U.S. children and adolescents are now considered obese. And although obesity rates are stabilizing, Hispanic, African-American, and American Indian youth are disproportionately affected.
Today’s overweight children are more likely to become tomorrow’s chronically ill adults. Obesity in childhood is associated with serious health conditions including type 2 diabetes, sleep disorders, fatty liver disease, and increased risk of heart disease. In addition, mental health issues such as stigmatization, discrimination, depression, and emotional trauma frequently accompany childhood obesity.
Many factors influence the diet and physical activity patterns of children and teenagers that lead to obesity. Family, peers, schools, neighborhoods, time spent with television and other electronic media, the availability of fresh food markets, and genetics all can play a role. Past research has shown that for prevention and treatment strategies to be effective, they must address multiple factors.
Recognizing this fact, the National Institutes of Health launched the Childhood Obesity Prevention and Treatment Research (COPTR) Consortium to examine the many influences on childhood and adolescent obesity and to intervene at multiple levels of influence, including the home, school, neighborhood, and pediatric primary care settings.
“Everyone is part of the team in preventing childhood obesity: parents, pediatricians, teachers, friends, and community members. To effectively prevent and treat obesity we must reach children where they live, learn, and play,” said Charlotte Pratt, Ph.D., M.S., R.D., F.A.H.A., program director, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (NHLBI).
The COPTR consortium, launched in August 2010, is testing multi-level, multi-component interventions, in real world settings to prevent obesity in preschoolers and to treat overweight or obese children ages 7-13. The consortium is sponsored by the NHLBI, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and the Office of Behavioral and Social Sciences Research (OBSSR).
What makes the COPTR trials unique is its rigorous testing of multiple interventions in multiple settings with children and teenagers from diverse economic and racial backgrounds. As shown below, the interventions target children where they live, learn, and play.
COPTR includes four research centers – Vanderbilt University School of Medicine, Nashville; Stanford University, Stanford; University of Minnesota, Twin Cities; and Case Western Reserve University in Cleveland. Collectively, these centers will enroll 1,700 children and adolescents of diverse backgrounds with a target population comprised of 50 percent female and 20 percent Hispanic, 50 percent African American, and 30 percent white participants.
Each COPTR site is measuring changes in body mass index (BMI) – a measure of body fat based on height and weight – along with diet, physical activity, home and neighborhood influences, and social and physiological aspects of daily life in multiple environments: primary care physician offices, pediatric care units, parks and recreational centers, schools, and Head Start centers. Two of the sites will focus on preventing obesity and overweight in preschoolers and two will focus on treating obesity in 7 to 13 year olds.
Preventing obesity and overweight in preschoolers
Addressing the high prevalence of obese and overweight preschoolers remains a public health priority, particularly in minority populations. Although it is promising that rates of obesity among children ages 2-5 decreased from 14 percent to 8 percent between 2003 and 2012, the percentage of obese and overweight Hispanic and African-American preschoolers is markedly higher. In 2012, approximately 30 percent of Hispanic preschoolers and 22 percent of African-American preschoolers were overweight or obese.
Two of the COPTR trials – at Vanderbilt University and University of Minnesota – are working hard to prevent childhood obesity in preschoolers with a focus on minority children.
The GROW trial at Vanderbilt University School of Medicine
“I wake up each day and think, ‘How can we measurably reduce pediatric obesity?’” said Dr. Shari L. Barkinprincipal investigator for the Growing Right Onto Wellness (GROW) Trial at Vanderbilt University School of Medicine in Nashville. “This drive comes from serving patients as a pediatrician and seeing how obesity can have a domino effect on children’s lives: poorer health, increased depression, and more days of missed school – and, later in life, work – if they continue with a poor trajectory of body mass index. With this incredible grant opportunity from NHLBI and NICHD, we have a chance to test interventions that may help prevent obesity among preschool-aged children in the context of the real world.”
The GROW Trial is a family-centered, community-based obesity prevention trial for preschool child-parent pairs. In the GROW trial, 600 parent-preschool (ages 3-5) child pairs are being randomized to a three-year healthy lifestyle intervention or a three-year school readiness program. So far, more than 450 parent-preschool child pairs have signed up to participate and recruitment will be completed by May. The child participants are not obese and come from minority communities.
In the school readiness program – a skills building curriculum on literacy promotion and school readiness in partnership with the Nashville Library Foundation – families participate in six fun activities and classes with library staff at their local community centers.
The parent-preschool child pairs randomized to the healthy lifestyle intervention, or Grow Healthier group, participate in a tiered intervention. For the first 12 weeks, the parents attend intensive weekly skill building classes focused on supporting healthy lifestyle behaviors at local community recreation centers while their children engage in supervised play activities. The sessions focus on building skills in nutrition, physical activity, and parenting. Parents learn how to set and keep goals, make healthy food choices – such as eating more fiber and less sugar – and stay physically active with their kids by finding a “fitness home” at their local community centers. Each session includes a hands-on activity for the parent and child and a tangible tool – such as chopsticks, pedometer, or a child drinking cup – to reinforce that session’s healthy living message.
During the next nine months, parents receive monthly phone call coaching, structured activities at the community centers with their children, and access to a website that provides support for living a healthy lifestyle. For the remaining two years, families continue attending monthly activities at community centers and using the healthy lifestyle website. Parents are encouraged to develop SMART (Specific, Measurable, Achievable, Realistic, Timely) goals during each session and those goals are reviewed throughout the trial.
The NET-Works trial at University of Minnesota
“Today's children are growing up in an environment in which unhealthy food and beverage options are readily available and opportunities to engage in sedentary pursuits, such as TV watching and video games, are the default option,” said Simone French, Ph.D. co-investigator for the NET-Works trial and a professor at the University of Minnesota School of Public Health.“This type of environment contributes to obesity among preschool children. Lower income and minority children are at even greater risk for obesity, for reasons that include lack of neighborhood spaces to be physically active and limited food access due to food costs and availability of retail stores that sell affordable healthful foods.”
In the University of Minnesota NET-Works (Now Everybody Together for Amazing and Healthful Kids) community preschooler obesity prevention trial, 534 economically challenged and racially diverse preschoolers ages 2-4 and their parents were randomized to participate in a three-year intervention program or to receive standard care.
The standard care group receives annual well-child visits – during which doctors assess height, weight, skin-fold, and waist circumference and collect information on activity levels and diet – and three postcards per year with parenting tips.
In contrast, the intervention group receives annual well-child visits, monthly parenting classes and home visits from “family connectors” who teach parents about positive parenting behaviors that support healthy family actions such as exercising, healthy eating, and limiting TV and screen time, along with annual well-child visits.
The family connectors help the families set goals based on the positive parenting behaviors, such as eating five fruits and vegetables daily, eating out once per week or less, and aiming for 60 minutes per day of physical activity and active play. The family connectors also determine the walkability of the family’s neighborhood, an important factor in physical activity levels.
In addition to receiving home visits, parents in the intervention group participate in monthly community-based parenting classes that reinforce the positive parenting behaviors and healthy family actions outlined in the graphic below.
During one class, parents take a field trip to a local grocery store where a parent educator provides them with nutritional, economical and practical shopping tips to learn how to select healthy foods. The goal of the session is for parents to gain an appreciation for and the information to know how to make healthier food choices on a limited budget. During the classes, parents also share lessons learned with one another.
“Integrating obesity prevention messages and strategies and creating linkages among these settings where families spend much of their time offers potential for a sustainable approach that promotes healthy eating and physical activity as key factors in overall healthy child development,” explained Dr. Nancy Sherwood, Ph.D., co-investigator for the NET-Works trial and director of scientific development at the HealthPartners Institute for Education and Research.
Results from the GROW and Net-Works trials will be available in 2017.
This is the first in a two-part series about the COPTR trials. Part 2 will highlight the COPTR trials based at Stanford University and Case Western Reserve University.
Recent articles about the COPTR trials:
- Forging a future of better cardiovascular health: addressing childhood obesity (Journal of the American College of Cardiology, 2014)
- Childhood Obesity Prevention and Treatment Research (COPTR): interventions addressing multiple influences in childhood and adolescent obesity (Contemporary Clinical Trials, 2013)
- IMPACT: a multi-level family and school intervention targeting obesity in urban youth (Contemporary Clinical Trials, 2013)
- IMPACT brochure: http://www.prchn.org/Downloads/IMPACT%20brochure.pdf
- Growing Right Onto Wellness (GROW): a family-centered, community-based obesity prevention randomized controlled trial for preschool child-parent pairs (Contemporary Clinical Trials, 2013)
- NET-Works: Linking families, communities and primary care to prevent obesity in preschool-age children (Contemporary Clinical Trials, 2013)
- Family, community and clinic collaboration to treat overweight and obese children: Stanford GOALS-A randomized controlled trial of a three-year, multi-component, multi-level, multi-setting intervention (Contemporary Clinical Trials, 2013)