Drink Responsibly: Are Pediatricians and Parents Taking Sweetened Beverage Choice Seriously in the Battle Against Childhood Obesity?

Transcription

1 Drink Responsibly: Are Pediatricians and Parents Taking Sweetened Beverage Choice Seriously in the Battle Against Childhood Obesity? Introduction With childhood obesity on the rise, 1 it has become increasingly important for parents to make healthy choices with respect to their children s diets and activities. If parents can prevent obesity in their children by encouraging healthy patterns of behavior, they are lowering their children s risk for such maladies as hypertension, hyperlipidemia, sleep apnea, diabetes, and depression. 2 For pediatricians, the first step in these efforts is letting parents know what these healthy choices are and how they can most effectively be implemented in the home. The connection between sugar-sweetened beverage and juice overconsumption and childhood obesity has been supported by consistent evidence (see Background). The American Academy of Pediatrics (AAP) has endorsed seven target behaviors to prevent childhood obesity that are supported by empirical evidence, the very first of which is limiting consumption of sugar-sweetened beverages. 3 The AAP also recognizes that high intake of 100% fruit juice by young children can create an energy imbalance that contributes to overweight. 4 Many parents may know that sodas and other sweet beverages are not the healthiest drinks for their child to consume, but may be confused about what specific actions they should take. Parents may also be confused about the role of beverages such as 100% juice in the diet that provide some nutritional value in addition to higher amounts of sugar and calories. If so, it is especially important for pediatricians to be building discussions about sugary beverages into their nutrition counseling during every well-child visit. This study is designed to examine whether pediatricians are having these discussions, and whether they are doing so in ways that parents find effective. Hypotheses and Specific Aims Aim #1: Determine whether parents who were interviewed as part of a larger study on childhood obesity believe limiting sugar-sweetened beverages is important in helping their children maintain healthy weight. Ascertain whether their ideas and beliefs vary based on the weight status of their children. I hypothesize that parents do consider limiting sugary drinks an important component of maintaining a child s healthy weight, but that parents with overweight and at risk children have a more difficult time recognizing unhealthy beverage choices and have a more difficult time setting limits for these beverages. Aim #2: Determine what suggestions parents have for pediatricians regarding nutritional counseling with respect to beverage choice. Attempt to isolate certain counseling techniques or tips parents feel are most likely to lead to real behavioral changes in the home. I hypothesize that parents find it most effective when pediatricians give specific suggestions and helpful tips as opposed to vague limit-setting to cut down on sugar-sweetened beverages. Aim #3: Determine whether the recommendation given by the AAP regarding the limitation of sugar-sweetened beverages is communicated by pediatricians to parents during age 3-8 well-

2 child visits. If it is communicated, determine how closely the beverage counseling techniques match what parents describe as effective. I hypothesize that conversations about limiting sugary beverages have not yet become a part of routine nutrition counseling during well-child visits. When counseling about this behavior occurs, it is vague (i.e. Drink less soda. ) and without specific tips (i.e. Try to have only low-fat milk and cold water in your refrigerator. ) Background The AAP recommendation to limit sugar-sweetened beverages 3 and juice 4 was based on consistent research linking these beverages to childhood obesity. In a 19-month study of diverse children, each additional serving of sugar-sweetened beverage translated to both an increase in BMI and an increase in frequency of obesity, even after controlling for demographic differences. 5 This is true on a smaller scale as well; children who drank more sugary drinks gained more weight, even over a short period of 4-8 weeks. 6 Children are drinking more sugar-sweetened beverages over time, 7 and these habits do not change as children get older. Over 10 years, adolescents intakes of sugar-sweetened beverages increased 3-fold while their milk intake decreased by 25%; decreasing calcium consumption. 8 This is not the only example of nutritious food and drink choices being displaced by high-sugar, low-nutrient beverages. Children who drink more sugar-sweetened drinks also get lower amounts of daily protein, magnesium, phosphorus, and vitamin A. 6 Today, 10-15% of a child s daily calories are from sugar-sweetened beverages and fruit juice. 7 We know, then, that sugar-sweetened beverages are associated with obesity and that consumption of these unhealthy drinks is growing. A problem of such widespread proportions requires public health strategies to reverse these growing trends. 9 One randomized, controlled trial was done in which an experimental group of schoolchildren took part in a year-long educational program on nutrition. At the end of the program, students from the experimental group consumed less carbonated drinks over a 3-day period than they had before the program; by contrast, students from the control group who had not been part of the program consumed more. The students from the intervention group experienced a decreased percentage of overweight and obesity, while the students from the control group experienced an increase. 10 These results are promising, as they indicate that educational interventions aimed at preventing obesity via the limitation of sugary beverages can indeed be effective. Pediatricians are ideally placed to be at the forefront of these educational efforts. Often, however, pediatricians report feeling that their overweight prevention counseling is ineffective. 11 In a cross-sectional survey of pediatricians, only 12% identified themselves as having high self-efficacy in obesity management. 12 The goal of this study is to compare the self-reported counseling needs of parents to what is actually going on in the exam room during well-child visits. Hopefully this comparison will illuminate some discrepancies and lead to more effective counseling tools with which pediatricians can combat obesity more successfully. Research Design and Methods SUMMARY. This study has three components that correspond to the three aims: 1. The first is to ascertain parents ideas and beliefs regarding sugar-sweetened beverages (Aim #1.) This will be done by using established qualitative methods to analyze

3 transcripts of interviews with parents that have been conducted and transcribed by Dr. Eliana Perrin and Joanne Finkle. Qualitative methods are useful when we are aware of the existence of a public health problem but need a better understanding of current knowledge and barriers before implementing a solution The second is to collect parents suggestions for pediatricians regarding effective methods of nutritional counseling (Aim #2.) This will also be done via qualitative analysis of transcripts of the aforementioned interviews. 3. The third is to discover whether and to what degree pediatricians conduct conversations about sugar-sweetened drinks during well-child visits (Aim #3). This will be done by recording a sample of actual well-child visits for children ages 3-8 at the Child and Adolescent General Clinic and Continuity Clinic. DETAILS. Aim #1: As part of a larger NIH-supported study on weight status communication, Dr. Eliana Perrin and her research associate, Joanne Finkle, conducted 24 face-to-face interviews with individual parents of children ages 3-8. The participant pool was a purposive sample of 8 parents of obese children, 8 parents of overweight children, and 8 parents of children at a healthy weight. Half were African American and half were Caucasian. They all sought care at UNC s Child and Adolescent General Clinic and Continuity Clinic. Interviews were audiotaped and transcribed. I plan to analyze the responses by developing qualitative coding categories and using ATLAS/ti software (a qualitative analysis software package) to evaluate parents ideas and beliefs regarding sugar-sweetened beverages. Responses to the following questions (derived from the original interview guide) will be examined to determine whether parents who were interviewed believe limiting sugar-sweetened beverages is important in helping their children maintain healthy weight. We will also examine whether these ideas and beliefs vary based on the weight status of their children. Here are the original questions asked that guided the interview (I include numbering only to demonstrate they were not asked in successive order): 1c. What habits do you believe are important for a child to stay a healthy weight? How important are beverages? 4b. Tell me about your experience with trying to make changes to diet and physical activity habits in your home. (Probe on limiting TV time, limiting sugar-sweetened drinks, and encouraging more active play.) What do you see as the good things that would happen with these changes? What do you see as the bad things that would happen with these changes? 7a. Tell me about how you make beverage choices for your family? For [Child s name]? (Probe on influence of media, friends, family, other children.) 7b. Give me an example if you can of a rule in your house about what [Child s name] drinks? How does trying to stick to this rule usually play out in your house? Aim #2: During the aforementioned interviews, participants viewed a short videotape which depicted a pediatrician informing a parent of her child s weight status as either obese, overweight, or at a healthy weight. There was a separate videotape for each weight status, and each participant watched the encounter that matched his or her own child s weight status. Some questions during the interview were based on participants reactions to the videotape. I plan to analyze the responses by developing coding categories and using ATLAS/ti software to evaluate

4 parents suggestions for pediatricians regarding effective methods specifically for beverage counseling within the framework of nutritional counseling. Responses to the following questions will be examined: 1a. Imagine you are in your pediatrician s office with your child. As part of this visit, your child s doctor talks with you about [Child s name] weight, his/her eating habits and his/her exercise habits. You walk away from the visit feeling good about the conversation and motivated to make some changes so that your child will grow up at a healthy weight. How would you describe how this visit went? How would the physician talk to you about making changes to your child s diet and physical activity habits? 1c. Can you tell me about an actual experience you have had talking to the doctor about your child s weight? Was this a good or bad experience? Why? Describe for me if you can how your experience changed the way you or your child eats or exercises? 2a. How would you compare the conversation between the doctor and the parent in the video with the perfect visit you described earlier? What do you see as the good things about this conversation? What do you see as the bad things about this conversation? What suggestions would you make to the doctor to make this a better conversation? 7c. Tell me about an experience you have had talking with [Child s name s] pediatrician about what he/she should drink. (If they have had an experience, probe on how parent felt about this experience). Aim #3: This component of the study will recruit 10 parents and children ages 3-8 who have their well-child visits tape recorded at the University of North Carolina Continuity Care Clinic. Appropriate consent will be obtained prospectively from parents and pediatricians who are blind to the hypotheses to allow small, digital tape recorders be placed in exam rooms to record the entire visit. Only the nutritional counseling portion of the visit will be transcribed and coded. I will code text independently with one other member of the research team. As with Aim #1, I plan to use Atlas/ti software to identify key phrases and coding categories. This will be a largely inductive, iterative process. Inductive themes will be identified as they emerge to evaluate how closely the well-child visit discussion of sugar sweetened beverages and juice meets the AAP recommendations and parent suggestions for an ideal visit. Bibliography 1. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, JAMA 2004;291: Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 1998;101: Barlow S. E. and the Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics 2007;120: American Academy of Pediatrics. The use and misuse of fruit juice in pediatrics. Pediatr 2001;107(5):

5 5. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugarsweetened drinks and childhood obesity: a prospective, observational analysis. Lancet 2001;357: Mrdjenovic G, Levitsky DA. Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children. J Pediatr 2003;142: Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugarsweetened beverages and 100% fruit juices among US children and adolescents, Pediatrics 2008;121(6): Striegel-Moore RH, Thompson D, Affenito SG, Franko DL, Obarzanek E, Barton BA, et al: Correlates of beverage intake in adolescent girls. J Pediatr 2006;148(2): Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006;84(2): James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004;328: Perrin EM, Finkle PF, Benjamin JT. Obesity prevention and the primary care pediatrician s office. Curr Opin Pediatr 2007;19: Perrin EM, Flower KB, Garrett J, et al. Preventing and treating obesity: pediatricians self-efficacy, barriers, resources, and advocacy. Ambul Pediatr 2005;5: Shortell SM. The emergence of qualitative methods in health services research. Health Serv Res 1999;34(5pt2):