Pediatric health providers daily face the reality of the growing childhood obesity epidemic. Individual consultation and treatment may seem futile at times, when so many external influences pressure children and families to make unhealthy choices. Toxic environmental changes have developed in concert with growing rates of obesity over the past several decades, including increased portion sizes; availability of low-cost, low-nutrient convenience foods; and decreased physical activity, among others.1 Unfortunately, given these pressures, clinical advice shared in the examination room does not always translate seamlessly into a patient’s life. The pediatrician must consider his or her recommendations in the context of the child’s full home environment, which includes not only the household but also family culture, neighborhood, school, and larger state policies. True health is determined in this wider, nonmedical world.2
So how can a clinician help, if individual choice is only one small piece of the childhood obesity epidemic? A growing number of pediatricians are embracing their role as change agents for creating a healthy environment. Trusted and respected, pediatricians hold influence among policy makers, school officials, and community groups that help shape laws and services for families. Understanding the role of the provider in the context of the socioecological model as it pertains to childhood obesity, as well as the fundamentals of community-engaged research, program development, and evaluation, sets the stage for productive advocacy efforts.
The Social Context for Health
Family, school, community, and myriad other social influences affect obesity and health.3,4 The socioecological model (Table 1) describes this process in a series of nesting zones, which illustrates the interwoven relationship between individuals and their surroundings. The model suggests that, while personal choice is central to health behavior change, social factors (eg, friends, workplace programs, state laws and regulations) determine whether that change is sustained. Similarly, barriers to health behaviors are shared across sectors. Therefore, the most effective interventions will cohesively promote the desired change with consistent messaging in all sectors.5
The Socioecological Model
For example, what might a strategy to promote breastfeeding look like within the socioecological model construct? On the individual level, the patient or family must understand the importance of the behavior and feel equipped and empowered to choose breastfeeding. On the interpersonal level, the patient’s extended family helps ensure the mother has the time, space, and support needed to initiate or continue breastfeeding, and the health care provider educates the mother on the benefits of breastfeeding and develop a patient-centered plan. On the organizational level, the mother’s workplace makes pumping and milk storage space available and accessible, and the patient’s child care facility helps encourage continued breastfeeding by demonstrating willingness to store and properly warm pumped milk. On the community level, neighborhood agencies, such as recreation centers and libraries, post breastfeeding-friendly signs or designate quiet spaces for feeding, and the chamber of commerce starts a social media campaign encouraging breastfeeding, which would be advertised on buses, billboards, and cable access television. On the public policy level, the state government ensures that state-administered hunger relief programs, such as Women, Infants, and Children (WIC), incentivize breastfeeding, or it introduces legislation to mandate that employers allow pumping breaks for breastfeeding, working mothers.
In this scenario, the role of the health care provider may take several forms. Pediatricians can voice their support of local initiatives and pattern breastfeeding-supportive workplace practices by designating pumping rooms in medical offices. Providers may volunteer to speak at a local parenting group for new mothers, offer to consult with a postpartum home-visiting program about breastfeeding promotion, or visit with one of the large area employers about worksite support of nursing mothers. Pediatricians may also effectively advocate for policy change by providing expert testimony on bills relevant to breastfeeding promotion. Regardless of the audience—local parenting groups or legislative subcommittees—pediatricians are viewed as unbiased authorities on child health and welfare.6
Applying Patient-Centered Obesity Care to Communities
Effective obesity care relies on the patient’s readiness to change, and the same holds true for community-engaged work. Clinical guidelines support the use of patient-centered care, and specifically motivational interviewing, in the medical management of children with obesity.7 In motivational interviewing, the patient stands at the center of the care plan. Providers and patients collaborate to determine goals, and providers evoke the patient’s values and honor their autonomy. At the outset, the provider assesses the patient’s strengths, supports, and resources and then explores the patient’s understanding of the problematic health behavior. The patient identifies a behavior change to address the problem and, together with the provider, develops a treatment plan. Providers refrain from forcing a particular change because doing so is neither effective nor sustainable.8
Much like individuals, communities vary widely on prevalent health needs, service gaps, political influences, and cultural attitudes. Similarly, schools, health care institutions, churches, and social services stand in various stages of action. The principles of community-based participatory research (CBPR) align with the spirit of evidence-based motivational interviewing practice, respecting community autonomy and advocating in support of self-identified goals.
Rooted in Kurt Lewin’s participatory action research model, CBPR seeks to ignite positive social change through collective inquiry and experience and solve an immediate problem through a reflective community process and collaborative intervention.9 Recognizing the unique value in the approach, the National Institutes of Health is funding a growing number of CBPR projects in academic health centers across the United States.10,11 Suitable for both programmatic and research-based interventions, CBPR involves convening a trained group of experts in a particular field with community partners to define and tackle a project. In childhood obesity, content experts may include public health workers, pediatricians or other physicians, epidemiologists, nurses, or dietitians. The community is involved at the outset, and experts assist in setting a mutually conceived plan into motion. The principles of CBPR include definition of community, establishment of equitable partnerships, asset and needs assessment, collaboration, and flexibility.5
In CBPR, establishing a clear definition of community prior to launching an initiative proves critical to success. In obesity work, the target community may be defined as a group of child care facilities; a school system or single school; a state, township, or county; or any other entity defined by geography, mission, or shared challenge. Project planning and implementation teams include experts in the field, leaders of organizations, and representatives of those who will be affected by the program or project.
The project team establishes equitable partnerships, and enlisted collaborators must own the change they seek. Paralleling with individual intervention, communities identify what they want to change and, with the help of content experts, develop a workable plan. Success is shared, which may include academic papers, grant funds, publicity, or financial sponsorship. Whatever the currency, sustainability depends on equitable distribution of the profits.
Prior to launching any initiative, the project team conducts asset mapping and a needs assessment. Evaluating the community’s strengths and existing resources minimizes duplication of services and often presents opportunities for building on existing programs. The assessment team may be different from the project team and includes community members, agency partners, clinical providers, and content experts.12
In successful community partnerships, ongoing collaboration proves critical to success. Bidirectional communication among partners needs to be well established. Involving the right partners is key yet often not immediately realized. Table 2 is a partial list of types of agencies that have been successful partners in obesity coalitions.
Potential Community Collaborators
Finally, in the most successful programs, partners understand the iterative process of community-focused work and remain flexible. Continuous change is the natural result of seeking community input, forming equitable decision-making processes, responding to identified needs, and establishing collaborative working relationships. Providers approach community partnerships without expectations of a linear or predictable outcome. Partners change, lose funding, and are subject to shifting rules and regulations beyond their control. Communities experience economic downturns, natural disasters, and changes in political leadership. Knowing how and when to change the course of the project depends on a thorough understanding of the variables involved.2
Program Measurement and Evaluation
As in health care, community agencies are pressured to measure delivered services and report meaningful outcomes. Doing so leads to sustainability and credibility. Health care providers are familiar with evidence-based interventions; other disciplines will similarly refer to work being data-driven. The project team should form a measurement plan early and report outcomes according to specified guidelines of the project funder.
As in patient-centered obesity care, providers may help a community project team select realistic deliverables with achievable outcomes. Too often, well-meaning and even well-designed community interventions fail because planning teams set overly ambitious or unattainable goals. For example, many choose body mass index (BMI) as the primary outcome measure because it is an objective and relatively simple data point to gather and represents the core of the childhood obesity problem. However, significant shifts in BMI—especially in small or short-term interventions in highly uncontrolled community settings—prove difficult to achieve.2
Thankfully, many other measures can help assess the effectiveness of an obesity project. Although BMI reduction may remain the ultimate goal, smaller interventions can develop project outcomes that target specific recognized causes or correlates with obesity. These may include sweet drink consumption, minutes of physical activity, sleep, or emotional health. For the most basic intervention, tracking the number of participants is appropriate. Larger programs may gather self-reported data on healthy behaviors, such as number of meals cooked at home or days per week a child consumes breakfast. In robust interventions, objectives measures are suitable, such as a validated physical fitness assessment screen or other health data.2
Consistent with the principles of CBPR, thoroughly understanding existing resources may assist in developing a reasonable evaluation plan. For example, a community parks and recreation center’s beverage vendor may track sales of each drink sold in vending machines. Accessing these data may generate a meaningful measurement and require few additional resources to collect.
Setting Priorities and Building Partners
As a health care provider, finding worthwhile community or advocacy projects to combat childhood obesity is usually not difficult. The struggle is choosing which effort makes the best use of limited time. Although legislative advocacy tends to generate the greatest effect,13 smaller efforts can lead to meaningful change as well. Providers should weigh their available time, resources, training, and experience against the issues or advocacy needs they find most compelling. Partnering with a colleague who holds similar interests and sharing an advocacy effort or position on a project team may prove most doable (Table 2).
Following the principles of patient-centered care and community-engaged work, clinicians evaluate where their interests fit into existing efforts and capitalize on available resources. Pediatric obesity advocates represent an active and cohesive group that has developed programs to enable busy clinicians to get involved in evidence-based projects. Two such resources include opportunities available through the state and national chapters of the American Academy of Pediatrics (AAP).
State chapters of the AAP determine advocacy goals pertinent in each state, and many identify topics or proposed legislation related to childhood obesity as priorities each year. Some have established obesity task forces well versed in evidence-based interventions, whereas others organize continuing education events for practicing pediatricians on obesity and advocacy. As state chapter members, pediatric health professionals may request the chapter’s guidance on a particular advocacy project, such as working with school officials to increase recess time or contacting a city official about repairing public drinking water fountains. Many chapters also request that members provide expert testimony during the legislative season and help arrange individual meetings with lawmakers. Chapter members also remain aware of similar advocacy projects in the state or one-time opportunities through ongoing email or listserv communication.2
The national AAP’s Division of Community-Based Initiatives provides pediatricians guidance and technical support on a variety of community-based projects, including those to address childhood obesity. The Division manages several grant programs for pediatricians working to deepen their involvement in their communities. Residents and practicing pediatricians may apply for Community Access to Child Health (CATCH) grants to fund projects with local community partners that address neighborhood-specific child health and welfare needs.14
The state and national AAP offices also sponsor special advocacy events for pediatricians, including North Carolina’s White Coat Wednesdays at the state legislative building or Kentucky’s Children’s Day at the Capitol. Many offer legislative advocacy training in advance of the event, either in person or via podcast or webinar. The AAP also holds an annual pediatric advocacy conference in Washington, DC, for practicing pediatricians, residents, and other child health care providers.14
Effective advocacy demands not only an understanding of the issue and evidence, but also an awareness of the work already underway to address the health problem. Given the growing public attention to and interest in childhood obesity, identifying strong community partners, building coalitions, and forming actionable projects is increasingly accessible, even for busy health care professionals. Finding the appropriate fit proves the greatest challenge. Opportunities range from programmatic to policy interventions, local to city or state government, and topic variation among nutrition and physical activity–focused projects.
Effective advocates know their personal strengths, community, and professional resources and needs. Strong advocates articulate their own interests and skills and, perhaps most importantly, the amount of time they have to accomplish their advocacy goals. Advocates learn from both failures and successes and remain energized and committed to the cause regardless of the intermediate outcomes. Learning by doing, just as pediatricians are trained to practice medicine, will create the next generation of capable community change agents.
- Ebbeling C, Pawlak D, Ludwig D. Childhood obesity: public health crisis, common sense cure. Lancet. 2002;360(9331):473–482. doi:10.1016/S0140-6736(02)09678-2 [CrossRef]
- Bolling C, Wacker J, Bosley E. Community advocacy: taking obesity care from the exam room to the streets. In: Hampl S, ed. Clinical Management of Childhood Obesity. New York, NY: McGraw-Hill; in press.
- Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Kerr J. An ecological approach to creating active living communities. Annu Rev Public Health. 2006;27:297–322. doi:10.1146/annurev.publhealth.27.021405.102100 [CrossRef]
- Kerr J, Sallis JF, Owen N, et al. Advancing science and policy through a coordinated international study of physical activity and built environments: IPEN adult methods. J Phys Act Health. 2013;10(4):581–601.
- Robinson T. Applying the socio-ecological model to improving fruit and vegetable intake among low-income African Americans. J Community Health. 2008;33:395–406. doi:10.1007/s10900-008-9109-5 [CrossRef]
- Satcher D, Kaczorowski J, Topa D. The expanding role of the pediatrician in improving child health in the 21st century. Pediatrics. 2005;115(4 Suppl):1124–1128. doi:10.1542/peds.2004-2825C [CrossRef]
- Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120Suppl 4:S254–S288. doi:10.1542/peds.2007-2329F [CrossRef]
- Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change. New York, NY: Guilford Publications; 2002.
- Adelman C. Kurt Lewin and the origins of action research. Educational Action Research. 1993;1:1, 7–24. doi:10.1080/0965079930010102 [CrossRef]
- Boyce CA, Olster D. Strengthening the public research agenda for social determinants of health. Am J Prev Med. 2011:40(Suppl 1):S86–S88. doi:10.1016/j.amepre.2010.10.006 [CrossRef]
- Clinical and Translational Science Awards: Advancing Scientific Discoveries Nationwide to Improve Health: Progress Report 2006–2008. National Center for Research Resources, National Institutes of Health. http://www.ncats.nih.gov/files/2008_ctsa_progress_report.pdf. Accessed August 13, 2014.
- Kretzmann JP, McKnight JL. Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community’s Assets. Chicago, IL: ACTA Publications; 1993.
- Fenton M. Increasing physical activity with the three Ps: programmatic, physical project, and policy level interventions. http://www.markfenton.com/resources.html. Accessed August 15, 2014
- Community advocacy. American Academy of Pediatrics. http://www.aap.org/en-us/advocacy-and-policy/community-advocacy/Pages/Community-Advocacy.aspx. Accessed June 2, 2014.
The Socioecological Model
||Individual characteristics that influence behavior, such as knowledge, attitude, skills, and beliefs
||Interpersonal processes, including family, friends, and social networks, that provide identity and support
||Organizations and social institutions that have rules, regulations, and policies
||Relationships among organizations that set norms and standards for behaviors
||Local, state, and national laws and policies that regulate behaviors
Potential Community Collaborators
||Early childhood care centers
||Parks and recreation
||Boys & Girls Clubs
||Department of Social Services
||Cooperative extension offices
||Colleges and universities
||Youth mentorship programs
||Professional sports teams
||Chamber of Commerce
||Summer academic programs
||Boy and Girl Scouts