Person:

Marshall, Richard

Objective

New approaches for obesity prevention and management can be gleaned from 'positive outliers', i.e., individuals who have succeeded in changing health behaviors and reducing their body mass index (BMI) in the context of adverse built and social environments. We explored perspectives and strategies of parents of positive outlier children living in high risk neighborhoods.

Methods

We collected up to five years of height/weight data from the electronic health records of 22,443 Massachusetts children, ages 6-12 years, seen for well-child care. We identified children with any history of BMI ≥95th percentile (n=4007) and generated a BMI z-score slope for each child using a linear mixed effects model. We recruited parents for focus groups from the sub-sample of children with negative slopes who also lived in zip codes where >15% of children were obese. We analyzed focus group transcripts using an immersion/crystallization approach.

Results

We reached thematic saturation after 5 focus groups with 41 parents. Commonly cited outcomes that mattered most to parents and motivated change were child inactivity, above-average clothing sizes, exercise intolerance, and negative peer interactions; few reported BMI as a motivator. Convergent strategies among positive outlier families were family-level changes, parent modeling, consistency, household rules/limits, and creativity in overcoming resistance. Parents voiced preferences for obesity interventions that include tailored education and support that extend outside clinical settings and are delivered by both health care professionals and successful peers.

Conclusions

Successful strategies learned from positive outlier families can be generalized and tested to accelerate progress in reducing childhood obesity.

Objective

To explore outcomes and measures of success that matter most to 'positive outlier' children who improved their body mass index (BMI) despite living in obesogenic neighborhoods.

Methods

We collected residential address and longitudinal height/weight data from electronic health records of 22,657 children ages 6–12 years in Massachusetts. We defined obesity “hotspots” as zip codes where >15% of children had a BMI ≥95th percentile. Using linear mixed effects models, we generated a BMI z-score slope for each child with a history of obesity. We recruited 10–12 year-olds with negative slopes living in hotspots for focus groups. We analyzed group transcripts and discussed emerging themes in iterative meetings using an immersion/crystallization approach.

Results

We reached thematic saturation after 4 focus groups with 21 children. Children identified bullying and negative peer comparisons related to physical appearance, clothing size, and athletic ability as motivating them to achieve a healthier weight, and they measured success as improvement in these domains. Positive relationships with friends and family facilitated both behavior change initiation and maintenance.

Conclusions

The perspectives of positive outlier children can provide insight into children’s motivations leading to successful obesity management. Practice implications: Child/family engagement should guide the development of patient-centered obesity interventions.