Childhood Obesity as a Pediatric Vital Sign: A Population Health Initiative

In 2020, Central Ohio community agencies, public leaders, and private funders in partnership with Nationwide Children’s Hospital (NCH) launched the Pediatric Vital Signs (PVS) initiative. This comprehensive 10-year population health initiative focused on addressing child health risk(s) by building partnerships across sectors and fostering population-level change for children.¹ Obesity affects 14 million children (19%) in the United States, with much higher rates among minority groups (Black, Hispanic, American Indian) and low-income youth.^2–5 The high prevalence rate, associated serious comorbid conditions, and persistence of obesity from childhood into adulthood led to the selection of obesity as a child health indicator in the PVS initiative.

The guiding framework we used to address childhood obesity across Franklin County, Ohio, is the enhanced chronic care model put forth by The National Academy of Medicine Roundtable on Obesity Solutions.⁶ Implementation of the model involves integration of health care, community, and public health sectors. A core pillar in the model is patient empowerment, which emphasizes shared decision-making and individual autonomy.⁶ Other components of the model include appropriate metrics, educational and training programs, incorporating the voices from those with the lived experience, ensuring health equity, and financial and infrastructure support to manage obesity.⁶ To a large extent, the success of the model depends on the level of trust among stakeholders and in identifying an entity integrator to oversee integration of the different components. Dietz et al define the integrator as a trusted entity or organization responsible for “engaging clinical and community partners, convening and coordinating efforts, effecting policy change, organizing and sharing data, identifying and accessing funding and establishing open and ongoing communication.”⁶ 

When the model is fully implemented, the result is a systemic, sustained portfolio of synergistic initiatives with a high probability of decreasing childhood obesity.^6,7 In keeping with the model, we include partners from community organizations, health care, schools, local government, and nonprofit organizations (Table 1). The integrator is NCH Center for Healthy Weight and Nutrition (CHWN), a comprehensive tertiary care pediatric obesity center that is recognized for childhood obesity expertise and routinely engages with community programs.

Four considerations guide the project’s logic model (Figure 1), a graphic representation of the between our programs, key partnerships, activities, and intended outcomes in the short term and long term. We selected population-level multisector prevention activities to occur alongside clinic-based interventions as recommended in the 2023 American Academy of Pediatrics Childhood Obesity guidelines² and the enhanced chronic care model.⁶ Second, we acknowledge obesity as a chronic disease with underlying complex and interconnected biological, psychological, social, and environmental risk factors.² Third, our interventions considered characteristics that are unique to children (eg, age, growth, cognition, and developmental capacity).^2,8 For instance, interventions were not isolated to the child but implemented within the context of the family, school, community, and society.⁹ Lastly, we address the impact of weight bias and stigma, social (eg, food insecurity, neighborhood safety) and commercial (eg, factors that influence location of fast food restaurants, content of marketing campaigns) drivers of health on obesity-related disparities, with the aim of improving health equity.

The composition of the team was directed by the vision, strategic aims, governance structure, and available resources. Housed within the CHWN at NCH, the project is led by a physician champion and steering group with expertise in nutrition, pediatrics, community engagement, data management, public health, and policy. The steering group is responsible for determining the goals, strategy, metrics, organizing and managing relationships with external stakeholders, oversight of program implementation and evaluation, and obtaining funding and resources. Goals and activities are reviewed and revised annually, taking into consideration prior progress, available resources, changes in contextual factors (eg, the COVID-19 pandemic), and input from the overall PVS leadership. As the integrator, CHWN undertakes memorandum of understanding or contracts with external community partners and obtains funding for programs.

Franklin County is in Central Ohio. The population of Franklin County is 59.5% non-Hispanic white, 22.6% non-Hispanic Black, and 6.9% Hispanic; 25.4% have only a high school degree or equivalent; and the median income is $69 681.^10,11 Of the 297 700 children younger than 18 years, 18.4% live in poverty, and 52.6% of children are eligible for free and reduced lunch program.^10,11 There is no countywide recurrent assessment of childhood overweight or obesity for Franklin County. Therefore, we identified a proxy population with comparable childhood obesity prevalence rates that we could assess over time. We included 2 large pediatric primary care networks affiliated with NCH, the Primary Care Network (PCN) and the school-based health clinics (SBHCs), and a large private community practice network (Central Ohio Primary Care [COPC]), which together met our criteria for our proxy population (Table 2).

The PCN has 14 urban primary care centers staffed by more than 80 pediatricians and 15 advanced nurse practitioners. The network provides care for more than 130 000 children annually, with 83% on public insurance. The clinics are in predominantly underresourced communities and offer an integrated model of care with a team of social workers, psychologists, and community health workers. The SBHC was established following a collaborative agreement between NCH and Columbus City Schools. The SBHC system is based on the Centers for Disease Control and Prevention (CDC) Whole School, Whole Community, Whole Child model,¹² which supports the academic achievement, health, and well-being of the student using a network of social services and school nurses. The SBHCs serve 8 high schools and 4 middle schools, staffed by 10 advanced nurse practitioners and support staff who provide care to 4500 children in collaboration with the child’s primary care clinicians. Most (84%) of these children are enrolled in Medicaid.

COPC is an independently owned physician group with 26 pediatric primary care clinics across Central Ohio. COPC includes 105 pediatricians who provide care to about 137 000 patients under 18 years of age. Most of the COPC practices are in suburban areas.

The primary measure for is the proportion of children and adolescents with overweight or obesity, defined as age- and sex-specific body mass index (BMI) ≥85th percentile using the 2000 CDC growth charts. We abstract weight and height measures quarterly. We exclude anthropometric measurements that are biologically implausible (BMI z-score <−4 or >8).^13,14 For annual rates of overweight and obesity, we use the most recent weight and height measure recorded during the year.

The overall 10-year goal is to decrease the proportion of children aged 2 to 17 years in our proxy population with overweight and obesity from 33.5% in 2019 to 28.5% in 2030. We established short and intermediate goals (eg, maintaining the rate at 33.5% by 2020, and a decrease from 33.5% in 2019 to 31% in 2025).

Below, we describe key public health, community, and health care interventions which is outlined in the logic model (Figure 1).

This coalition is a multisector group of 45 recreation, public health, industry, faith-based, school, early childhood education, nonprofit, and health care organizations or programs that serve children and adolescents. The mission of the Healthy Kids Coalition of Central Ohio (HKC) is to implement multilevel strategies targeting policies, systems, and environmental changes to improve the lifestyles and health of all children in Central Ohio. The HKC was convened by the Columbus Public Health Department from 2009 to 2021. CHWN was a founding and steering committee member. In 2022 CHWN took over as the convener as the Health Department stepped down due to a change in departmental strategy.

The Coalition launched the “Water First for Thirst” (WFFT) campaign to increase awareness about healthy beverage choices and developed the Columbus Food and Beverage Targeted Marketing Playbook.¹⁵ The WFFT Campaign materials have been used at PVS-Obesity primary care practices, community events, school programs, and training programs for clinicians. Through a memorandum of agreement, CHWN partnered with the 2nd & 7th Foundation, a national literacy nonprofit organization, to provide educational materials on WFFT campaign at all advertised elementary school and community events in Franklin County.

With the American Heart Association, the HKC members successfully lobbied the Columbus City Council to enact the “Columbus Default Beverage Policy for Children’s Meals” ordinance¹⁶ in alignment with WFFT campaign and the American Academy of Pediatrics recommendation to limit sugary drink consumption in children and adolescents.¹⁷ The CHWN provided scientific expertise and met with Columbus council members to advocate for the ordinance which limits access to sugar sweetened beverages, educates families, and decreases nonnutritious calorie intake. In 2020, Columbus City passed the ordinance to require restaurants to offer healthier beverages (eg, low-fat milk, water, and 100% juice) as the default option for children’s meals.

Food Matters is a 4-week nutrition education and cooking class adapted from the national 6-week Cooking Matters program.¹⁸ Food Matters is implemented by 2 organizations, Local Matters and CHWN. Local Matters is a nonprofit organization in Central Ohio with the mission of building healthier communities through equitable food education, access, and advocacy.¹⁹ The aim of Food Matters is to improve food choices for health and teach meal preparation while eating on a budget. The families who participated in the Food Matters programming were asked to complete pre- and post program surveys. At the end of the class, families receive a $10 grocery coupon or a bag of food. Between 2020 and 2021, classes were delivered virtually due to the pandemic. Of 400 families who attended Food Matters classes, 84.1% reported an improvement in at least 1 of the program outcomes such as an increase in use of the cooking skills, frequency of meals cooked at home, selecting healthier food choices, and trying out recipes. In partnership with a local community center, in-person cooking classes were restarted in 2022 and are offered monthly.

The Veggie Van, a mobile farmers market run by Local Matters, is co-located at pediatric practices participating in these activities and at large early childcare centers in underresourced neighborhood in Franklin County twice a month. The Veggie Van helps families connect with benefits programs such as the Supplemental Nutrition Assistance Program, Produce Prescriptions, and dollar-for-dollar matching on fresh fruit and vegetables. Produce prescriptions is a clinic-community integrated program in which families can pick up fresh vegetables and fruits from designated vendors, which include Local Matters Market and Veggie Van, with a prescription from their health care provider. Over 3 years, Local Matters helped families use $195 000 of benefits that they otherwise would not have accessed. In quarter 4 2023, Local Matters began a pilot program funded and overseen by CHWN called Fresh Connect. The pilot established an electronic system to allow low-income families seen at the NCH primary care clinics to purchase fresh fruits and vegetables from the Mobile Farmers Market or a local grocery store. In addition to grocery tours, nutrition education, and counseling, the 6-month pilot program provides $150 per month to each family to make purchases of fresh produce. There will be analysis of pre- and post program survey following completion of the project.

CHWN developed and implemented an obesity-focused training program for pediatric clinicians using the Extension for Community Healthcare Outcomes (ECHO) platform,^20,21 a national practice model that uses case-based learning to train health care clinicians. The ECHO obesity core curriculum is an 8-session series on assessment and management of childhood obesity. Topics include implementing lifestyle interventions; motivational interviewing and counseling techniques for parenting, nutrition, and physical activity; coding and billing for obesity-related visits, pharmacotherapy, and bariatric surgery; with additional sessions on obesity-related comorbidities and spectrum of disordered eating. The ECHO program also provides information about resources in the community. Some participants can use the ECHO program to meet certain requirements for the American Board of Pediatrics Maintenance of Certification. Over 18 months, the ECHO program trained 70 physicians and nurse practitioners from the PCN, SBHC, and COPC practices. After the 8-week series, ECHO participants reported an increase in knowledge for managing a child with overweight or obesity (60% vs 88%), nutrition (61% vs 71%), physical activity (69% vs 84%), and behavioral counseling (31% vs 53%).

To assess change in nutrition and physical activity counseling among ECHO participants, we implemented a quality-improvement project limited to patients enrolled in Medicaid. We first abstracted encounters with diagnostic codes for obesity diagnosis, and then any diagnostic code for nutrition counseling, or physical activity counseling for those encounters for the ECHO clinician participants. The frequency of nutrition and physical activity at 6 months after the ECHO sessions increased by 12.4% relative to the baseline rates. We conducted Plan-Do-Study-Act cycles to improve provider billing and coding, as obesity diagnosis or counseling services are not often coded for and are poorly reimbursed. The results of the pilot will inform an evaluation algorithm embedded into the electronic health record that will track clinician’s counseling practices and referral to community resources during the patients visit. The goal is to train at least 60 health care providers annually, expand training to allied health care professionals (eg, dietitians, care navigators and social workers), and create a consultation service for ECHO participants on obesity pharmacotherapy, nonsyndromic genetic obesity, and disordered eating.

The prevalence of obesity in children rose during the pandemic, with the largest increase in weight gain occurring during the first 9 months.^22,23 In our proxy population, the rate of overweight and obesity was lower at the COPC private practice than the NCH’s PCN and SBHC practices in 2019 (28.2% vs 42.1%; P < .01) and 2021 (28.9% vs 44%; P < .01). In the PCN and SBHCs, the proportion of clinic visits for patients with overweight or obesity rose from 37.8% to a peak of 46.1% in the second quarter of 2021, and then declined steadily to 40.1% by early 2023 (Figure 2). We were unable to assess overweight and obesity in the COPC from late in 2022 through 2023 due to an electronic health record change.

The rise in overweight and obesity during the pandemic has been attributed to increased consumption of calorie dense foods, limited physical activity, and distorted sleep and eating patterns.^24,25 The reasons for the post–COVID-19 pandemic decline remain unclear. It may reflect a slowing down of weight gain balanced by linear growth as most children became more active as COVID-19 mitigation efforts were lifted, and there were fewer opportunities for indiscriminate snacking with a corresponding increase in access to nutritious school lunches.²⁵ In response to the pandemic, the team focused on virtual programming, developing curricula for online videos on weight bias and stigma for health care workers, creating signage in the high schools to encourage physical activity, and participating as a site for the US Department of Agriculture Farmers to Families Food Box program to address food insecurity.

Disparities in obesity prevalence were further exacerbated during the COVID-19 pandemic.²² Thus, we focused on translating materials and resource sheets into Spanish, developed grocery tours in Spanish, and piloted our school physical activity programs and outreach events in communities with a large Latino or Black population. We positioned programs on food insecurity (eg, Farmers to Families Food Box Program) at clinic sites and community centers that reach immigrant families ineligible for federal benefits (Table 1). In addition, screening questions on social drivers of health (eg, food insecurity and health insurance coverage) are embedded into the clinic electronic health record where a positive screen triggers a follow-up by a social worker.

Several funding sources are needed to sustain population health initiatives. As a key initiative in the population health and equity pillar of the NCH’s strategic plan, the hospital supports funding for PVS-Obesity program implementation, personnel, and data analysis. In addition, with oversight from CHWN as the integrator, we funded community-based projects with local nonprofit organizations. Examples include the Food Matters program, the Fresh Connect program, Columbus City School physical activity program, and the food boxes delivered at PlayStreet events. The nonprofit community organizations in PVS-Obesity provide in-kind support and tap into their large network of volunteers to deliver programs. They also raise philanthropic funds to support food access activities, early childhood educational and gardening programs, and the health literacy project that incorporated the WFFT campaign. Another funding stream is through grants. For example, the Ohio insurance marketplace funded CHWN to train clinicians using the ECHO program and to implement a clinic-community integration pilot in a historically marginalized neighborhood.

Stakeholders with the lived experience provide an important and unique perspective. In 2022, input from focus groups with teenagers, aged 14 to 17 years, was incorporated into school lunch and learn sessions and social media content (eg, TikTok videos).

The work to decrease the prevalence of overweight or obesity was successful in building partnerships; implementing programs on healthy eating, active living, education, and advocacy; and engaging clinicians and allied health professionals. To be effective, we will need to replicate and sustain the initiative, evaluate the global outcomes of the children in Franklin County, maximize the synergy of the various interventions, and examine dose-effects of various combinations of the interventions.

Thank you to the Center for Healthy Weight and Nutrition team, to Christina Toth and Venita Robinson for data analysis, to Milena Senko for program coordination, and to Dr Marnie Walston for co-facilitating ECHO-Obesity.

BMI

body mass index

CDC

Centers for Disease Control and Prevention

CHWN

Center for Healthy Weight and Nutrition

COPC

Central Ohio Primary Care

ECHO

Extension for Community Healthcare Outcomes

HKC

Healthy Kids Coalition

NCH

Nationwide Children’s Hospital

PCN

Primary Care Network

PVS

Pediatric Vital Signs

SBHC

School Based Health Clinics

WFFT

Water First for Thirst