Counseling to Prevent Obesity among Preschool Children: Acceptability of a Pilot Urban Primary Care Intervention

M. Diane McKee, MD, MS; Stacia Maher, MPH; Darwin Deen, MD, MS; Arthur E. Blank, PhD


Ann Fam Med. 2010;8(3):249-255. 

In This Article

Abstract and Introduction


Purpose To help design effective primary care-based interventions, we explored urban parents' reactions to a pilot and feasibility study designed to address risk behaviors for obesity among preschool children.
Methods We conducted 3 focus groups (2 in English, 1 in Spanish) to evaluate the pilot intervention. Focus group participants explored the acceptability of the pilot intervention components (completion of a new screening tool for risk assessment, discussion of risk behaviors and behavior change goal setting by physicians, and follow-up contacts with a lifestyle counselor) and the fidelity of the pilot intervention delivery.
Results Parents expressed a desire to change behaviors to achieve healthier families. They believed that doctors should increase their focus on healthy habits during visits. Parents were more accepting of nutrition discussions than increasing activity (citing a lack of safe outdoor space) or decreasing sedentary behaviors (citing many benefits of television viewing). Contacts with the lifestyle counselor were described as empowering, with parents noting her focus on strategies to achieve change for the whole family while recognizing that many food behaviors relate to cultural heritage. Parents expressed frustration with physicians for offering advice about changing behavior but not how to achieve it, for dismissing concerns about picky eating or undereating, and in some cases for labels of overweight that they believed were inappropriately applied.
Conclusions Parents welcomed efforts to address family lifestyle change in pediatric visits. The model of physician goal setting with referral for behavior change counseling is highly acceptable to families. Future interventions should acknowledge parental concerns about undereating and perceived benefits of television viewing.


Obesity in children is an increasing public health concern. Currently, national estimates indicate that 36% of the pediatric population is overweight or obese.[1,2] Inner-city minority populations are disproportionately affected.[3,4] For example, 43% of New York City's elementary public school children are overweight or obese.[5] Although nutrition is one of the most common topics addressed by pediatricians during health maintenance visits of children aged 2 to 5 years[6] and is addressed in at least 40% of these visits,[7] the role of the primary care clinician in the prevention of childhood obesity has not been demonstrated.

Prevention is more likely to be effective when the family is the focus of the intervention[8] and when nutrition education, increased physical activity, and decreased sedentary behaviors are addressed.[9] Starting from this premise, we piloted an intervention aimed at promoting behavior change for families, targeting health maintenance visits of children aged 2 to 4 years. The Family Lifestyle Assessment of Initial Risk (FLAIR) project was 1 of 10 initiatives funded by the Robert Wood Johnson Foundation's Prescription for Health program aimed to address multiple behavioral risks in the primary care setting. Our approach was based on a socioecological model[10] that targeted families of young children by addressing lifestyle behaviors known to place children at risk for overweight.[11]

We report the results of a series of focus groups with parents conducted as part of the evaluation strategy of the FLAIR pilot intervention. The evaluation focused on 4 aims: (1) to explore caregivers' perceptions of the importance of family behavior change; (2) to assess the acceptability of the pilot intervention components; (3) to assess the usefulness of the pilot intervention in facilitating behavior change; and (4) to assess the fidelity of the pilot intervention.

Overview of the FLAIR Pilot and Feasibility Study

The pilot intervention was based in 3 hospital-affiliated primary care health centers staffed by primary care physicians (family physicians, pediatricians, and internists), located in the central or south Bronx, New York. Clinic staff were oriented to the pilot intervention and instructed to give a FLAIR screening form to caregivers of children aged 22 to 59 months when preparing them for physical examinations. They introduced the screen as a new form that would help identify unhealthy behaviors. Physicians participated in workshop-style, case-based training to provide evidence-based guidelines for targeting key behavioral risks and to acquire skills in brief behavior change counseling.

The pilot intervention (Figure 1) was organized around the elements of the National Cancer Institute's 5 A's model:[12] ask, assess, advise, assist, arrange. Parents or guardians (hereafter referred to as parents) were first asked to complete the FLAIR screening questionnaire, which is a self-administered screening form, and later asked by physicians whether they were interested in learning ways they could reduce their family's risk for future health problems. The physicians assessed the family lifestyle risk according to the responses on the form and assessed the parents' readiness to change by using the simple concepts of perceived importance and confidence to change behaviors;[13] they then negotiated agreement on a behavior change goal with parents.

Figure 1.

Outline of the FLAIR pilot intervention.
FLAIR = Family Lifestyle Assessment of Initial Risk.

The physicians were trained to advise parents by providing specific brief counseling about the behavior selected for change. They assisted parents by offering visits with lifestyle counselors to provide more in-depth counseling based on motivational interviewing.[14] Follow-up was arranged with either the physician or the lifestyle counselors to reinforce behavior change and identify additional behavior change goals.

Lifestyle counselors had completed health educator training and were experienced bilingual motivational interviewers. Counselors were available in each practice for 1 half-day each week during the pilot intervention. In sessions that typically lasted 1 hour, lifestyle counselors worked with parents to identify behavioral strategies to achieve the goals that were set during the well-child visit.


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