calling, shaming, and
criticism related to weight). Providers may want to be
familiar with the report Provider Competencies for the
Prevention and Management of Obesity (Bradley, Dietz,
and the Provider Training and Education Workgroup, 2017)
as well as a summary of children and adolescents’ experience with weight stigma by Pont, Puhl, Cook, Slusser, and
the Section on Obesity, The Obesity Society (2017) that
details important recommendations for working with children and adolescents who have obesity or overweight.
Fifth, these are multicomponent interventions, often delivered by multidisciplinary teams. There was insufficient
evidence to conclude that type of provider has an effect on
outcome of the child’s BMI. It should be noted, however,
that studies of high-intensity interventions were more likely
to report that providers had expertise in behavior change,
diet, and physical activity. These interventions can be delivered in specialty clinics as well as integrated care settings, but consensus suggests that providing treatment for
obesity within integrated systems of care is preferred (Wilfley et al., 2017). Integrated care that includes both physical
and behavioral health experts has been shown to provide
many benefits to patients through improved adherence to
treatment recommendations, decrease in hospitalizations
and improvements in patient outcomes (APA, 2016). The
care delivery team for the treatment of children with obesity
and overweight typically consists of a primary provider
tasked with medical oversight along with a behavioral
health care provider specifically trained in the management
of childhood obesity. Additional team members may include physical activity specialists and dietitians.7
Sixth, obtaining 26 or more contact hours may be cost
prohibitive for many families. Most insurance coverage does
not include participation in intensive multicomponent treatment, weight management programs, or nutritional counseling.
The panel urges providers, professional associations, and patient advocacy organizations to continue to work with insur-
ance companies and government policymakers to advance
coverage for obesity prevention and treatments generally, and
for children, in particular.
Limitations
The trials included in the review spanned a range of ages,
settings, recruitment methods, and types of professionals
delivering the intervention. There is some concern, however, about the applicability of results for certain populations, including groups most affected by obesity. Race and
ethnicity were not reported in many trials, and there were
relatively few trials that included at least 50% Black or
Latino youth. The panel was also not able to answer questions related to socioeconomic status due to limited data,
and very few trials specifically targeted participants of low
socioeconomic status.
Additionally, studies with youths who have an eating disorder, were pregnant or postpartum, or have overweight or obesity secondary to a genetic or medical condition were not
included in the review. Although these youths also could
potentially benefit from family-based, multicomponent behavioral interventions, modifications may be needed with these
populations, and this is an important area for further research.
Although interested in exploring other outcomes, the
panel ultimately decided to examine only BMI/zBMI as a
critical outcome (along with serious adverse events), as that
was the only one consistently captured across studies.
Therefore, although interventions may have impacted other
outcomes—including health behaviors (e.g., food choices,
amount of exercise), other anthropometric variables besides
BMI, and/or psychosocial variables, any of which could
affect weight status over time—these other outcomes would
not be captured in this document.
Further, more research is needed to establish the minimal
amount of reduction in BMI/zBMI needed to achieve clinically
relevant health improvements, particularly cardiometabolic
health, in children and adolescents. Also needed are evaluations of the durability of outcomes over longer time periods (at
2 years or 5 years), especially by subpopulations.
Conclusion
This clinical practice guideline for the treatment of obesity and overweight in children and adolescents was created
according to current standards and best practices for conducting systematic reviews and developing guidelines
(IOM, 2011a, 2011b). The guideline recommends family7
Although not discussed specifically in the guideline document, it is
worth noting that psychologists can have various roles in this field. In
addition to providing interventions, psychologists can develop strategies to
address weight bias and stigma, conduct research to ascertain critical
components of interventions, and work to advance policies surrounding
reimbursement for services.
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CLINICAL PRACTICE GUIDELINE FOR OBESITY
based multicomponent behavioral interventions with at least
26 contact hours for children and adolescents with overweight or obesity. This recommendation is consistent with
those of previous guidelines.
Given insufficient evidence, the panel was not able to
make recommendations regarding specific intervention
characteristics or strategies, or to make recommendations
for patients or families with particular characteristics. This
points to the need for additional research that examines the
comparative effectiveness of interventions, the impacts of
specific components of interventions, and the factors that
contribute to engagement and adherence.
Further, more research needs to be conducted with children and adolescents who belong to racial and ethnic minority groups and/or are of lower socioeconomic status.
Research articles should also regularly report on the composition of their samples on these dimensions. It would be
useful as well to pursue research that assesses the efficacy
of culturally tailored interventions.
Regarding outcomes, more research is required to understand what counts as a clinically meaningful reduction in
BMI/zBMI in children and adolescents. More broadly, research that considers other types of outcomes (biological,
behavioral, and psychosocial) is needed as well.
Finally, although considerations of the costs and economic impacts of interventions were outside the scope of
the guideline, it can be noted that the intensive form of
intervention that is recommended is expensive and often not
covered by insurance. This guideline and the evidence that
underlies it can be used to argue to policymakers and payers
for enhanced coverage for recommended interventions as
well as other measures to increase their availability.
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Whitlock, E. P., O’Connor, E. A., Williams, S. B., Beil, T. L., & Lutz,
K. W. (2010). Effectiveness of weight management interventions in
children: A targeted systematic review for the USPSTF. Pediatrics, 125,
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Wilfley, D. E., Staiano, A. E., Altman, M., Lindros, J., Lima, A., Hassink,
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http://dx.doi.org/10.1002/oby.21712
Received March 4, 2019
Revision received July 31, 2019
Accepted July 31, 2019 䡲
Original Research Article
Medical Students’ Perceived Educational Needs to
Prevent and Treat Childhood Obesity
Natalie K. Cooke, Sarah L. Ash, L. Suzanne Goodell
Department of Food, Bioprocessing, and Nutrition Sciences, North Carolina State University, Raleigh, NC 27695, USA
ABSTRACT
Background: Medical schools are challenged to incorporate more prevention‑based education into curricula, offering an opportunity to
revisit approaches to nutrition education. The objective of this study was to explore United States (US) medical students’ understanding
of childhood obesity, specifically barriers to childhood obesity prevention and treatment and students’ perceived educational deficits.
Methods: The research team conducted phone interviews with 78 3rd‑ and 4th‑year medical students, representing 25 different medical
schools across the US. Using a semi‑structured interview guide, researchers asked students to describe the etiology of childhood obesity
and reflect on where they acquired knowledge of the etiology and what additional resources they would need to treat obese children. Using
a phenomenological approach to analysis, researchers identified five dominant emergent themes. Results: Student‑perceived barriers to
childhood obesity prevention and treatment in clinical care included student‑centered (e.g., lack of knowledge), patient‑centered (e.g., lack
of access), and healthcare system‑centered barriers (e.g., limited time). Students requested more applicable nutrition information and
counseling skills relevant to preventing and treating childhood obesity; however, they tended to identify others (e.g., parents, schools),
rather than themselves, when asked to describe how childhood obesity should be prevented or treated. Discussion: To provide students with
an understanding of their role in preventing and treating childhood obesity, US medical schools need to provide students with childhood
obesity‑specific and general nutrition education. To build their self‑efficacy in nutrition counseling, schools can use a combination of
observation and practice led by skilled physicians and other healthcare providers. Increasing students’ self‑efficacy through training may
help them overcome perceived barriers to childhood obesity prevention and treatment.
Keywords: Childhood obesity, interviews, medical education, qualitative research
Background
and recent healthcare system policies point to the timely need
to alter US medical school curricula accordingly.[4]
Once thought to be a problem in only high‑income countries,
obesity is now a global epidemic, impacting low‑, middle‑, and
high‑income countries.[1] Obesity was recently classified as a
disease,[2] drawing attention to the importance of prevention
and treatment in clinical settings. United States (US) medical
schools now promote prevention‑based medical education,[3]
Access this article online
Quick Response Code:
Website:
www.educationforhealth.net
DOI:
10.4103/efh.EfH_57_16
Address for correspondence:
Dr. Natalie K. Cooke, Department of Food, Bioprocessing, and
Nutrition Sciences, North Carolina State University, Campus
Box 7624, Raleigh, NC 27695, USA.
E‑mail: nkcooke@ncsu.edu
156
Globally, overweight and obesity impact more than 2 billion
people.[1] Within the US, childhood obesity affects 17% of
children 2–19 years of age,[5] threatening their physical and
psychological health[6‑8] and significantly increasing healthcare
costs.[9] Physicians can play a key role in early prevention
because they see children at frequent, regular intervals[10]
and because patients believe physicians hold the authority
to help them lose weight.[11] To facilitate pediatric weight
management, physicians need to encourage patients to limit
consumption of sugar‑sweetened beverages and energy dense
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Cooke NK, Ash SL, Goodell LS. Medical students’
perceived educational needs to prevent and treat childhood obesity. Educ
Health 2017;30:156-62.
© 2017 Education for Health | Published by Wolters Kluwer – Medknow
Cooke, et al.: Medical students’ needs to prevent childhood obesity
foods, consume high‑fiber diets rich in fruits and vegetables,
and participate in daily physical activity with limited screen
time.[12] Nutrition behavior change counseling can help promote
healthier eating practices;[13] therefore, physicians‑in‑training
need to understand both nutrition information and counseling
practices to engage patients in change.
Unfortunately, nutrition education in medical school is often
limited, both in the US[14‑16] and in other countries.[17] In the
US, this inadequacy has been reported since the 1950s,[18]
and the most recent reports indicate that medical schools
provide an average of only 19.6 hours of nutrition‑related
education.[14] These statistics reflect nutrition education as
a whole, which suggests that childhood obesity content
is even more limited. Not surprisingly, this lack of training is
reflected in the beliefs and actions of practicing physicians,
who express low self‑efficacy in obesity management.[19] Only
half of pediatricians report using nutrition behavior change
counseling,[20] and fewer than half follow recommendations[21]
or believe they can help obese patients lose weight.[19] Few
feel competent in treating childhood obesity, and most do not
address weight concerns in overweight children.[22] This is not
just a US phenomenon, rather lack of nutrition knowledge
is seen in other parts of the world,[17,23‑25] with both medical
students and physicians expressing desire for more nutrition
education in medical school.[17] These inadequacies highlight
the need to increase nutrition knowledge and build nutrition
counseling self‑efficacy among medical students around the
world.
The medical community has expressed the need for medical
nutrition education reform,[4,15,18] urging that the time for
change is now. The research to date has been primarily
quantitative;[26‑29] however, qualitative methodologies could
reveal the complexity of US medical students’ experiences.
Therefore, we employed a qualitative, phenomenological
approach [30,31] to explore medical students’ educational
experiences relative to the etiology, prevention, and treatment
of childhood obesity.
Methods
Participants and recruitment
Participants were 3rd‑ and 4th‑year students at allopathic and
osteopathic medical schools in the US who were recruited
through listservs or referral from another medical student.
The final sample (n = 78) was determined by saturation,[32]
with students representing 25 medical schools in 16 different
states in each of the four major census regions of the US.
Students’ ages ranged from 23 to 44 years, and they came
from a variety of educational backgrounds [Table 1]. The
Institutional Review Board at North Carolina State University
granted ethical approval.
Education for Health • Volume 30 • Issue 2 (May‑August 2017)
Data collection and analysis
Before data collection, we developed a standardized
interview guide to explore medical student views through
open‑ended questions and probes [Table 2]. Each of the four
research assistants engaged in standardized qualitative
research training before beginning data collection.[33] Each
phone interview lasted for 30–90 minutes and was digitally
audio‑recorded. We transcribed interviews verbatim except
two files lost due to technical difficulties, where we used
interviewer notes instead.
While data were being collected, we held weekly meetings
to determine saturation and begin preliminary data analysis
through reflexive critical dialogue and identification of
preliminary dominant emergent themes.[32] After reaching
saturation, we developed a coding manual containing twenty
codes organized into seven coding categories, with the
structure being guided by preliminary dominant emergent
themes. During secondary analysis, four coders used
the coding manual to individually code transcripts. Before
beginning the individual coding process, coders became
familiar with the process by all individually coding the
same transcript and reviewing differences. After coders felt
comfortable with the process of coding, we randomly assigned
one‑third of the transcripts to three of the four coders. The
remaining, primary coder coded all of the transcripts and
reviewed all transcripts.[34] During these weekly meetings,
coders discussed difficulties with codes to reduce coder drift[35]
and determined dominant emergent themes.[36] After entering
codes into NVivo9 Qualitative Software, we then reviewed
quotes in each coding category to determine a comprehensive
Table 1: Participant demographics of qualitative interviews with
United States allopathic and osteopathic medical students (n=78)
Characteristic
Type of medical school
Allopathic (18 schools)
Osteopathic (7 schools)
Year in medical school at time of interview
Third
Fourth
Gender
Male
Female
Prior course in nutrition
Planning to specialize in family medicine
or pediatrics
Additional degrees
Completed/currently pursuing: Masters
of Public Health or Masters of Nutrition
Completed/currently pursuing: Other
graduate degree
Considering: Masters of Public Health
Number of
students
Percent of
students
57
21
73
27
35
43
45
55
32
46
26
32
41
59
33
41
11
14
14
18
7
9
157
Cooke, et al.: Medical students’ needs to prevent childhood obesity
Table 2: Major interview questions and probes asked of United States allopathic and osteopathic medical students (n=78) during qualitative
interviews
Major questions
What do you think of when you hear the phrase “obese child”?
What leads to childhood obesity? Who contributes to the cause?
What do you think are the consequences of childhood obesity?
What should or can be done to prevent childhood obesity, if anything?a
What should or can be done to treat childhood obesity?a
How important do you think nutrition knowledge is in preparing you to treat obese
children?b
We’ve heard a lot of students say that their medical school coursework or clinical
rotations did not completely equip them to treat obese children or prevent childhood
obesity. What information, resources, or skills do you need to treat obese children?
What information, resources, or skills do you need to prevent childhood obesity?b
Major probes
How do you define “childhood obesity?”
What do obese children look like?
How do obese children act?
Is there anything different between a “normal weight” child and an obese child?
Think about what you might have learned about the causes of childhood
obesity in your medical school courseworkc
Think about what you might have learned about the causes of childhood
obesity in your clinical experiencec
Think about what you might have learned about the consequences of
childhood obesity in your medical school courseworkc
Think about what you might have learned about the consequences of
childhood obesity in your clinical experiencec
Think about what you might have learned about the prevention/treatment of
childhood obesity in your medical school courseworkc
Think about what you might have learned about the prevention/treatment of
childhood obesity in your clinical experiencec
Think about what you might have learned in your medical school courseworkc
Think about what you might have learned in your clinical experiencec
The question about treatment was added after 34 of the 78 interviews were completed, and the question about prevention was maintained, bThe nutrition knowledge question was replaced by the
information, resources, and skills question after saturation was reached on the nutrition question, cProbes were asked after each major question
a
understanding of the phenomenon and a final list of dominant
emergent themes within and across coding categories.[36]
Results
Analysis surfaced five dominant emergent themes relative to
the phenomenon of medical students’ perceived barriers and
needs associated with their childhood obesity training [Table 3].
Students’ descriptions of barriers were revealed throughout
the interviews in their discussion of the etiology of childhood
obesity and their reflection of where they learned about the
causes, consequences, prevention, and treatment of childhood
obesity. Their perceived needs associated with training surfaced
primarily from the end of the interview when asked about the
importance of nutrition or what information, resources, and
skills they would need to treat childhood obesity.
Medical student‑centered barriers
Medical students described a variety of student‑centered
barriers, with the most prevalent one being limited nutrition
education in medical school. Students said that they learned
nutritional biochemistry but not basic nutrition knowledge to
share with patients. Recognizing their nutrition coursework
was limited, students said they felt unprepared to provide
nutrition recommendations in a clinical setting. One student
said, “If someone were to tell me right now, ‘We have an
obese child, can you help put this child on… a healthy diet?’
I don’t know what I would say.” Students explained that their
nutrition coursework was not applicable to patients and they
were not prepared to counsel patients. One student said,
158
Table 3: United States medical student‑perceived barriers and
requested needs relative to childhood obesity prevention and
treatment
Themes
Barriers
Medical student‑centered
Patient‑centered
Healthcare system‑centered
Needs
Knowledge
Counseling skills
Examples
Limited nutrition education in medical school
Limited experience in clinical rotations
Limited access to healthy food and safe play
Limited nutrition knowledge
Socioeconomic stresses
Limited time
Limited time with patients
Minimal follow‑up with patients
Need to treat the immediate medical concern
Evidence‑based nutrition knowledge
Easily‑relatable information for patients
Tips and hints for finding and preparing
healthy foods
Opportunities for observing physicians skilled
in nutrition counseling
Opportunities for practicing counseling skills
“When (my future patients) ask me something about nutrition,
I’m going to have to Google (it)… because I don’t feel like I
have a very solid foundation.”
In addition, some students felt their clinical rotations did not
provide them with enough experience to prevent and treat
childhood obesity. Some students explained that they either
did not have the opportunity to see obese children in their
clinical rotations or that if they did, obesity was not addressed.
Education for Health • Volume 30 • Issue 2 (May‑August 2017)
Cooke, et al.: Medical students’ needs to prevent childhood obesity
Patient‑centered barriers
The medical students recognized that childhood obesity is
a complex issue mitigated by many internal and external
factors. This acknowledgment allowed them to understand
there are many barriers patients face when trying to lead a
healthy lifestyle, including socioeconomic status and limited
access to healthy food and safe play. One student said, “(A)
ccess to things like healthy food is going to be important.
I didn’t really believe this until I saw for myself here (where
my medical school is located). It’s really hard to eat healthy if
the only food source within two or three miles of your house
is fast food restaurants.”
In addition, students said that patients might not be able
to prepare healthy foods because of limited time. One
student described this frustration by saying, “I can’t write
a prescription for you to get vegetables at your store. I can’t
write a prescription for you to be able to leave work 2 hours
early to go exercise.” Students recognized that their patients
might have limited nutrition knowledge, preventing them
from being able to choose and prepare healthy foods. One said,
“I’m sure there are plenty of people out there that don’t know
what’s healthy and what’s not healthy.” Students understood
these barriers prevent patients from healthy lifestyles but did
not feel confident helping patients overcome the barriers.
Healthcare system‑centered barriers
Students expressed problems with a healthcare system
that prevented them from delivering the type of care they
thought necessary. Students explained that because of limited
in‑office time with patients, it is difficult to provide nutrition
counseling. One student said, “I think you’re very limited
in what you can do as a physician in the set‑up of general
clinic because… it’s complicated and requires behavior
intervention… (T) here’s really not enough time for that.”
Students saw this limitation in clinical experience and reported
that their preceptors discussed frustration with limited time.
Students saw that physicians felt a need to treat the immediate
medical concern instead of the more distant concern of
childhood obesity. One student explained that childhood
obesity is often not addressed because “if you don’t deal with
this (immediate) thing in your office right now, today, there’s
going to be a bad outcome tomorrow.” This student went on
to say, “Well, if you have problems with obesity, well come
back… and we’ll address it.” Students frequently reported that
the need to treat immediate needs kept them from gaining
experience with counseling patients. Students also expressed
that minimal follow‑up with patients often left them without
a chance for patient feedback.
In addition to their discussion of barriers, students also
displayed a sense of disconnect between the causes of
childhood obesity and their specific role in prevention and
treatment. Few students described themselves as fitting into
Education for Health • Volume 30 • Issue 2 (May‑August 2017)
the solution but instead described other solutions, including
parent education provided by community programs and
changes needed in the school system. The limited perception
of their role in the solution might be because of the healthcare
system barriers, lack of training, and not feeling equipped to
overcome barriers.
Need for knowledge
These students wanted more nutrition education, which they
said could be provided through didactic portions of medical
school, pediatric rotations, or lunch seminars. Students
explained they learned about adult obesity but not childhood
obesity. One student said, “We have lectures on asthma, why
do we not have a lecture on childhood obesity? And not
just in terms of teaching us about the epidemiology of it
but actually teaching us… what you do with your patients,
and even showing us some of those skills and resources we
might need later.” As this student also expressed, students
want this nutrition information to be easily relatable to
patients, including the practical aspects of how to maintain
a healthy lifestyle. One student said, “(Physicians) need to
know what they can tell patients to get them to improve
their lifestyle… specific concrete advice they can give them
regarding diet – where to eat, what to eat, when to eat, (and)
how to eat.”
Some students also wanted specific tips and hints for finding
and preparing healthy food that could be shared with
patients. Not only did students say they want information
that patients can understand, but they also said that they
want evidence‑based nutrition knowledge. They valued
recommendations based on scientific literature but reported
that medical school did not provide them with this information.
Need for counseling skills
In addition to more knowledge, students also said they
need more skill building in nutrition counseling. Students
requested more opportunities for practicing counseling
skills with children and families. They reported having had
opportunities to practice motivational interviewing related to
other health behaviors but wanted experience with childhood
obesity counseling. One student explained how this might
be facilitated: “A childhood obesity clinic… (where) we could
spend some time – that would be useful. And then we would
feel comfortable knowing… (how) to motivationally interview
people.” Students said they needed to know how to speak to
children about the emotionally charged subject of childhood
obesity and how to provide effective family counseling that
is culturally sensitive.
Discussion
The US medical students in this study described a limited
amount and depth of nutrition education in their medical
159
Cooke, et al.: Medical students’ needs to prevent childhood obesity
curricula, similar to previous studies in the US and globally.[37‑40]
The lack of emphasis on childhood obesity, in particular, might
lead students to believe that prevention and treatment are
not a priority. In addition, given that nutrition has historically
been under‑represented on examinations,[41] it is possible that
students believe that nutrition, in general, is not as important
as more heavily‑tested subjects, and further, that it is not
their responsibility to answer patients’ nutrition‑related
questions. While registered dietitians are the experts in
nutrition counseling, physicians need to be able to address
their patients’ nutrition‑related concerns and be competent in
nutrition assessment and education,[42] including those related
to childhood obesity. During preclerkship coursework, students
could learn basic nutrition information (e.g., tips for finding
and preparing healthy foods) or even be exposed to behavior
change activities that could be shared with patients. [15]
However, given time constraints, clerkships might offer a more
realistic opportunity for students to gain this knowledge from
registered dietitians.
In addition to a lack of nutrition knowledge, students described
a lack of time for nutrition counseling during clinical rotations,
feeling the need to treat more immediate medical concerns,
mirroring reports from practicing healthcare providers.[17,38,43‑45]
In addition, students seemed unsure regarding the feasibility
of obesity prevention and treatment, similar to previous
research.[17,29] In fact, despite repeated probing, these students
rarely described a role for themselves in this aspect of health
care. That is, they tended to describe community programs’
obesity‑related efforts but not their own, a phenomenon also
seen in prehealthcare undergraduates.[46] Once again, when
a component of healthcare is not emphasized – in this case
preceptors modeling the physician’s role in obesity prevention
and treatment – students may not see it as important.[28] To
mitigate this, medical schools can provide students with a
better understanding of their role within the broader context
of a social ecological framework.[47]
To address students’ perceived need for more counseling
skills, nutrition behavior change counseling trainings can be
designed to increase both knowledge and self‑efficacy[48‑50]
by incorporating both observation (modeling) and
practice (mastery of skills). Having preceptor “buy‑in” as
role models is important; however, the preceptors’ own lack
of skills[51] might need to be addressed first.[41,52] Registered
dietitians with the appropriate background could also serve
this role.[15]
collection and analysis.[30,33] However, despite these efforts,
there were limitations. Because this was a volunteer sample,
students might have been more interested in the subject
or more educated than the general population of medical
students. We attempted to decrease this effect by offering a
gift card raffle ticket incentive. However, the study subjects
over‑represent the percentage of students pursuing pediatrics
and family medicine careers and those graduating with
Masters of Public Health degrees, so the sample may not have
fully captured all medical students’ experiences. Given the
nature of the referral recruitment strategy, students might
have shared interview questions with friends even though we
asked them not to do so. In addition, due to timing, students
might not have started their pediatrics rotation, where they
might have received the training they requested. While we
did not ask specifically if the participant had completed their
pediatrics rotation, all students were 3rd‑ and 4th‑year medical
students who had begun their clinical rotations and were
aware of the nature of their training. Finally, because these
findings describe the phenomenon of nutrition education in
US medical schools, they are not necessarily generalizable to
other countries. However, given similar global trends that
indicate lack of physician nutrition knowledge,[17,23‑25] these
results may spur similar evaluations in other countries.
Future research
Medical schools may use the findings of this study to adapt
their curricula to include more applicable nutrition and
childhood obesity‑specific knowledge and nutrition‑related
behavioral change counseling skill building through
observation and practice. Given curricular time constraints,
medical schools may choose to incorporate this training to
varying degrees, with the ultimate goal of preparing physicians
who are both competent in the basics of nutrition and also
able to collaborate with other, more skilled nutrition experts in
the healthcare field. Future research could explore the impact
of these different levels of curricular changes on students’
self‑efficacy in childhood obesity prevention and treatment,
specifically through a self‑efficacy survey, like the Childhood
Obesity Prevention Self‑Efficacy Survey.[53]
Acknowledgment
We are grateful for research assistants De’Ja Alexander,
Amanda Antono, Brittany Lang, Megan Lee, Alice Raad,
Samantha Walker, and Jennifer Wheeley, who contributed their
talents to data collection and/or analysis.
Limitations
Financial support and sponsorship
Throughout the study, we sought to increase trustworthiness
of the data using nonjudgmental and unbiased language
during interviews,[51] member‑checking at the end of each
interview, [32,51] and multiple trained researchers in data
Nil.
160
Conflicts of interest
There are no conflicts of interest.
Education for Health • Volume 30 • Issue 2 (May‑August 2017)
Cooke, et al.: Medical students’ needs to prevent childhood obesity
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