May 2019, Volume XXXIiI, No 2

Pediatrics

The Minnesota NET-Works program

Addressing pre-school obesity

pproximately 27 percent of children ages two to five are overweight or obese. Overweight children are at high risk for hypertension and other cardiometabolic risk factors and are five times more likely than normal weight children to become overweight adults. Children who identify as ethnic or racial minorities, and children in lower-income households, are at even greater risk for obesity.

Childhood obesity is the result of a complex interaction between biological, behavioral, family-based, and community environmental factors, thus intervention at multiple levels and across multiple settings is critical for short- and long-term effectiveness. Public health efforts need to address all levels of influence on childhood obesity. However, primary care providers may more readily focus on family-level influences—and should stress the long-term health risks facing overweight or obese children.

Parents as agents of change

Parents are vital agents in obesity prevention because of their central role in influencing their child’s eating and physical activity behaviors, and creating a home environment that supports healthful behaviors. Interventions that directly and effectively engage parents are needed, but identifying how best to engage parents to affect the home environment is a major challenge. Parents with a lower income may experience even greater challenges in creating a healthful home environment due to the many stressors unique to their lives, including having limited income for food or housing, working several jobs with varied work schedules, and lack of access to affordable childcare.

Community environments

In addition to the primary care setting, the neighborhood community environment may provide resources that could enhance or create barriers to parent efforts to support healthy eating and physical activity in their child. Neighborhoods may or may not have safe and attractive playgrounds and parks nearby, and access to affordable retail food stores varies across neighborhoods. Without perceived access to these healthful resources, parents may face significant economic, physical, and social barriers to adopting behavioral intervention messages related to healthful eating and physical activity. For example, small screen use (such as television, cell phone, computer, iPad) by their child might be viewed as a safe alternative to time spent playing outdoors in the neighborhood. Primary care providers can support parents’ efforts to create a healthful home food and physical activity environment by connecting them to existing neighborhood resources, including family-supportive organizations and programs.

Approximately 27 percent of children ages two to five are overweight or obese.

The NET-Works Multi-Component Community-Based Pediatric Obesity Prevention Program

The goal of the Minnesota NET-Works (Now Everybody Together for Amazing and Healthful Kids) study was to integrate home, community, primary care, and neighborhood intervention strategies to promote healthful eating, activity patterns, and body weight among low-income, ethnically diverse preschool-age children. Critical to the success of this intervention was the creation of linkages among these settings to support parents in making home environment and parenting behavior changes to foster healthy child growth.

Participants were recruited in partnership with 12 Minneapolis-St Paul primary care clinics that serve diverse populations. Body mass index (BMI) > 50th percentile was an eligibility criterion because the trial was an obesity prevention intervention, and low-income, racial/ethnic minority children with BMI 50-85th percentile were considered at risk for excess weight gain. Children who were already in the overweight or obese categories were also included (BMI > 85th percentile). A child was eligible for the study if the child was between two and four years of age; had no medical problems that would preclude study participation; family income was below $65,000 per year; and a parent spoke English or Spanish.

The families enrolled in the study were all low-income and demographically diverse. Fifty-eight percent of the enrolled children were Hispanic; 48 percent had BMI > 85th percentile; 75 percent of parents were overweight or obese; 55 percent of parents had high school or less education; 30 percent were working full time and an additional 28 percent were working part time; 72 percent were married; 62 percent had annual household incomes of < $25,000/year; 43 percent of the households participated in the SNAP federal food assistance program; 37 percent were food insecure; and over 95 percent of children had health insurance. Over the three-year study period, families experienced many social and economic challenges. Thirty-seven percent of the 534 families moved once and an additional 25 percent moved two or more times.

NET-Works Intervention Program

Intervention settings and strategies were chosen based on social ecological theory, previous research, and potential for dissemination and sustainability of the intervention. The program consisted of home visiting, community-based parenting classes, and telephone check-in calls. Referrals to community resources for healthy foods and physical activity opportunities were embedded in the home visiting and parenting class components. Intervention component curricula were developed and pilot-tested by the researchers and designed to be synergistic. The home visit setting enabled behavior and home environment change strategies to be tailored for individual families, while the parenting class setting provided group support for behavior changes. Target behaviors and behavior change strategies were similar across the home visiting and parenting class components. Family behaviors and routines were targeted and included healthy food choices for meals and snacks, including limited sweetened beverages and high-calorie packaged snack foods; increases in fruit and vegetable intake; reduction in screen time; and increased time spent in active play.

Planned intervention dose was the same across all three intervention years and included monthly home visits, a series of 12 community parenting classes each year, quarterly phone calls from the home visitor to check in about progress, and annual primary care provider visits. The home visiting and parenting class components were conducted by trained professionals with a minimum of a bachelor’s degree and several years of experience working with families and children. The home visitor met with parents and children in their own home, tailoring the intervention messages and strategies to best fit with the resources and motivations of parents. Home visits were about one hour in duration and were planned for monthly intervals with telephone check-in calls between home visits. Motivational interviewing and behavior change models were used as the intervention foundation. Weekly parenting class series were held in the communities where the family resided with the goal of having parents take part in a 12-week parenting class series each year. Efforts were made to accommodate family schedules and transportation was provided or reimbursed by the study. Referrals to community resources were designed to support parent and family use of food and physical activity resources in their neighborhood and were implemented through the home visits, parenting classes, and check-in calls.

Families received an average of 35.4 contacts over three years (an average of 18.3 home visits, 9.3 parenting classes, and 7.4 check-in calls).

Parents are vital agents in obesity prevention.

What were the main results of the study?

After three years, the NET-Works program had no significant impact on the BMI of NET-Works-enrolled children compared with children in the usual care condition. NET-Works children did significantly reduce their television viewing and intake of calories and added sugars compared with comparison-condition children. NET-Works was also successful in reducing increases in BMI among high-risk subgroups. Children who were overweight or obese at the beginning of the study, and children who were of Hispanic ethnicity, significantly reduced BMI after three years, compared with comparison-condition children in these high-risk subgroups.

What do these findings mean for pediatric obesity prevention?

The multi-component, high-intensity, accessible intervention was designed to provide a consistent level of support to parents over a three-year period. It was initially hypothesized that a longer, more intense dose would result in larger reductions in child BMI by the end of three years. However, given the competing priorities in these low-income families’ lives and changes in life circumstances over a lengthy period, it seems necessary to revisit the optimal dose and type of intervention contact. In the present study, we observed that intervention families moved in and out of various intervention program components across time. Families may have participated in home visiting for several months, then taken a break for several months due to family circumstances, then later rejoined the home visiting program. The continuity in contact between the families and their home visitors enabled families to receive the intervention contact and dose that was feasible for them across three years. Flexible amounts of intervention contact and channels of delivery may optimize results for families at different time points in their lives. Research that evaluates the effectiveness of varied combinations of intervention components and dose could be a useful approach to better understand how best to create family-optimized interventions.

A second important take-away finding from the NET-Works study is that focusing on parents of preschool-aged children who are already overweight or obese is an effective strategy. Pediatric primary care providers should focus their efforts on overweight children who are at the highest risk for excess weight gain and higher-than-healthy body mass index. Parents may be more motivated to make family and household changes if their preschool-aged child is already overweight and perceived as having a significant health risk.

Recommendations for pediatric obesity intervention and follow-up care include working with parents to change the home environment and family routines associated with healthy food choices, screen time, and physical activity. Children who are overweight or obese, and children of racial/ethnic minorities, are at highest risk and should therefore be prioritized for resources related to child obesity prevention and treatment. Primary care provider organizations and physicians should work with community-serving organizations that already serve low-income, diverse families, such as early childhood and family education, through the public school systems; school district nurses and school administrators to affect food and physical education policies; and municipal civic bodies that create policies and programs for building a supportive built environment for active transport and family-friendly leisure time activities. Several existing home visitation programs could be partnered with to implement a healthy family curriculum that focuses on food choices, physical activity, and screen time.

Conclusion

A three-year, multi-component, multi-level, parent-targeted behavioral intervention was successful in decreasing child energy intake and television viewing time, but not in reducing BMI increases or increasing physical activity among preschool-aged children. Significant intervention effects on reducing BMI increases at three years were observed among Hispanic children and in children who were overweight or obese at baseline. Family-level behavioral interventions may be most effective in children who are already overweight and when delivered through channels that are attractive to parents and at a dose that is tailored to optimize participation.

Simone A. French, PhD, professor of epidemiology and community health at the University of Minnesota School of Public Health, served as a co-principal investigator of the study. Dr. French has conducted NIH-funded community-based obesity prevention interventions in worksites, schools, and homes for over 20 years.

Nancy E. Sherwood, PhD, associate professor in the division of epidemiology and community health at the University of Minnesota School of Public Health, served as a co-principal investigator of the study. Dr. Sherwood’s research focuses on the development and evaluation of behavioral obesity prevention and treatment interventions across the lifespan.

Sara Veblen-Mortenson, MSW, MPH, served as a co-investigator and project director of the study. She has 28 years of experience in the development, implementation, and evaluation of community-based randomized controlled trials and contributes skills in both public health project management and intervention prevention research development, implementation, and evaluation.

 

The authors would like to acknowledge the participating families for their contributions to the study, and the research staff team who contributed to its implementation. 

 

Grant Funding: This research was supported by NIH award U01HD068990, with additional support from other members of the Childhood Obesity Prevention and Treatment Research Consortium from the National Heart, Lung, and Blood Institute, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Office of Behavioral and Social Sciences Research at the National Institutes of Health.

 

Clinical Trial Identifier: NCT01606891

 

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The authors would like to acknowledge the participating families for their contributions to the study, and the research staff team who contributed to its implementation.