Elsie M. Taveras, MD, MPH, Chief, Division of General Academic Pediatrics, Massachusetts General Hospital, Associate Professor of Pediatrics and Population Medicine at Harvard Medical School and Associate Professor of Nutrition at the Harvard School of Public Health
When I first decided to become a pediatrician I was interested in prevention and caring for the well-child. As a trainee, the majority of patients I saw in my clinic had one or multiple chronic diseases such as obesity, asthma, or behavioral/mental health concerns and were not simply being brought in for well-child visits. At the time, I was working in an inner-city practice where I predominately saw African American and Hispanic children from low-income households. There, I repeatedly noticed a triad of co-occurring symptoms among many of patients living in poverty: obesity, asthma, and mental health issues. As a result, I turned my attention to the socioeconomic issues common among members of these underserved populations. I became increasingly interested in health and health care disparities, shared obstacles of inner-city poor and their seemingly shared diagnoses. I also realized that research at the time had barely scratched the surface regarding the prevention of obesity in underserved populations and that I could help augment this work.
As early as the age of two, there are already significant obesity disparities between African American and Hispanic children and their White counterparts. Although the obesity epidemic overall may appear to have plateaued, indeed the disease is becoming progressively more characteristic of lower-income, minority, high-risk populations. In one of our epidemiologic studies of a large pre-birth cohort called Project Viva, we have studied the early origins of racial/ethnic disparities in childhood obesity. Our study found racial/ethnic differences in many early life risk factors for obesity not explained by maternal obesity or socioeconomic factors (Figure 1).1 In a follow up study of the children at age 7 years, we also found that adjustment for these early life risk factors almost entirely explained the substantial disparities in obesity prevalence observed among white, black, and Hispanic children.2 Our results are now leading to the design and implementation of interventions to reduce these risk factors during pregnancy, infancy and early childhood which could help eliminate racial and ethnic disparities in childhood obesity. One example intervention is our Healthy Habits, Happy Homes study (Figure 2). Funded by the Centers for Disease Control and Prevention, Happy Homes is a clinical and home-based behavioral intervention delivered to low-income, black and Hispanic parents of 2-5 year old children, designed to promote adoption of household routines to prevent obesity. The intervention was conducted in 4 community health centers. The trial completed recruitment and follow up on 120 parent-child dyads. The 6-month intervention included 1) motivational counseling by a health coach, 2) educational materials coupled with behavior change incentives, and 3) weekly text messages. Intervention children successfully reduced their TV viewing, improved sleep, and reduced their BMI.3
Identifying positive outliers as being potentially key to the success of a given population is something that is very important to obesity research. The idea is that lessons can be learned from individuals who have managed to succeed where many others have not to positively change their behaviors in the face of sometimes adverse environments. Such individuals and their strategies can then be applied to others in similar environments. However, it may be a challenge to apply this perspective in a clinical or research setting and, in truth, it is the tendency in clinical practice to focus on those who do poorly. Nevertheless, when practitioners and researchers are in tune with the problems that face a specific community, they are better suited to recognize that the solutions to the problems facing that community may be within members of that community who have developed tools and strategies in the face of similar obstacles. Health professionals and the obesity research community can use positive outliers to inform intervention work and the research agenda and to ultimately identify best practices for obesity prevention through family-centered access to sound care.
Our research team has learned a variety of interesting perspectives on the tools and strategies that our successful patients adopt. Our research group is currently funded to conduct focus groups and interviews of “positive outlier” families which should provide insights for childhood obesity prevention. The data are very interesting and certainly deserve to be studied further for their potential value in the treatment of other families.
Positive outliers are becoming easier to detect through the use of electronic health records. Through meaningful use and federal funding, clinical practices are increasingly going completely paperless. Rather than being concerned that this methodology can slow down processes, clinicians could benefit greatly from leveraging the electronic health records to improve their assessment and management of chronic diseases. Increased uptake of electronic health records can result in a seamless process that provides better quality of care. For example, decision support or “pop-up alerts” can be used in pediatric records to indicate elevated body mass index. We have tested such automatic alerts (Figure) and supports in one of our large randomized controlled trials and have shown that electronic decision supports to clinicians leads to improved quality of care for children who are obese.
From a research standpoint, electronic health records could be an incredibly useful surveillance tool and in the near future we will be able to use electronic health records to efficiently survey and track both the prevalence of chronic diseases and the impact of national policies meant to intervene on those diseases. Essentially, we will have a record of what is going on with every child that walks through a clinic door in the US and such information will be a new frontier in prevention and surveillance measures.
There is currently too little work on early childhood obesity disparities. There is an urgent need for more multidisciplinary research characterizing the origins of obesity in different populations and to accurately identify points for intervention. Furthermore, we must do more research to benefit high-risk populations and make sure that high-quality research of this nature gets picked up by the media and legislators to ensure that this topic is kept relevant and informs policy. Specifically, obesity researchers can play a role by supporting strong epidemiological and interventional research on obesity and related disparities and assisting in getting and keeping the message visible.
- Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW, Rifas-Shiman SL. Racial/ethnic differences in early-life risk factors for childhood obesity. Pediatrics. Apr 2010;125(4):686-695.
- Taveras EM, Gillman MW, Kleinman KP, Rich-Edwards JW, Rifas-Shiman SL. Reducing Racial/Ethnic Disparities in Childhood Obesity: The Role of Early Life Risk Factors. JAMA pediatrics. Jun 3 2013:1-7.
- Haines J, McDonald J, O'Brien A, et al. Healthy Habits, Happy Homes: Randomized Controlled Trial to Improve Household Routines for Obesity Prevention Among Preschool Aged Children. JAMA pediatrics. 2013;in press.