In this article, we review evidence about the treatment of obesity that may have applications in primary care, community, and tertiary care settings. We examine current information about eating behaviors, physical activity behaviors, and sedentary behaviors that may affect weight in children and adolescents. We also review studies of multidisciplinary behavior-based obesity treatment programs and information about more aggressive forms of treatment. The writing group has drawn from the available evidence to propose a comprehensive 4-step or staged-care approach for weight management that includes the following stages: (1) Prevention Plus; (2) structured weight management; (3) comprehensive multidisciplinary intervention; and (4) tertiary care intervention. We suggest that providers encourage healthy behaviors while using techniques to motivate patients and families, and interventions should be tailored to the individual child and family. Although more intense treatment stages will generally occur outside the typical office setting, offices can implement less intense intervention strategies. We not ony address specific patient behavior goals but also encourage practices to modify office systems to streamline office-based care and to prepare to coordinate with professionals and programs outside the office for more intensive interventions.

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Approximately 35.5% of U.S. children ages 6-11 are overweight or obese. Obesity prevention programs in the school setting have produced mixed results, but interventions conducted in the afterschool setting may increase healthy eating (HE) and physical activity (PA) beyond efforts in a typical school day. Studies to date have shown some success in increasing PA in this setting. Moreover, 23% of children grades K-5 attend afterschool care programs. Treatment successes using a family-based approach warrants parental involvement in this setting, but few studies have examined the impact of parent inclusion. The CATCH Kids Club is a curriculum aimed to increase HE and PA in the afterschool care setting with children grades K-5. The NIH We Can! is a family-based intervention geared towards parents of children ages 8-13 and aims to assist families in increasing HE and PA as well as reducing screen time. The current study sought to understand 1) school community perceptions of child obesity, nutrition, and PA, 2) current efforts of the afterschool care program to promote HE and PA, and 3) how a combined student- and parent- focused intervention could be integrated into afterschool care. Researchers conducted focus groups and tested measurement instruments with afterschool personnel and parents of children in the afterschool care program. All personnel (N = 12; 83% Female; 92% Caucasian) agreed that greater afterschool care health promotion efforts could be made. Over half the sample (58%) described afterschool snacks as “not very healthy” or “not at all healthy” and placed the average amount of daily PA at 1 hour. Barriers to healthy habits included mandates on individually wrapped snack purchases and space available for PA. Personnel demonstrated interest in learning the CATCH curriculum. However, personnel were concerned about amount of staff needed to deliver the program, effects of varying attendance levels of students, and parent participation due to busy schedules. Results revealed that parents (N = 8; 75% female; 100% Caucasian) had little knowledge of what occurred during the afterschool care program including types of snacks provided and amount of PA received. All parents were supportive of the implementation of CATCH Kids Club, and all expressed interest in participating in the We Can! sessions. Parents reported preference for short (30-45 minute), bimonthly sessions occurring upon child pick-up. Results suggest that delivering 2012 Appalachian Student Research Forum Page 81 CATCH Kids Club and the NIH We Can! curricula in the afterschool setting would be of interest to both personnel and parents and would be feasible if time-limited and convenient. These findings will contribute to the development of an afterschool care program pilot intervention, Wellness Partners, directed at both students 5-11 years of age and their parents using modified CATCH Kids Club and NIH We Can! curricula. This cluster randomized controlled pilot study utilizing both quantitative and qualitative methodologies will provide preliminary data to further refine and conduct a fully-powered, large scale trial of the intervention’s efficacy in preventing obesity

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Case Report: The Tennessee Initiative for Perinatal Quality Care (TIPQC) is a statewide quality improvement collaborative founded in 2009. Members elected to develop a project to address Tennessee’s low breastfeeding rates. The project aim is to improve the health of infants and mothers in Tennessee by increasing initiation and duration of breastfeeding through systematically promoting breastfeeding at prenatal care visits. The short-term project goal is to increase the fraction of infants who are fed breastfmilk at the maternal post-partum visit by 50% by March 2012. A toolkit of evidence-based practices was developed by an interdisciplinary project development team through a combination of face-to-face meetings and webinars. Published tools from the AAP, ACOG, ABM, and elsewhere were reviewed to complete this toolkit. Inclusion of a practice in the toolkit was based on evidence of effectiveness and consensus/approval by the project development team and pilot centers. Toolkit format and project protocols were designed to be consistent with other TIPQC projects. The target population for this project includes expectant mothers presenting for routine prenatal care in the outpatient clinic. Project outcomes will be measured at the first postpartum visit at 4-8 weeks post-delivery. The project pilot was launched in three TN practices in spring 2011. Participating practices will first establish a primary improvement team that includes relevant stakeholders and a project champion and team leader. Ongoing project support will be provided through regional learning session and webinars. In recognition of the range of needs and varied resources across the state, the toolkit includes a menu of “potentially better practices” (PBPs) that may be implemented individually, or as a bundle. Success of this project relies on high reliability (>90%) implementation of processes that promote breastfeeding in the prenatal clinic and the use of rapid Plan-Do-Study-Act (PDSA) cycles. Use of a web-based data-entry system through REDCap will allow practices to access on-demand run-charts and control charts for their project data as well as automated comparisons to project-wide aggregate data. The fractions of mothers’ exclusively feeding breastmilk, feeding both breastmilk and formula, and feeding exclusively formula at the first post-partum visit at 4-8 weeks post-delivery will be determined. The fraction of mothers with infants readmitted to the hospital after birth will be tracked as a balancing measure. Local audits will be used to evaluate reliability of implementation of potentially better practices. Discussion: This project may serve as a model for how quality improvement methodologies may be combined with use of distance-learning and web-based data entry and reporting to facilitate dissemination and measured implementation of potentially better practices across a broad geographic region with highly diverse populations. The approach has the potential to increase breastfeeding rates and improve health and could be modified for application in delivery and postnatal settings.

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