Automated Phone Counseling Helps Parents of Overweight Children Model and Encourage Appropriate Behaviors, Leading to Meaningful Reduction in Body Mass Index

Service Delivery Innovation Profile

Automated Phone Counseling Helps Parents of Overweight Children Model and Encourage Appropriate Behaviors, Leading to Meaningful Reduction in Body Mass Index

Snapshot

Summary

Kaiser Permanente Colorado offered parents of overweight children three interventions to promote a healthier diet and increased physical activity, including a workbook, two small-group discussions, and up to 10 interactive voice response phone calls that asked a series of questions, made recommendations based on the answers, and reinforced strategies to promote healthier lifestyles, including goal-setting. A randomized controlled trial found that the program led to a meaningful decline in body mass index for the children over a 12-month period.

Evidence Rating

Strong: The evidence consists of an RCT of 220 parent-child dyads randomly assigned to different combinations of the three interventions. The study assessed the interventions' effect on BMI, eating habits, and physical activity.

Use By Other Organizations

In the fall of 2010, the Kaiser Permanente Pediatric Nutrition Services, in collaboration with actor/educators from the Kaiser Permanente Educational Theatre Programs, created the Healthy Choice Hotline based on the Family Connections study. In addition, different regions of Kaiser Permanente requested a webinar that was hosted by their Care Management Institute.

Date First Implemented

2004

Problem Addressed

Despite a dramatic increase in childhood obesity in the United States and its deleterious impact on children's mental and physical health, health care providers have generally failed to effectively help parents promote healthier diets and more active lifestyles for their overweight children.

  • Rising rates of childhood obesity: National surveys show that childhood obesity increased dramatically between 1976-1980 and 2007-2008, from 5.0 to 10.4 percent among children aged 2 to 5 years, from 6.5 to 19.6 percent among children aged 6 to 11 years, and from 5.0 to 18.1 percent in those aged 12 to 19 years. The latest available statistics show that 16.9 percent of children and adolescents between the age of 2 and 19 years are obese.
  • Leading to increased health risks: Obese children face a higher risk of health problems, such as high blood pressure, high cholesterol, and type 2 diabetes and are more likely to remain obese as adults.
  • Parental struggles in helping children lose weight: Parents play a critical role in determining their children's diet and physical activity. Yet, many parents struggle to develop effective strategies to encourage weight loss.
  • Lack of provider support: Many clinicians have little or no interest in helping obese and overweight children lose weight. Weight management is often viewed as a lifestyle issue and an individual responsibility, with providers frequently blaming parents for their children's obesity. In addition, providers receive few rewards for addressing weight issues with parents and children and have access to few proven strategies for promoting healthier lifestyles in their young patients.

Patient Population

Parents whose children, aged 8 to 12 years, were overweight or at risk and who were enrolled in the Kaiser Permanente Colorado's health plan. Nearly all participants were middle class, two-thirds were white, and one-fourth were Hispanic.

Description of the Innovative Activity

Kaiser Permanente Colorado offered parents of overweight children three interventions to promote a healthier diet and increased physical activity, including a workbook, two small-group discussions, and up to 10 followup interactive voice response phone calls that asked a series of questions, made recommendations based on the answers, and reinforced strategies to promote healthier lifestyles, including goal-setting. Key elements of the program are described below:

  • Recruiting families: Kaiser Permanente Colorado used its electronic medical record system to identify children between the ages of 8 and 12 years who have a body mass index (BMI) at or above the 85th percentile for their age. Pediatricians were asked to exclude patients if children or their parents were not good candidates for the intervention. The health system sent letters, signed by the family's pediatrician, inviting parents to participate, and also contacted parents by phone.
  • Screening families: Roughly 38 percent of contacted parents agreed to participate, primarily those with children at or above the 95th percentile for BMI. Participants attended a group assessment session where their children had their BMI measured; physical activity level assessed (using Youth Behavioral Risk Survey questions); fruit, vegetable, and sugared drink consumption documented (using the Block Kids Questionnaire ); and any eating disorder symptoms identified (using the Kids' Eating Disorders Survey ). (This screening was performed for the purposes of the evaluation research study, and would not necessarily be required in a nonresearch setting.)
  • Weight loss interventions: The interventions focused on supporting parents as the key implementers of healthier, more active lifestyles for the entire family. They included a workbook, two small-group discussion sessions, and up to 10 interactive, recorded phone messages. (During the trial, three different groups were set up—one receiving just the workbook, one receiving the workbook and attending the group sessions, and a third receiving all three interventions.)
    • Family Connections workbook: This 61-page workbook promotes increased physical activity and consumption of fruits and vegetables while discouraging intake of sugared drinks, watching television, and playing on the computer. The workbook includes two sections to be completed over a 1-week period, with homework assignments designed to encourage lasting changes in family lifestyle.
    • Discussion groups: Participants attended two 2-hour small-group sessions (held 1 week apart) at a local clinic. Led by a dietitian for a group of 10 to 15 parents, the sessions used the workgroup to promote parents' behavioral health skills; enhance their knowledge of weight, nutrition, and physical activity; and improve essential parenting skills, such as setting limits, communicating effectively, and role modeling. The sessions concluded with role playing, problem-solving, and the development of action plans.
    • Automated phone calls: The 10 automated telephone calls began 1 week after the second group session.
      • Logistics: Parents either called the automated phone system themselves or waited for the system to call them at a time they designated as being convenient (generally between 7 and 9 p.m. on weekdays). During the first call, they entered their medical record number and recorded their names, making it easy for them to identify future calls (and not mistake them for telemarketing calls). The first four calls occurred weekly, the next four were biweekly, and the last two were monthly. Calls generally lasted between 5 and 10 minutes.
      • Topics covered: Each call focused on a different concept for strengthening parenting skills and promoting healthier living. Topics included the importance of consistency, praise, and communication; healthy eating habits (including the need to have the parents set an example in this area); using contingencies to reach desired outcomes; setting goals; and preventing relapses in unhealthy eating.
      • Customized guidance: During each call, the parent responded to questions using numbers on the phone's keypad. Depending on the answers given, the automated system provided information and advice on specific topics relevant to the caller's situation.
      • Goal-setting: At the end of each call, the parent selected a goal to implement during the following week. At the beginning of the following call, the parent heard the goal selected during the previous week and rated his or her success in meeting it on a 3-point scale (1 for excellent, 2 for mediocre, and 3 for failure). Depending on the response, the parent was given the option of hearing tips relating to that topic before moving on to a new subject area. During the sixth call and for all subsequent calls, parents received instructions on how to set family-wide goals related to healthy eating and physical activity. The calls encouraged parents to assess behavior and motivation and instructed them on how to reach collaborative agreements on goals and to identify and overcome barriers to achieving them. These later calls reinforced the basic skill-building activities and information provided in the workbook, meetings, and earlier calls.

Context of the Innovation

Kaiser Permanente Colorado is an integrated health care delivery system that offers several weight loss and healthy lifestyle programs to overweight adult clients. Kaiser's Institute for Health Research (which partners with area clinicians to research, develop, and evaluate new programs that can be implemented by primary care providers) developed this program based on earlier studies showing that interactive voice response technology can be effective in enhancing physical activity and promoting healthier diets among older adults with diabetes.

Results

A randomized controlled trial (RCT) found that the 38 children of parents who received the most comprehensive intervention (i.e., completing the workbook and participating in the group sessions and at least 6 of 10 automated phone calls) achieved a significant decline in BMI, while those receiving less intensive interventions experienced little or no decline.

  • Lower BMI: The 38 children in the group receiving all three interventions and attending at least six automated counseling calls achieved the greatest reduction in BMI z-score,* from 2.03 at baseline to 1.9 at 12 months. By contrast, for the 20 children whose parents received all three interventions but attended five or fewer automated calls, BMI z-score rose slightly, from 2.08 at baseline to 2.09 after 12 months. The 82 children whose parents received only the workbook and/or attended the two discussion groups experienced a very modest decline in BMI z-score, from 2.04 at baseline to 2.00 after 12 months.
  • Slight decline in consumption of sugary drinks, but no other lifestyle changes: Children in all three groups reported only slight declines in the number of sugary drinks they consumed, but no significant changes in their levels of physical activity or consumption of fruits and vegetables. Researchers did not objectively track the children's diets or measure their physical activity, and were dependent on the children's own memory when responding to those questions at 6- and 12-month followup screenings.

*The BMI z-score indicates the number of standard deviations above the mean BMI, adjusted for age and gender.

Evidence Rating

Strong: The evidence consists of an RCT of 220 parent-child dyads randomly assigned to different combinations of the three interventions. The study assessed the interventions' effect on BMI, eating habits, and physical activity.

Planning and Development Process

Key steps in the planning and development process included the following:

  • Creating workbook and curriculum: Kaiser Permanente Colorado's Weight Management Program and research staff developed the workbook and the curriculum for the two classes.
  • Designing automated phone system: Kaiser staff scripted the phone calls, while outside contractors developed the automated system. (See the Story section for a sample script.) They designed the system to identify whether a call had been answered by a live person or an answering machine, or whether there had been no answer. For unsuccessful calls (i.e., those not answered or picked up by a machine), the system was designed to attempt up to three calls per day to each parent; when an answering machine picks up, the system leaves a message explaining that Kaiser tried to contact them and will try again later. Programmers designed the system to track the number of unsuccessful calls and to minimize the need to listen to multiple voice prompts by allowing those who answer the call to key ahead before the completion of a voice message.
  • Training: Those responsible for maintaining and tracking the outbound call schedule received training on the phone system.
  • Introducing program to clinicians: Kaiser introduced the program to clinicians through practice-wide meetings. During these sessions, physicians were encouraged to screen candidates and to grant permission to use their names on recruitment letters sent to parents.

Resources Used and Skills Needed

  • Staffing: As noted, Kaiser used internal staff, some of whom worked on other weight loss programs, to design the trial, create the workbook's content, and script the automated phone calls. A project manager oversaw the program, including communications with providers and patients, while a Kaiser dietitian led the small group sessions. Outside programmers and technical contractors designed and created the interactive phone system.
  • Costs: Kaiser paid roughly $25,000 for the design of the phone system and received $250,000 to conduct the study over a 2-year period.

Funding Sources

The study was funded by a 2-year, $250,000 grant from the Garfield Memorial Fund, an internal funding arm within Kaiser Permanente.

Tools and Resources

Kaiser Permanente Colorado is willing to share its workbook with other organizations; contact the developer for more details. Other related resources include the following:

Getting Started with This Innovation

  • Assess screening capability: Determine whether the organization medical record system can be searched electronically to easily identify overweight and at-risk children who might benefit from the intervention. If not, customize screening protocols to accommodate each medical practice patient record technology.
  • Customize educational materials: Consider the Kaiser Permanente Colorado workbook as a potential starting point, and then customize the material to the target population, taking into consideration ethnicity and the community's recreational resources.
  • Assess automated phone system: Determine whether the program can be integrated into the organization's existing phone system or an independent system must be created. If necessary, contract with a programming company to develop the system.
  • Encourage physician participation: Introduce the program to physicians, highlighting any evidence to support its effectiveness. Solicit physician input on the program design, including the appropriate process for screening patients and identifying those who may not be good candidates.
  • Create a monitoring and evaluation system: Identify staff (nurses or dietitians) to conduct periodic assessments of participants' progress, and establish how frequently such assessments should occur. Create a system to document parent involvement, including how many automated phone calls they complete.

Sustaining This Innovation

  • Maintain parent interest: The trial found that the children of highly involved and motivated parents (i.e., those completing six or more calls) reaped the biggest benefits in terms of reduced BMI.

Use By Other Organizations

In the fall of 2010, the Kaiser Permanente Pediatric Nutrition Services, in collaboration with actor/educators from the Kaiser Permanente Educational Theatre Programs, created the Healthy Choice Hotline based on the Family Connections study. In addition, different regions of Kaiser Permanente requested a webinar that was hosted by their Care Management Institute.

Lessons Learned

The program worked best in children younger than 11 years but was less successful with adolescents, likely because parents have limited control over their diet and physical activity.


Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Paul Estabrooks, PhD
Professor, Virginia Tech
Translational Obesity Research Program
1 Riverside Circle SW, Suite 104
Roanoke, VA 24016
Phone: (540) 857-6664
Fax: (540) 857-6658
E-mail: estabrkp@vt.edu



Innovator Disclosures

Dr. Estabrooks has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Estabrooks P, Shoup J, Gattshall M, et al. Automated telephone counseling for parents of overweight children: a randomized controlled trial. Am J Prev Med. 2009;36(1):35-42. [PubMed]

Footnotes

  1. Centers for Disease Control and Prevention. Obesity and overweight. March 31, 2010. Available at:http://www.cdc.gov/obesity/childhood/.

  2. Ogden C, Carroll M. Prevalence of Obesity among Children and Adolescent: United States, Trends 1963-1965 through 2007-2008. Health E-Stats. Centers for Disease Control and Prevention. June 4, 2010. Available at:http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.pdf.

  3. Edmunds L. Parents' perceptions of health professionals' responses when seeking help for their overweight children. Family Practice. 2005;22(3):287-92. [PubMed] Available at: http://fampra.oxfordjournals.org/cgi/reprint/22/3/287.

Sample Script Promotes Use of Contingencies and Consistency to Encourage Healthy Snacks

Kaiser Permanente Colorado's automated phone counseling for parents of overweight children provided information on a variety of healthy lifestyle and effective parenting strategies. The phone calls were scripted so that parents could select topics and tips relevant to their family's situation. What follows is a sample script for a call that reinforces the importance of using contingencies and consistency when encouraging healthy snacks and that helps in setting goals for the week.

Introductory Message Explaining Consistency and Contingencies
“Everyone knows that being consistent means that you do the same thing over and over again. For example, when a child asks to ride her bike, parents consistently tell her to wear a helmet. However, the word 'contingent' can be confusing. Being contingent means preparing for something that might happen in the future. So if you want your child to have a healthy snack when they come home from school, you may offer a banana. But what happens if your child doesn't feel like eating a banana? This is where contingencies come into play.

“If she doesn't feel like eating a banana, then the contingency plan is that she can have an apple. If she doesn't want an apple, she probably isn't really hungry, so the final contingency could be that she doesn't have an after-school snack. This isn't punishment; it is simply providing a range of options that are all healthy. It is also important to be consistent with contingencies. That means that when you plan your child's after-school snack options, you stick with those options.

“Some parents think being consistent means that they can't ever let their kids eat unhealthy foods. This really isn't the case. It is okay to have unhealthy foods, like ice cream or soda, in moderation. But just like with healthy foods, parents should be consistent in when and how often unhealthy foods are eaten. For example, a consistent rule could be that your family has a dessert with dinner twice a week. The contingency can be that the family chooses which nights dessert is served.”

Support in Setting and Reaching Goals
“Now I would like you to set a goal for this week. I am going to read four statements and I would like you to listen to each of them and then press the number that reflects the statement you will live by this week.
To set a goal to be consistent in helping your child do some physical activity everyday this week, press 1.
To set a goal to be consistent in offering a number of fruit and vegetable options at every dinner this week, press 2. To set a goal to a plan for contingencies for after-school snacks that your child can choose from, press 3.
To set a goal to be consistent in limiting the amount of television your child watches this week to less than 2 hours a day, press 4.
If you would like me to repeat the goals press the star key.”

Because the system has stored the parent's goal selection in its database, during the next call it asks the parent to rate how well he or she did in reaching the goal (1 being excellent, 2 being mediocre, and 3 being failure). If the parent failed to reach the goal, the automated system seeks to reassure and instruct the parent; a sample script appears below:

“I'm sorry to hear this last week has been tough. Making changes in the way you parent can be difficult, especially when you and your child are used to doing things a certain way. Keep in mind that these changes are for the better and they won't happen overnight. Use this next week as a fresh start! Please listen to the following tips on how to make small changes.”

Comments

By MT on
Since there was no participant group that received the phone call intervention only, it is unclear whether it was simply a dose effect (from receiving 3 interventions) or the phone calls themselves that influenced BMI outcomes. Do the author's have any thoughts about whether the information reinforced during the phone calls could be implemented in another way (text message, group meeting, workbook, etc) that might be more cost effective than setting up a phone system.

By Barry Ross on
Since all three groups in the study showed a decrease in consumption of sugary drinks but no measurable change in consumption of fruits and vegetables or increase in physical activity, do the researcher have an understanding of what behavioral change the group had who showed a significant decrease in BMI?
Original Publication: 08/05/09

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 11/06/13

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 10/28/13

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