Article
Case Study of a Transtheoretical Case Management Approach to Addressing Childhood Obesity

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Childhood obesity is an increasing health concern that is strongly associated with chronic health problems persisting into adulthood. Obesity in childhood is resistant to interventions that involve only recommendations to decrease caloric intake and to increase caloric expenditure. The challenge with this approach to childhood obesity is twofold: It is neither theoretically based nor does it consider the children's or their parent's perceptions of their health problems. Of significance, this traditional approach also ignores the transition along the stages of behavioral change. Case management has proven to be successful in managing various chronic health problems in both adults and children. This case study will present a new intervention model to treat childhood obesity based on the transtheoretical framework utilizing case management in a primary care setting.

Section snippets

Prevalence

There has been a marked increase in the prevalence of overweight and obesity in children in the past 25 years (Hedley et al., 2004). In the United States, the percentage of obese children aged 6–11 years has increased from 5% in 1970 to 18.8% in 2002 (Ogden et al., 2002). The percentage of overweight children aged 6–11 years rose from 28.2% in 1999 to 33.6% in 2004 (Ogden et al., 2006). Furthermore, data from 2003 to 2004 indicate that the burden of overweight and obesity in children is

Underlying Cause and Outcomes

Healthy People 2010: Understanding and Improving Health lists low level of physical activity and overweight/obesity as the top two leading indicators of health among children and adults (U.S. Department of Health and Human Services, 2000). Childhood obesity is the result of a seemingly complex interaction between genetics, caloric intake, and caloric expenditure. Modifiable risk factors associated with childhood obesity can be dichotomized into two groups: physical inactivity and excessive

Rationale for the Study

One potential low-cost treatment for overweight and obesity is increased physical activity. There is an increasing amount of evidence supporting the immediate health benefits associated with physical activity, including weight management and reduction of adiposity among children (Janz, Burns, & Levy, 2005). It is widely accepted that physical activity of moderate intensity results in enhanced general health in youth, with increased intensity (i.e., activities that record higher MET levels)

Background

One of the most logical starting points for the treatment of the obese child is the primary care provider. Unfortunately, interventions targeting the physician as the catalyst for weight loss have yielded mixed results (Galuska et al., 1999, Stafford et al., 2000). A potentially promising approach is expanding the target to other health care providers (e.g., health educators, dieticians, and nurses) through case management of children and their families. Case management is defined as a

Conceptual Framework

Integrated into the case management approach described in this article is the use of Prochaska and DiClemente's (1992) Transtheoretical Model (TM) of behavioral change. Inherent to the TM is the notion that individuals progress through as many as six distinct stages as they attempt to make a lasting change in behavior. The interpretation of the TM for this study refers to four stages of change through which individuals progress as they attempt to modify their weight status. These four stages

Underlying Assumptions

The TM has been utilized by a number of investigators to design successful interventions to modify health behaviors, including smoking, emotional distress, alcohol abuse, weight loss, and mammography screening (Prochaska & DiClemente, 1992). The success of these previous interventions has been dependent upon two assumptions of the model. First, movement between stages in the model is linear and may involve back-and-forth movement between stages before permanent transition to the next stage is

Purpose and Hypothesis

The primary purpose of this study was to examine the efficacy of a case management intervention pilot program that is designed to decrease markers of childhood obesity and the risk factors associated with childhood obesity. A secondary purpose was to pilot test the feasibility of administering this program in 12 weeks and its impact on participants' stages of change.

Research Methods

Two African-American children and their parents were recruited from primary care community-based clinics and randomized to receive either 12 weeks of family-based case management interventions designed to decrease the markers of childhood obesity and the risk factors associated with childhood obesity in the African-American population, or a control weight management program for the same period. The subjects provided informed consent and were advised that they would receive monetary incentives

Results

Both A.W. (intervention) and J.D. (control) and their parents exhibited similar stage-of-change scores for precontemplation, contemplation, action, and maintenance stages at baseline, indicating similar inabilities to identify and address the children's weight problems. In addition, both subjects recorded similar baseline levels of physical inactivity, spending most of their time in light physical activity, closely followed by sedentary activity. However, stage-of-change scores revealed

Discussion

Previous research supports a number of assumptions underlying the basis of this case study. First, obesity among African-American children is increasing in the United States at an alarming rate (Ogden et al., 2006) and is associated with a number of chronic health conditions during childhood (Dietz, 1998, Ogden et al., 2002). Second, childhood obesity commonly persists into adulthood; adult obesity is also associated with a number of chronic health conditions (Epstein et al., 1998,

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