Understanding and Enhancing Pediatric Obesity Interventions: A Focus on Dose and Sustainability

Abstract

Pediatric obesity presents a critical public health issue, affecting over 14.7 million children in the United States, with prevalence rising from 5% in the 1960s to 19% in recent years.1 American Academy of Pediatrics (AAP) Clinical Practice Guidelines (CPGs) recommend Intensive Health Behavior and Lifestyle Treatment (IHBLT) programs that involve at least 26 hours of family-based counseling on nutrition and physical activity over a three to twelve-month period.2 However, achieving the recommended dosage is challenging, and the sustainability of these interventions is further complicated by the significant resources required.3 As a result, the availability of IHBLT programs that meet these guidelines is limited. To maximize the impact and accessibility of pediatric obesity interventions, it is crucial to understand the dosage and sustainability of IHBLT programs in real-world settings. Over the past decade, our research team has developed and evaluated Fit Together, an integrated clinic-community pediatric obesity intervention aligned with AAP guidelines.4 The Hearts & Parks (H&P) study demonstrated that Fit Together improved body mass index (BMI) among children with obesity at six months, however, only 13.8% of participants in the study achieved the recommended dosage. In the first project, we analyzed data from the H&P study to examine the association between Fit Together dosage and changes in BMIp95 and cardiorespiratory fitness over a six-month period. We examined the overall Fit Together dosage, as well as clinic and community program dosage, respectively. We examined the overall Fit Together dosage and clinic and community program dosage, respectively. Using general estimated equations, we found that 5 to 8 hours of clinic dosage was significantly associated with a reduction in BMIp95 (β=-4.19; 95% CI: -7.33, -1.04). Additionally, a dose-response trend was observed, with 13 or more hours of Fit Together dosage linked to a BMIp95 reduction (β=-3.87; 95% CI: -7.84, 0.11) and 2 to 12 hours of dosage associated with a reduction in 4-minute heart rate (β=-11.16; 95% CI: -22.60, 0.28). In the Active Recreation Through Community-Healthcare Engagement study (ARCHES) conducted in 2018, we successfully implemented Fit Together in eight North Carolina counties,67 guided by an implementation toolkit, called “The Playbook.” However, the COVID-19 pandemic disrupted data collection on sustainability. Although The Playbook has been modified based on the ARCHES study, it still lacks comprehensive strategies for ensuring long-term sustainability and overcoming barriers to broader implementation. The second project of this dissertation used an explanatory, sequential mixed methods design to explore the sustainability of the Fit Together program across the seven ARCHES sites. We conducted a quantitative assessment using the Program Sustainability Assessment Tool, followed by qualitative interviews with Fit Together program directors and coordinators. These findings highlighted the importance of strategic planning, financial stability, and community partnerships in overcoming obstacles to sustainability of Fit Together. The third study focused on developing evidence-based sustainability strategies for Fit Together to integrate into The Playbook. Through a qualitative secondary analysis of interviews with Fit Together program coordinators and directors, we identified key barriers, facilitators, and recommendations for program sustainability, which were further developed in a focus group. The resulting strategies were integrated into The Playbook to enhance the long-term viability of Fit Together. This research aims to ensure that IHBLT programs like Fit Together can be effectively sustained, ultimately improving health outcomes for children with obesity and supporting the AAP’s goals for equitable healthcare access.