Assessing Implementation of Clinic–Community Partnerships Treating Pediatric Obesity

Childhood Obesity · 2026-04-08

Background: Although intensive health behavior and lifestyle treatment (IHBLT) is effective for treating youth obesity, it is not accessible to many. Our objective was to examine the implementation of Fit Together, an evidence-based IHBLT clinic–community model delivered by health care and local parks and recreation. Methods: This study used a hybrid type 3 implementation-effectiveness design to examine uptake and implementation of the Fit Together model in eight North Carolina counties from 2016 to 2021. Each Fit Together partnership was provided with an implementation manual, training, technical assistance, and financial support. Implementation outcomes included partnership characteristics and program delivery (e.g., hours, referrals, attendance). Effectiveness outcomes included engagement (dose received), changes in child lifestyle habits, quality of life, and body mass index (BMI). Descriptive statistics described implementation outcomes, and linear regression models examined changes in participant-level outcomes. Results: All eight locations implemented Fit Together (range: 5–18 months). A total of 1193 youth with obesity (12 years ± 3.0, 52.4% female) were referred to a Fit Together program. Of referred youth, 20% (241/1193) attended ≥ 1 session, of which 85% (205/241) attended ≥2 sessions. Nearly a third of engaged participants (29%, 70/241) received ≥26 treatment hours. For each additional session attended, BMI percent of the 95 th percentile declined ( β = −0.12, p = 0.06). Conclusions: The Fit Together model can be delivered in diverse settings, engage priority populations, and deliver IHBLT in a variety of locations. Future work should test scalability and dissemination strategies for clinic–community models of child obesity treatment.

Nutrition and obesity in under-represented population (NOURISH): study protocol to examine the effect of restricted and unrestricted financial benefits on infant food insecurity, growth, and nutrition

BMC Pediatrics · 2026-01-10

Studies have shown that food insecurity (FI) during infancy is associated with higher odds of obesity in early childhood, but the evidence regarding the impact of FI interventions on improving child body mass index (BMI) remains inconclusive. This study explores whether reducing food insecurity during infancy is effective in preventing early life obesity. Using a randomized comparative effectiveness design, NOURISH delivers two interventions: an “unrestricted benefit” group that receives a cash benefit in the form of study-specific debit cards, and a “grocery benefit” group that receives healthy groceries with nutritional guidance. Additionally, a “usual care” contemporary comparison matched cohort of infants will be constructed using electronic health record data. The primary endpoint is change in infant BMI z-score over one year. The secondary endpoints are FI status and diet quality. Study findings will be instrumental in guiding future policy decisions around food assistance and the development of “food as medicine” interventions, offering evidence-based strategies regarding the types of support that families facing food insecurity need to improve children’s health outcomes.

Parent Perspectives on the 2023 Clinical Practice Guideline for Pediatric Obesity: A Mixed‐Methods Study of Acceptance and Concerns

Pediatric Obesity · 2025-10-26 · 2 citations

BACKGROUND: The 2023 Clinical Practice Guideline for pediatric obesity recommends immediate, intensive treatment, including behavioral therapy, medications, and surgery when indicated. Understanding parental agreement with the guideline is critical for successful implementation. OBJECTIVE: To evaluate parental awareness of and agreement with the guideline. METHODS: = 37.6 ± 7.4 years) completed an online survey assessing guideline awareness and agreement. K-means cluster analysis identified parent subgroups based on agreement patterns. Linear regression examined predictors of agreement (e.g., parent age, BMI). Inductive content analysis explored underlying perspectives. RESULTS: Few parents (5.3%) were aware of the guideline before the survey. Cluster analysis identified three subgroups: Guideline Skeptics (34%; broadly disagreed), Selective Supporters (28%; mostly agreed but opposed medications and surgery), and Guideline Supporters (38%; broadly agreed). Higher parental BMI predicted lower agreement (β = -0.20, p = 0.018). Qualitative findings added nuance to parents' preference for lifestyle changes, highlighted concerns about mental health and eating disorders, and emphasized parental responsibility in the development and treatment of obesity. CONCLUSIONS: Parental agreement with the guideline varies widely. While most support behavioral treatment, many express concerns about medications and surgery, and a subset of "Guideline Skeptics" reject core principles such as the use of BMI. Tailored implementation strategies are needed to address these diverse views.

Use of an Electronic Health Record Order to Directly Refer Patients With Prediabetes to Community-Based Diabetes Prevention Programs

The Annals of Family Medicine · 2025-09-01

<h3>PURPOSE</h3> Rates of participation in community-based diabetes prevention programs (DPPs) are low among patients with prediabetes. This may be due, in part, to low rates of referrals to these programs from health systems. One key opportunity to augment clinicians’ referrals to and patients’ participation in DPPs may be through electronic health record referrals (eReferrals). <h3>METHODS</h3> We undertook a quality improvement initiative in a large, academic health system. Using the EpicCare Link feature of Epic (Epic Systems Corporation), we created an eReferral to local community-based DPPs. Eligibility criteria required that patients have an age of at least 18 years, a body mass index of at least 25 kg/m², and prediabetes or a history of gestational diabetes. We conducted a retrospective evaluation of implementation outcomes from June 1, 2021 to June 30, 2022 using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) evaluation framework. <h3>RESULTS</h3> During the evaluation period, 577 patients were referred to DPPs and 21% enrolled, defined as attending an information session and registering for a program. Thirty percent of 350 targeted primary care clinicians used the eReferral across 14 primary care clinics. Among all 124 referring clinicians, referral rates varied widely with a range of 1 to 46 referrals per clinician; 11% of referring clinicians contributed more than 50% of all referral orders. The large majority of referred patients (73% to 81%) met DPP eReferral eligibility criteria. <h3>CONCLUSIONS</h3> An eReferral is a promising, scalable strategy to connect patients with prediabetes to community DPPs. Additional strategies are needed to enhance clinicians’ use of the eReferral and patients’ subsequent program engagement to fully optimize the reach and effectiveness of DPPs.

Randomized Controlled Trial of a Text-Based Smokeless Tobacco Cessation Intervention for Rural and Medically Underserved Communities

Nicotine & Tobacco Research · 2024-07-18 · 3 citations

INTRODUCTION: Smokeless tobacco use remains prevalent in rural and medically underserved populations, leading to increased rates of tobacco-related cancers and chronic disease. While access to effective cessation programs is limited, text-based interventions may offer a delivery approach with broad reach. This two-armed randomized control trial (RCT) assessed the efficacy of #EnufSnuff.TXT, a text-based smokeless tobacco cessation intervention, in rural and medically underserved communities. AIMS AND METHODS: We conducted a two-arm RCT assessing #EnufSnuff.TXT, a text-based scheduled reduction intervention paired with text-based cessation support messages compared with the modified Enough Snuff intervention comprised of a cessation education booklet and bi-weekly motivational text messages. We recruited participants via social media and surveyed participants at 3 and 6 months post-randomization. The primary outcome was self-reported 7-day point prevalence abstinence at 6 months. RESULTS: We recruited and randomized 532 participants. At 3 months post-randomization, the quit rate was significantly higher in #EnufSnuff.TXT arm compared to the Enough Snuff arm for intent-to-treat (ITT) cases (29.2% vs. 19.0%, odd ratios [OR] = 1.75, p = .0066). The quit rate at 6 months post-randomization remained higher in #EnufSNuff.TXT compared to Enough Snuff for ITT cases (23.1% vs. 20.9%, OR = 1.14, p = .5384), although no longer significantly different. CONCLUSIONS: This is the first large-scale text-based cessation clinical trial for individuals in underserved areas who use smokeless tobacco. The #EnufSnuff.TXT intervention performed better in the short term; however, both interventions yielded similar quit rates at 6 months post-randomization. Future research should focus on improving long-term abstinence in the #EnufSNuff.TXT intervention. IMPLICATIONS: Text-based cessation approaches have the potential to increase access to cessation interventions in rural and medically underserved areas and reduce tobacco-related chronic disease morbidity and mortality. Our study shows short-term efficacy from the first-ever randomized controlled trial of a smokeless tobacco cessation intervention, #EnufSnuff.TXT, for rural and medically underserved residents in the United States. Our #EnufSnuff.TXT Intervention offers a scalable solution to reach and provide much-needed access to cessation interventions in medically underserved, rural communities in the United States. This work provides the foundation for further inquiry on augmented text-based approaches to increase cessation in this at-risk group. CLINICAL TRIALS REGISTRATION: A text-based Reduction Intervention for Smokeless Tobacco Cessation, NCT04315506.

Willingness to trade-off years of life for an HIV cure – an experimental exploration of affective forecasting

AIDS Research and Therapy · 2024-08-06 · 1 citations

BACKGROUND: In the US, 1.2 million people live with HIV (PWH). Despite having near-normal life expectancies due to antiretroviral therapy (ART), many PWH seek an HIV cure, even if it means risking their lives. This willingness to take risks for a cure raises questions about "affective forecasting biases," where people tend to overestimate the positive impact of future events on their well-being. We conducted a study to test two interventions to mitigate affective forecasting in the decisions of PWH about taking HIV cure medication. METHODS: We recruited PWH to complete a 30-minute survey about their current quality of life (QoL) and the QoL they anticipate after being cured of HIV, and assigned them to either no additional intervention, to one of two interventions intended to reduce affective forecasting bias, or to both interventions: (1) a defocusing intervention designed to broaden the number of life domains people consider when imagining life changes associated with new circumstances (e.g. HIV cure); and (2) an adaptation intervention to help them gauge fading of strong emotions over time. The study design included a 2 × 2 design: defocusing (yes/no) x adaptation (yes/no) intervention. We assessed PWH's willingness to take hypothetical HIV sterilizing cure medication using the Time Trade-Off (TTO) and their quality of life predictions with WHOQOL-HIV. RESULTS: 296 PWH participated. Counter to what we had hypothesized, neither intervention significantly reduced PWH's willingness to trade time for a cure. Instead, the defocusing intervention increased their willingness to trade time (IRR 1.77, p = 0.03). Exploratory analysis revealed that PWH with lower current quality of life who received the defocusing intervention were more willing to trade time for a cure. CONCLUSION: These negative findings suggest that either these biases are difficult to overcome in the settings of HIV curative medication or other factors beyond affective forecasting biases influence willingness to participate in HIV curative studies, such as respondents' current quality of life.

Parental Awareness of and Agreement With the American Academy of Pediatrics Clinical Practice Guideline for Obesity Treatment

The Annals of Family Medicine · 2024-11-20 · 1 citations

<h3>Context:</h3> Primary care providers (PCPs) frequently treat children and adolescents with obesity. In 2023, the American Academy of Pediatrics released new clinical practice guidelines (CPG) for the evaluation and treatment of pediatric obesity. The ability for PCPs to implement the guidelines depends, in part, on parental awareness of and agreement with the CPG. <h3>Objective:</h3> To describe parental awareness of and agreement with the pediatric obesity CPG. <h3>Study Design and Analysis:</h3> An online survey was conducted. Parents answered questions about their awareness of the CPG and agreement with 8 CPG recommendations. They described any personal experiences/beliefs that influenced their feelings towards the CPG. Linear regression and inductive content analysis was used. <h3>Population Studied:</h3> Eligibility criteria: age ≥18 years old, US Nationality, fluency in English, and parent to child(ren) &lt;18 years old. <h3>Results:</h3> 151 parents responded. Most were female (63%), white (75%), non-Hispanic (91%), married (74%), and completed a bachelor’s degree or higher (55%). Nearly half (44%) screened positive for financial insecurity. Most had overweight or obesity (29% and 34%, respectively), and 15% had a child diagnosed with overweight or obesity by a doctor. Very few parents (5%) were aware of the CPG. Over half of parents agreed with 6 of the 8 CPG recommendations (range 51-74% of parents), whereas fewer parents agreed with the recommendation to offer medications (27%) or surgery (16%). Parents with a higher BMI had lower overall CPG agreement (beta=-0.6, p=0.2); parent age, sex, and financial insecurity did not predict overall CPG agreement. Many parents’ opinions on the CPG were influenced by beliefs not supported by the current scientific understanding of obesity (e.g., lifestyle-focused education is a highly effective treatment for obesity, parents are responsible for and potentially should be punished for pediatric obesity). <h3>Conclusions:</h3> Few parents were aware of the CPG, suggesting a need for continued public education of the guidelines. Parents’ perspectives on the CPG were largely based on anecdotal experiences and commonly held “obesity myths” that focus on parental responsibility, personal choice, and lifestyle education as a highly effective treatment for obesity. To improve uptake of the CPG without worsening weight stigma/bias, PCPs should continue efforts to educate parents about the new guidelines while simultaneously addressing commonly held obesity myths.

Communication, Bias, and Stigma

2023-01-01

Community-based organizations’ perspectives on piloting health and social care integration in North Carolina

BMC Public Health · 2023-10-04 · 9 citations

BACKGROUND: Community-based organizations (CBOs) are key players in health and social care integration initiatives, yet little is known about CBO perspectives and experiences in these pilot programs. Understanding CBO perspectives is vital to identifying best practices for successful medical and social care integration. METHODS: From February 2021 to March 2021, we conducted surveys with 12 CBOs that participated in the North Carolina COVID-19 Social Support Program, a pre-pilot for North Carolina's Medicaid Sect. 1115 demonstration waiver program that addresses social drivers of health. RESULTS: CBO participants preferred communication strategies that involved direct communication and felt clear communication was vital to the program's success. Participants expressed varied experiences regarding their ability to handle a changing volume of referrals. Participants identified their organizations' strengths as: strong organizational operations, past experiences with and understanding of the community, and coordination across organizations. Participants identified challenges as: difficulty communicating with clients, coping with capacity demands for scaling services, and lack of clear processes from external organizations. Almost all CBO participants expressed enthusiasm for participating in similar social care transformation programs in the future. CONCLUSIONS: CBO participants in our study had broadly positive experiences in the pilot program and almost all would participate in a similar program in the future. Participants provided perspectives that can inform health and social care integration initiatives, including strengths and challenges in such programs. To build and sustain health and social care integration programs, it is important to: (1) support CBOs through regular, direct communication that builds trust and power-sharing between CBO and health care entities; (2) leverage CBO community expertise; and (3) pursue an individualized assessment of CBO capacity and identify CBO capacity-building strategies that ensure program success and sustainability.

Two Specialists, Two Recommendations: Discordance Between Urologists’ &amp; Radiation Oncologists’ Prostate Cancer Treatment Recommendations

Urology · 2022-06-26 · 4 citations