The Journal of the American Dental Association
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J Am Dent Assoc, Vol 140, No 3, 313-316.
© 2009 American Dental Association
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CLINICAL PRACTICE

A Healthy Weight Intervention for Children in a Dental Setting

A Pilot Study



Mary Tavares, DMD, MPH and Virginia Chomitz, PhD


   ABSTRACT
TOP
 ABSTRACT
OVERWEIGHT CHILDREN: A GROWING...
 THE PILOT STUDY
 CONCLUSION
 REFERENCES
 
Background. There are twice as many U.S. children who are overweight or at risk of being overweight as there were 20 years ago. Dental care professionals have an opportunity to provide obesity prevention interventions to their patients. The authors present a dental office–based healthy weight intervention (HWI) protocol designed for all children.

Conclusions. Preventive dental office visits are an opportunity for dental care professionals to provide HWIs to children. The authors found that the HWI they described is feasible and can be well-accepted in a pediatric dental care setting. Caregivers and dental care providers said they considered the HWI to be useful, and it was well-accepted by children.

Clinical Implications. Healthy eating and lifestyle behaviors can have a positive effect on systemic health and oral health. Better food choices can reduce dental caries, and the prevention of obesity-related systemic diseases, particularly diabetes, can help patients maintain good oral health.

Key Words: Dental care for children; dental offices; obesity; nutrition; weight loss; behavioral sciences

Abbreviations: BMI: Body mass index. • HWI: Healthy weight intervention.

Dental settings offer an opportunity for dentists to provide healthy weight promotion with patients. The model for standard dental care combined with the factors that promote oral health provide a suitable environment for obesity prevention. For instance, there is a great deal of similarity between the foods that dental care providers recommend to prevent dental caries and those recommended by nutrition experts to help prevent patients from becoming overweight. Sweets and refined carbohydrates not only have been implicated in tooth decay, they also are calorie-intensive foods. Dental care involves two preventive or diagnostic dental office visits annually, which is one more than in the medical model. This allows for twice as many interventions per year.

In a 2005 editorial, Glick1 said that dentists should institute and monitor behavioral obesity interventions with their patients to protect their oral health and general health. Because a patient’s weight status can be associated with his or her oral health, Hague and Touger-Decker2 advocated that weight screening be a part of a comprehensive dental examination. In this article, we provide an overview of the problem of excess weight in children and describe a healthy weight intervention (HWI) that can be introduced into preventive dental care visits for children.


   OVERWEIGHT CHILDREN: A GROWING HEALTH PROBLEM
TOP
 ABSTRACT
 OVERWEIGHT CHILDREN: A GROWING...
THE PILOT STUDY
 CONCLUSION
 REFERENCES
 
The results of the 2003–2004 National Health and Nutrition Examination Survey showed that 18.8 percent of U.S. children aged 6 to 11 years were overweight and that 37.2 percent were at risk of becoming overweight, which is double the prevalence of 20 years ago.3 Overweight children are at an increased risk of developing type 2 diabetes, sleep apnea, orthopedic complications,4 hypertension and other cardiovascular risk factors,5,6 as well as long-term psychological effects resulting from teasing and discrimination.7 An estimated 70 percent of overweight children will become obese adults,8 who will be at further risk of developing chronic disease and cancer.9 Pediatric obesity rates have increased among all racial and ethnic groups, but they are higher among Hispanic, African-American and multiracial children.10 The rates also have increased among children in low-income households.11

These statistics prompted the authors of Healthy People 2010 to include a goal to reduce the proportion of children who are overweight or obese.12 However, in a recent report using national data and assuming that current trends will continue, researchers at Johns Hopkins University (Baltimore) projected that by 2030, 86.3 percent of adults will be overweight and 51.1 percent will be obese, and the prevalence of overweight children will double.13

Strategies for prevention and intervention Although increases in obesity are attributed to many factors, the energy imbalance created by increasing caloric intake levels and decreasing physical activity levels plays a large role.14 The boxGo summarizes the recommended behavioral strategies for promoting children’s healthy weight.15–23 The American Academy of Pediatrics24 recommends that health care providers encourage healthy eating patterns and routine physical activity and discourage television and video time (screen time) by providing education and anticipatory guidance to families. Evidence suggests that busy health care providers do not adequately follow these recommendations25 and that using office-based tools targeting specific behaviors may be helpful.26


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  		BOX Recommended behavioral strategies: promoting healthy weight for children.

 
One method of providing office-based obesity prevention or intervention is motivational interviewing.27,28 In motivational interviewing, a person self-assesses the importance of a targeted behavior and his or her confidence in changing it and then sets behavioral goals that reflect this confidence. In an article widely used in behavior change research, Bandura29 specified that setting goals is an important strategy. The results of studies promoting dietary and physical activity behavior change in adults have shown that setting goals is effective and, therefore, it is a promising office-based strategy for preventing child obesity.28,30

We conducted a pilot study to assess the feasibility of including as part of primary dental care an intervention promoting awareness of pediatric obesity risk and providing recommendations, goal-setting frameworks and referrals.


   THE PILOT STUDY
TOP
 ABSTRACT
 OVERWEIGHT CHILDREN: A GROWING...
 THE PILOT STUDY
CONCLUSION
 REFERENCES
 
As part of this pilot study, we developed an HWI protocol for the dental setting. This HWI is based on the concepts of motivational interviewing and is for children of all weights.

We tested the HWI in 139 children aged 6 to 13 years from two community dental clinics, who returned for two or three preventive dental office visits across 18 months. At each visit, a hygienist collected information about each child’s obesity risk factors with respect to food, physical activity, screen time and meal habits. The hygienist then measured the child’s height and weight and calculated the child’s body mass index- (BMI-) for-age percentile. (BMI-for-age percentile is used to rank a child’s weight in relation to his or her stature compared with the Centers for Disease Control and Prevention growth charts for male and female children aged 2 to 20 years.) The hygienist used this information to complete an individualized health report card with recommendations for healthy behavior modifications. At the end of the visit, the child selected a healthy living goal for the next six months and recorded it on the health report card. The hygienist or dentist provided medical referral for children with a BMI-for-age percentile of 85 percent or higher. The hygienists recorded the length of the dental office visits to assess the feasibility of including this HWI in a typical preventive visit.

We obtained feedback about including obesity prevention in the dental office visit from the children’s caregivers and the dental care providers. We gave the caregivers a short questionnaire to answer during their child’s second visit. We held focus groups for the dental care providers so that they could express their opinions about the HWI. We gauged the children’s acceptance by their compliance with and enthusiasm for the HWI.

We found that, by the six-month visit, the hygienists were able to perform all of their duties for the dental office visits, including the HWI, in less than 40 minutes (mean time). The dental staff members and providers who participated in the study thought that the HWI was important, and they were willing to make minor scheduling adjustments to accommodate it. At the same time, they did not think that performing it was a burden on their schedules.

The results of a survey of the participating children’s caregivers were encouraging (TableGo). Nearly all caregivers (95.5 percent) reported that they made better food choices for their children to help them meet their goals.


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  		TABLE Caregivers’ feedback about the HWI.*

 
Through the two focus groups of both practicing dentists and hygienists, we found that they would be more likely to incorporate the HWI if parents and families liked it, if there was a positive effect on dental health and weight, and if it was cost-neutral. Overall, clinicians were enthusiastic about the HWI; most thought that it would be possible to implement and that their offices would consider it.

This pilot study allowed us to evaluate the extent to which children and caregivers adopted the hygienist’s recommendations and met the children’s healthy living goals. The preliminary results showed that the HWI is feasible and can be well-accepted in a pediatric dental setting.

Some dental care professionals have suggested that they are well-positioned to counsel patients about weight.31,32 Additionally, Vann and colleagues33 recommended that pediatric dentists "take a bold step forward and embrace a reliance on calculating and monitoring BMI in each child’s dental record." The American Academy of Pediatric Dentistry34 has set monitoring, preventing and managing the treatment of excess weight in children as an important research agenda item.

We are analyzing additional data from this pilot study to prepare a final report. These data will include changes in reported obesity risk behaviors and any changes in weight status.


   CONCLUSION
TOP
 ABSTRACT
 OVERWEIGHT CHILDREN: A GROWING...
 THE PILOT STUDY
 CONCLUSION
REFERENCES
 
Our preliminary findings show that an HWI is feasible and is acceptable in pediatric dental care settings. Caregivers and dental care providers considered it to be useful, and it was well-accepted by the subjects. Providing healthy eating and lifestyle messages may lead to positive results for oral health and systemic health. Better food choices can reduce dental caries, and the prevention of obesity-related systemic diseases, particularly diabetes, can help maintain oral health.

The tools we developed in our pilot study (for example, the report card), along with those from other working groups, can be the basis of dental office–based preventive obesity interventions for children and adults.


   FOOTNOTES
 

Dr. Tavares is a senior clinical investigator, The Forsyth Institute, 140 The Fenway, Boston, Mass. 02115, e-mail "mtavares{at}forsyth.org". Address reprint requests to Dr. Tavares.


Dr. Chomitz is a senior scientist, Institute for Community Health, Cambridge, Mass.


Disclosure. Neither author reported any disclosures.


This study was supported by National Institutes of Health grant 1 R21 DE017446-01.


   REFERENCES
TOP
 ABSTRACT
 OVERWEIGHT CHILDREN: A GROWING...
 THE PILOT STUDY
 CONCLUSION
 REFERENCES
 

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Right arrow Articles by Chomitz, V.

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