Introduction

Primary preventive health services could play an important role in addressing child and adolescent overweight, given that the majority of youth in the United States interact with the health care system at least once during any given year (1). However, as many as 50% of pediatricians do not regularly counsel youth about maintenance of a healthy weight, and close to 40% of pediatricians do not regularly counsel about physical activity (2). Furthermore, few pediatricians believe their advice is effective in motivating behavior change around diet and activity (3).

Guidelines for pediatric and adolescent preventive care recommend annual screening and counseling on nutrition and physical activity (4, 5, 6) but are not very specific about what aspects to focus on to prevent overweight. Both epidemiological and experimental evidence from the past decade supports targeting reduction in television viewing (7, 8, 9, 10, 11), sugar-sweetened beverages (12, 13, 14), and fast food (15, 16) as primary preventive intervention outcomes impacting overweight and other chronic disease risks (17). How a practitioner approaches counseling is also important. The literature stresses the importance of cognitive-behavioral approaches in management of overweight, both in short- and long-term interventions (18). Knowing which children are most ready and amenable to changing their lifestyle behaviors and developing stage-matched interventions can increase the likelihood of actual behavior change. To our knowledge, no studies have assessed youths' readiness to change specific overweight-related behaviors. The purpose of this study was to examine youths' report of receiving overweight-related prevention counseling during ambulatory care visits and to describe youths' perceived readiness to change their nutrition and physical activity behaviors recommended by their clinicians.

Research Methods and Procedures

Study subjects were participants in a community survey conducted as part of Play Across Boston, a project of the Harvard Prevention Research Center and Northeastern University. The Human Subjects Committee at the Harvard School of Public Health approved this study.

We recruited a convenience sample of 13 after-school programs, one Boston public high school, and two Boston public middle schools to participate. Youth were eligible to participate if they resided in Boston, were between the ages of 10 and 18, spoke and read English, were in attendance at the selected program or school on the day the survey was administered, and had received parental consent. In total, 421 students participated in the survey. Our estimated response rate, based on data from 13 sites where we also gathered an estimate of the number of youth present, was 52%. We limited our analyses to 324 (77%) participants who indicated they had a physical exam with a doctor or nurse within the past year.

We measured counseling rates using survey items modified from the Young Adult Health Care Survey (19). The Young Adult Health Care Survey is a 45-item self-report instrument for measuring adherence to consensus guidelines for adolescent preventive services validated among youth 14 to 18 years old. We created seven new questions focusing on overweight-related prevention topics such as television viewing and sugar-sweetened beverage consumption. The questions on perceived readiness to change were developed from well-established, motivational interviewing techniques (20, 21) and included whether youth would try to change their eating habits, physical activity, or television viewing if a doctor or nurse asked them to and if they responded that they would, which one of those three behaviors would they try to change. We also measured age, sex, race/ethnicity, maternal education, physical activity levels, television viewing, height, and weight (22) by self-report on the survey.

We used multiple logistic regression to assess the independent effects of predictors of interest on adolescents' report of having received counseling from their health care provider on obesity-specific topics and perceived readiness to change. We performed data analyses using SAS Software version 8.2 (SAS Institute, Inc., Cary, NC) for Windows.

Results

Table 1 shows the characteristics of our study sample. Youth reported that clinicians routinely discussed their weight (69%) and physical activity (69%) but less often discussed consumption of fast food (46%), sugar-sweetened beverages (38%), and television/video viewing (41%).

Table 1. - Sample characteristics: data from 324 participants of the Play Across Boston Youth Survey.

Full table

In multivariable analyses, we found that compared with youth whose BMI was <85th percentile, youth whose BMI 85th percentile were more likely to report receiving counseling about consumption of fast food [odds ratio (OR),¹ 1.74; 95% confidence interval (CI), 1.03, 2.95] and about time spent exercising, playing sports, or being active (OR, 2.04; 95% CI, 1.10, 3.78) (Table 2). Overall, reported rates of receiving clinician counseling on any overweight prevention topic and rates of discussing nutrition and physical activity were lower among participants whose mothers lacked education beyond high school or whose educational attainment was unknown (Table 2).

Table 2. - Overall reported rates and adjusted odds of receiving clinician counseling on specific overweight prevention topics during ambulatory visits: data from 324 participants of the Play Across Boston Youth Survey.

Full table

Forty-three percent of youth reported the counseling they received from their clinicians to be helpful, and an additional 24% reported the counseling was very helpful. Youth 10 to 14 years old were more likely to report their clinicians' advice as very helpful, compared with those 15 to 18 years old (29% vs. 14%, p = 0.01). Approximately 69% of youth reported they would try to change their nutrition and physical activity patterns if recommended to do so by their clinicians; 40% reported they would try to change their eating patterns, 36% reported they would try to change their physical activity patterns, and only 20% said they would try to make changes in their television viewing patterns.

In multivariable analyses, we found that youth whose BMI was 85th percentile were more likely than those whose BMI was <85th percentile to report they would try to change their activity patterns if recommended to do so by their clinicians (OR, 2.17; 95% CI, 1.24, 3.79) (Table 3). Compared with youth 15 to 18 years old, those 10 to 14 years old were more likely to report they would try to change their overall nutrition and physical activity patterns if recommended to do so (OR, 1.85; 95% CI, 1.07, 3.19).

Table 3. - Characteristics associated with youths' perceived readiness to change selected nutrition and physical activity behaviors: data from 324 participants of the Play Across Boston Youth Survey.

Full table

Discussion

In this study of adolescents ranging in age from 10 to 18 years, we found that youth do not report receiving specific, evidence-based, overweight prevention topics such as reducing sugar-sweetened beverage consumption and television viewing during routine visits. We also found differences in reported receipt of overweight-specific counseling by maternal education status and by age group. Our results are consistent with those of two recent studies that examined clinician counseling on nutrition and physical activity during ambulatory visits (2, 23). However, our results add more specificity and detail about the specific overweight preventive counseling that youth are receiving.

In this study, younger adolescents were more likely to report they would change their overall nutrition and physical activity patterns if recommended to do so by their clinicians. This finding could be important in developing effective interventions to prevent overweight during this period of adolescence when physical activity levels start to decline and children begin to make independent food choices.

We also found that participants whose mothers lacked education beyond high school were much less likely than those whose mothers were college graduates to report receiving clinician counseling on fast food consumption, television/video viewing, and sugar-sweetened beverage consumption. Although the reasons for such disparities are likely multifactorial, a recent study by Flores et al. (24) suggests that other topics such as community violence, household alcohol and drug use, trouble paying for children's needs, and spouse/partner parenting support, might predominate the discussion and anticipatory guidance during primary care for disadvantaged pediatric patients. Clinical and public health efforts are needed to reduce disparities on overweight prevention counseling among socioeconomically disadvantaged groups.

Our study should be interpreted keeping in mind several limitations. First, youth in the study were asked to recall events that may have taken place up to 1 year before the survey. In particular, the observed association between receipt of clinician counseling and overweight status could have stemmed from recall bias in that youth who were overweight may have been more likely to remember receiving counseling from their clinicians. Second, it is possible that the high reported rates of counseling on overall nutrition and physical activity are the result of a social desirability response bias. In addition, the unique characteristics of the sampled population, including youth living in an urban city, may limit the generalization of this study for specific groups, such as youth living in more rural communities. Third, we did not measure the source or frequency of medical care for youth in the study. Thus, we were unable to determine whether these factors were important predictors of receiving counseling and were unable to adjust for possible clustering of subjects by provider or practice site. Fourth, to minimize respondent burden, we asked youth to self-report their heights and weights by selecting one of seven predefined categories of each (based on national norms) from which we calculated BMI and classified youth as above or below the 85th percentile for age and sex. Although a previous study among older children supports the validity of BMI computed from self-reported height and weight (22), limited information exists supporting the validity of self-report among younger children or of calculating BMI and classifying as greater than the 85th percentile based on categorical heights and weights. Finally, our sampling strategy was limited to a convenience sample of youth. This might further affect the external validity of our results.

Conclusions

The primary care clinician's office provides a potentially powerful but often untapped resource for effecting changes in key behaviors related to overweight. Pediatric clinicians are interested in combating the rise of overweight in their patients, and youth want and need to discuss health care issues with their clinicians (25). Practical implications of the present results would be for clinicians to incorporate more specific, evidence-based overweight prevention counseling in their anticipatory guidance for youth ages 10 to 18 years to begin overweight prevention counseling, even among young children, and to match counseling to youth's readiness to change their behavior.

Notes

¹ Nonstandard abbreviations: OR, odds ratio; CI, confidence interval.

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Acknowledgments

This study was supported, in part, by grants from the Centers for Disease Control and Prevention (Prevention Research Centers Grants U48/CCU115807 and U48DP000064). This work is solely the responsibility of the authors and does not represent official views of the Centers for Disease Control and Prevention. E.M.T. is supported, in part, by the Minority Medical Faculty Development Program of the Robert Wood Johnson Foundation.