Skip to main content

Main menu

  • HOME
  • ARTICLES
    • Current Issue
    • Ahead of Print
    • Archives
    • Abstracts In Press
    • Special Issue Archive
    • Subject Collections
  • INFO FOR
    • Authors
    • Reviewers
    • Call For Papers
    • Subscribers
    • Advertisers
  • SUBMIT
    • Manuscript
    • Peer Review
  • ABOUT
    • The JABFM
    • The Editing Fellowship
    • Editorial Board
    • Indexing
    • Editors' Blog
  • CLASSIFIEDS
  • Other Publications
    • abfm

User menu

Search

  • Advanced search
American Board of Family Medicine
  • Other Publications
    • abfm
American Board of Family Medicine

American Board of Family Medicine

Advanced Search

  • HOME
  • ARTICLES
    • Current Issue
    • Ahead of Print
    • Archives
    • Abstracts In Press
    • Special Issue Archive
    • Subject Collections
  • INFO FOR
    • Authors
    • Reviewers
    • Call For Papers
    • Subscribers
    • Advertisers
  • SUBMIT
    • Manuscript
    • Peer Review
  • ABOUT
    • The JABFM
    • The Editing Fellowship
    • Editorial Board
    • Indexing
    • Editors' Blog
  • CLASSIFIEDS
  • JABFM on Bluesky
  • JABFM On Facebook
  • JABFM On Twitter
  • JABFM On YouTube
Research ArticleOriginal Research

FitwitsTM Leads to Improved Parental Recognition of Childhood Obesity and Plans to Encourage Change

Bethany A. Edwards, Jonathan R. Powell, Ann McGaffey, Valerie M. P. Wislo, Elaine Boron, Frank J. D'Amico, Linda Hogan, Kristin Hughes, Ilene Katz Jewell and Diane J. Abatemarco
The Journal of the American Board of Family Medicine March 2017, 30 (2) 178-188; DOI: https://doi.org/10.3122/jabfm.2017.02.160274
Bethany A. Edwards
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jonathan R. Powell
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ann McGaffey
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
MD, FAAFP
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Valerie M. P. Wislo
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Elaine Boron
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
DO
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Frank J. D'Amico
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
PhD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Linda Hogan
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
PhD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kristin Hughes
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
MFA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ilene Katz Jewell
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
MSHyg
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Diane J. Abatemarco
From the University of Pittsburgh Medical Center Urgent Care Wexford, Wexford, PA (BAE); Renaissance Family Practice, Glenshaw, Pittsburgh (JRP); the St. Margaret Bloomfield Garfield Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (AM, EB); Penn Plum Family Medicine, St. Margaret Hospital, University of Pittsburgh Medical Center, Pittsburgh (VMPW); Faculty Development Fellowship Program and St. Margaret Lawrenceville Family Health Center, University of Pittsburgh Medical Center, Pittsburgh (FJD, LH); Carnegie Mellon University School of Design, Pittsburgh (KH); Retired from Austen BioInnovation Institute in Akron, Akron, OH (IKJ); and the Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia (DJA).
PhD, MSW
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
Loading

Abstract

Introduction: Brief tools are needed to help physicians and parents reach consensus on body mass index (BMI) categories for children and to discuss health-improving behaviors. This study tested the FitwitsTM intervention with interactive flashcards and before and- after surveys to improve parents' perceptions of children's BMI status.

Methods: We enrolled 140 parents and their 9- to 12-year-old children presenting for well child care, regardless of BMI status, scheduled with 53 Fitwits-trained physicians. The Fitwits tool guided a conversation with all parent-child dyads regarding understanding BMI, nutrition, activity, and portion sizes. A survey addressed BMI category perceptions before and after the intervention, requested 2 goal selections, and included open-ended comment areas.

Results: Fifty-three percent of children were overweight or obese. The primary outcome variable was the rate of correct parental identification of their child's weight status (underweight, healthy, overweight, or obese). The survey before the intervention resulted in 50.0% correct BMI category designations. This changed to 60.6% correct perceptions after the intervention, with movement between correct overweight (34.5% to 51.7%) and obese (4.4% to 24.4%) categories. Secondary outcome variables included specific behavior change goals and the qualitative responses of parents, children, and physicians to the intervention. Parent-child dyads predominantly commented favorably and chose (75.8%) goals corresponding to Fitwits card suggestions.

Conclusions: An improvement was observed in parental ability to identify the correct BMI category after the intervention during a preadolescent well child visit. Parent underrecognition of overweight/obese children was also observed. Most parent comments were appreciative of the physician interaction, Fitwits flashcards, and health improvement exchange.

  • Body Mass Index
  • Body Weight
  • Childhood Obesity
  • Health Literacy
  • Portion Size
  • Surveys and Questionnaires

The 2007 Expert Committee recommendations encouraged physicians to screen children between 2 and 18 years of age at well-child visits for body mass index (BMI) percentiles, to provide anticipatory guidance for children at a healthy weight, and to effectively counsel overweight and obese children.1 However, physicians and parents often rely on visual and cultural impressions of weight status rather than objective BMI measurements when considering children.2⇓–4 Underrecognition of mildly obese and overweight children is common.5⇓⇓–8 When excess weight is observed, physicians and families frequently struggle to find accessible language and helpful management strategies within the confines of well-child visits.4,9,10 Calculated BMI percentiles may be difficult for parents to understand.9,11 In these instances, obese and overweight children are not properly assessed and treated.5,7,12 Studies in the medical literature are replete with subpar productive and documented BMI discussions with families.4⇓–6,10,13,14

To assist primary care physicians with these discussions, university-based design specialists, physicians, dietitians, and children from Pittsburgh, Pennsylvania codeveloped the FitwitsTM office tool as a brief well-child care intervention, irrespective of BMI status.15,16 Fitwits products were invented as a health communications–related preventive approach to reducing obesity in 2007 to 2009.17 Seventeen flashcards populated with “Fitwits” and “Nitwits” food and snack-based characters frame key expert-recommended elements: BMI discussion, use of the term obesity, exercise, nutrition, portion sizes, and behavioral management suggestions. Cards 3 and 4 depict accurate BMI percentile scales for girls and boys, respectively. They have ordinate labels and color-coded obese, overweight, and healthy weight BMI categories, illustrated with representative Fitwits and Nitwits characters. The flashcards prompt conversations about 60 minutes of daily activity, reducing fast food and sweetened beverages, and 7 hand-based portion sizes for any place a meal is being eaten. Our 2011 residency-based office study of this tool demonstrated increased physician comfort and competence in discussions, particularly those about BMI, obesity, and portion sizes.18 Physicians are more disposed to screen for obesity with concurrent training in prevention and treatment.19⇓–21 We have continued Fitwits training for physicians entering our program and are focused on patient outcomes.

This Fitwits BMI study is a response to the growing “norm” of childhood obesity and the concurrent fading parental recognition of a child's excess weight. Physicians need to help parents understand that their child is overweight or obese, and then help them take action.22 Our study assesses parents' awareness of their child's BMI status, perceptions of the physician-led discussion, and the child's longitudinal BMI percentile trajectory over 12 months. In this article we only report parent responses to questions about prior physician-led BMI discussion, health behaviors regarding eating and activities, parent's identification of the child's BMI category before and after the Fitwits intervention, selected goals, and visit comments; this well-child survey was administered on the day of enrollment.

Methods

Design

Our intention was to determine whether parents' perceptions of their child's weight status would change by using the Fitwits office tool during a well-child visit. The approximately 5-minute Fitwits-framed discussion replaced the usual well-child weight status, nutrition, and activity conversation. We used electronic medical record (EMR)–generated BMI percentiles, the physician-led Fitwits brief intervention, and self-reporting surveys administered before and after the intervention for parents/guardians and children ages 9 to 12 years. To attract enrollees, a home-use Fitwits game set was given to each child at the visit's conclusion; the games included (1) Fitwits or Nitwits food characters with simple fat and sugar scales and recipes using hand-based portion sizes; (2) a memory game connecting hand-based portion sizes and a variety of foods; and (3) a trivia game with engaging nutrition-related questions. This study was part of a larger longitudinal, nonrandomized intervention study that measured BMI category perceptions and child BMI trajectories at 4 time points (baseline and 2, 6, and 12 months). All procedures were approved by the University of Pittsburgh Institutional Review Board.

Setting and Participants

Our study was conducted in an urban western Pennsylvania family medicine residency program in 3 family health centers serving patients with low to middle socioeconomic status. A Fitwits research team of residents trained and obtained consent from 100 family health center residents, fellows, and faculty physicians. We enrolled 140 parents and 9- to 12 year-old children between May 2012 and November 2013.

Procedure

Inclusion and Recruitment Methods

The Fitwits team developed a training PowerPoint presentation for reception and nursing staff and separate printed pages for the staff and patients. These outlined the eligibility of all children ages 9 to 12 years, regardless of BMI status, provided that they were scheduled for a well-child visit and accompanied by a parent/legal guardian. Trained staff obtained informed consent from parents/legal guardians and assent from the children.

Process

Nursing staff weighed the child on well-maintained scales, which were different at each site, and measured their height using Seca 222 stadiometers (seca North America, Chino, CA). Measurements were entered in our EpicCare EMR (Epic Systems Corp., Verona, WI), producing a BMI and a BMI percentile to the 0.01 place. In the examination room, the parent and child completed the survey up to the indicated stopping point; then the physician narrated the flashcards and facilitated bidirectional conversations. The EMR-generated BMI percentile and the BMI category were discussed using the girls' or boys' BMI flashcard. After the Fitwits intervention, the parent and child completed the remaining survey. The physician completed his/her comment area.

Outcomes

The primary outcome variable was the rate of correct identification by parents of their child's weight status (underweight, healthy, overweight, or obese) before and after the brief Fitwits intervention. Secondary outcome variables included specific behavior change goals, chosen collaboratively by the parent-child dyad, and the qualitative responses of parents, children, and physicians to the intervention.

Survey and Study Development, and Physician Training

A validated children's behavioral health survey was not available. The pen and paper survey was constructed over several months by the Fitwits team of residents and faculty to reflect the contents of the Fitwits tool. Additional questions were developed based on published use of brief tools focused on BMI identification and communication, participant health habits, and goal-setting.23,24 The survey was not validated, but the team edited questions to improve the level of understanding.

Surveys completed by parents and children included questions related to demographics; parent perceptions that a physician discussed and helped them understand BMI in the 2 years before the intervention; understanding of BMI category before and after the Fitwits intervention; and 9 health-related behaviors (3 possible responses per question).1,23,25 The Fitwits office tool was implemented before the after-intervention survey, which requested the selection of 2 behavioral change goals from among 25 suggestions. The survey concluded with child and parent comment areas, prefaced by “Comments on visit with the doctor,” followed by “Physician comments on visit.”

Residency-based physicians have been trained by a Fitwits resident team to use the Fitwits intervention since 2008. Group intern orientation training was accomplished each June starting in 2012 with a PowerPoint presentation on the epidemiology of childhood obesity, child BMI percentile discussions, and a review of the card games, 17 flashcards, and surveys.

Sample Size Estimation

We based our sample size estimation on the major study goal of improving the rate of parents correctly identifying their child's weight status. Under the null hypothesis, a parent would guess their child's correct status 50% of the time before the intervention. A sample size of approximately 110 parents would be sufficient to determine an improvement of 15% (α = 0.05, 2-tailed; power = 0.90). Assuming a 20% loss to follow-up at 12 months resulted in us seeking to enroll 130 parents and children.

Statistical Analysis

In this article, basic descriptive statistical measures (frequency and relative frequency distributions, cross-tabulations) are used to describe the parent, child, and physician responses to survey questions. The McNemar test for matched dichotomous differences was used to compare the parent's accuracy (either correct or incorrect) of identifying their child's BMI status before and after the intervention.

Two qualitative analysts (IJK and DJA) independently coded the written comments of parents, children, and physicians; developed major themes; and grouped the comments. The analysts conferred on differences in applied codes and came to a consensus.

Results

We obtained consent from and enrolled 140 pairs of parents and 9- to 12-year-old children at well-child visits, regardless of BMI status, though 130 parent/child pairs were determined to be sufficient. A total of 53 Fitwits-trained physicians participated based on family enrollments.

As seen in the population description provided in Table 1, the 140 enrolled children were evenly distributed in age; 54% were male, and the children were predominantly English-speaking, African American, not Hispanic, insured by Medicaid, and accompanied by their mother. Fewer than half (46%) had a healthy BMI, 1% was underweight, and 53% were overweight or obese. Our concurrent outpatient population of 378 9- to 12-year-olds was 51% male; 61% African American, 33% white, and 7% other; 81% insured by Medicaid; and 42.1% overweight or obese (52.1% at center 1, 39.1% at center 2, and 32.7% at center 3). The demographics and high enrollment (53%) of overweight and obese children most closely resembled the preadolescent population at center 1 (86% African American). About half (71 of 140) of the parent/child cohort chose to enroll at center 1.

View this table:
  • View inline
  • View popup
Table 1.

Descriptive Characteristics of Child Participants (n = 140)*

Table 2 addresses parents' views of a prior physician-led, BMI-related discussion and a child behavior survey. Most children (94%) had weight and height measurements. Just over half (60%) recalled a discussion of BMI with their physician, and 55% felt that a physician had helped them understand BMI. A total of 29% had experienced Fitwits previously, in a study or informally. Table 2 also shows parental assessments of factors that were influential in normal or excessive weight gain. Most reported (their opinion) “about right” portion sizes (72%) and ≤1 fast food meals in a week (69%). The majority of responses indicated <5 servings of fruits and vegetables each day and ≥2 sweetened drinks and junk food snacks each day. For activity behaviors, only 7% thought their child actively played <1 hour per day, whereas 68% reported ≥2 hours of daily screen time. All responders (n = 135) owned a television; 68% had a television located in the child's sleeping area. By contrast, 80% of participant households owned a computer, and 12 of these were located in the child's sleeping area.

View this table:
  • View inline
  • View popup
Table 2.

Preintervention Parent Report of Physician Interactions and Child's Behaviors*

Perceptions about BMI categories are found in Table 3. Approximately 53% of the 140 enrolled children were overweight (n = 29) or obese (n = 45). Most parents whose children had a healthy BMI percentile recognized them as such (86.2% correct responses), whereas 34.5% correctly identified their child as overweight and just 4.4% correctly identified their child as obese. Eight children were perceived as being underweight, though actually 1 child was underweight, 6 had healthy weights, and 1 was obese. The results after the intervention showed a shift in the direction of more parents (11 of 45) correctly acknowledging their child's obesity. Total parent perceptions of the correct BMI category changed from 50.0% to 60.6%, with positive movement in both the overweight (51.7%) and obese (24.4%) categories. Nine children were identified as underweight, which was true only for 1 of them.

View this table:
  • View inline
  • View popup
Table 3.

Comparison of Parent Responses Before and After the Intervention*

A matched set of 135 parents responded to both the pre- and postintervention questions regarding their child's perceived BMI status. A total of 63 parents (47%) correctly identified their child's BMI status on the surveys both before and after the intervention, 48 (36%) were incorrect on both, and 24 (18%) changed their perception. Of the 24 who changed, 18 parents were incorrect on the survey before the intervention but answered correctly on the survey after the intervention, versus 6 who changed to incorrect after the intervention (P = .014).

Table 4 is a compilation of the 2 goals selected from among 25 choices by parents and children after the Fitwits discussion. Participants tended to select goals (191/252, 75.8%) corresponding to visual and conversational cues included in the Fitwits flashcards and/or physician training. Those selected ≥20 times included the visually cued increase in fruits and vegetables (n = 31), less junk food, more healthy snacks (n = 32), decrease sugary drinks (n = 21), drink more water (n = 25), proportionate hand-based portion sizes (n = 23), and active play at least 60 minutes each day (n = 20). The next tier, chosen 10 to 19 times, included built-in messages to eat less fast food (n = 12) and the activity inquiry (eg, dance, bicycle, walking), chosen 13 times. Fitwits cards do not include limiting screen time (chosen 14 times), but trainees were instructed to verbally add this message to the 60-minute activity card.

View this table:
  • View inline
  • View popup
Table 4.

Goals Selected by Parents and Children After the Intervention (Instructed to Select 2 of 25 Example Goals)*

Qualitative comments are summarized in Table 5. Of the 53 participating physicians, 39 wrote at least 1 comment. Remarks favored adult and child engagement (52 comments) over absent engagement (13 comments). Approximately 25% of comments were positive regarding the information provided. Nonacceptance of BMI was perceived for 5 adults. The parents and children (n = 31; child data not shown) who commented wrote mostly positive remarks about the physician, receiving information, and improved healthy eating/drinking or understanding of BMI. Comments from child-parent dyads are portrayed in the word cloud (Wordle, http://www.wordle.net) shown in Figure 1. Some comments are included in the discussion to support or refute BMI discussion and regarding activation expressed by parents and children after the intervention. Examples of additional comments follow.

View this table:
  • View inline
  • View popup
Table 5.

Qualitative Physician Comments and Parent Comments upon a Visit with the Doctor

Figure 1.
  • Download figure
  • Open in new tab
Figure 1.

Our physicians and 17 Fitwits flashcards guide each child and parent through an interactive conversation about body mass index status, “obesity,” nutrition, activity, and hand-based portion sizes. The thumb portion size (shown) is a recommended serving of peanut butter, mayonnaise, hummus, or other spreads at 1 meal. Responsive parent and child survey comments are captured in this word cloud.

Parent/guardian comments (set verbatim) reflecting physician communication included appreciation for the doctor's skills and Fitwits messages about BMI and changing health habits: “She was so informative. I really liked the way she does her job”; “Great advise [sic] and help to understand the importance of my childs [sic] BMI”; “Really helped us understand the importance of BMI being healthy—works well with my family.” A grandmother said, “This health care … is very informative about healthy eating, exercising, ways to help the parents out with this difficult task.” Other comments from parents/guardians included, “It was very informative about my niece's BMI and the Dr showed us great ways to improve our eating habits”; “Up until today I thought her weight was nice but I learned that we have to change her eating habit”; “Glad to have been introduced to fitwits and the info is very helpful.” Children commented: “I think that this was a good visit & I would like to thank my Dr for telling me how to be healthy. Thank you!”; “Learned how to stay healthy and active to keep a good weight!”; “He helped me very much about my weight”; “I liked the flash cards.”

Some negative but perceptive comments by physicians indicated parents' reluctance to accept BMI designations: “Mother is a little skeptical about BMI category”; “Mother frowning, reluctant to acknowledge BMI status, I think.” Additional physician comments pertained to examination room distractions: “Visit very busy & loud with multiple siblings but the 8 year old & 10 year old really tried to listen”; “Patient was interested but mother in & out of room with other children.”

Discussion

Physicians and families in pediatric care settings often experience a quadruple dilemma: (1) low rates of physician-led communication regarding BMI6,10; (2) parent misperceptions about their child's BMI status8,26,27; (3) low parental acceptance of their child's BMI status3; and (4) reaching agreement on a corrective plan.28 These themes support this Fitwits intervention study and the following discussion.

Systematic identification of overweight/obese children is deemed important to find associated health problems and to match treatment advice and services.6,7,14 Less than a quarter of parents of overweight children aged 2 to 15 years reported having been told by a health professional that their child was overweight, per the 1999 through 2008 National Health and Nutrition Examination Surveys.20 Notification to parents about their child's BMI has recently improved in practices using built-in EMR prompts and decision support, though without necessarily specifying parental buy-in.29⇓–31 Our results support previous studies reporting low rates of physician-led communication about BMI and feedback regarding health implications.4⇓⇓–7,10,12,32 In our setting, almost all parents (94%) noted that weight and height had been measured, but only 60% recalled physician-led discussion of BMI, and only 55% felt that a physician had helped them understand BMI. Some positive responses may have been skewed by prior exposure to Fitwits (29%). The Fitwits intervention assisted our physicians with BMI education by using the girl's or boy's BMI flashcard to discuss the BMI percentile and category for each child and their parent. The subsequent activity and nutrition flashcards were used to suggest maintaining a healthy BMI, if applicable, or to make behavior changes to move in a healthy direction if the child was underweight, overweight, or obese. This comment reflects parent satisfaction: “Very happy to learn more about BMI & ways to better my child's health.”

Before the intervention, looking at all individual parent responses as a whole, the numbers of underweight, healthy weight, and overweight children were overestimated and the number of obese children (3 of 45) was greatly underestimated. Parents' misperceptions about their child's BMI status before the intervention were particularly evident when the child was obese. The data represent a perceptive shift toward choosing lower rather than actual weight categories, with low overall correct recognition of BMI category (50.0%). Our study is consistent with analyses of National Health and Nutrition Examination Survey data from 1988 to 1994 and 2005 to 2010, in which interviewed parents were asked whether their 6- to 11-year-old child was overweight, underweight, or just about the right weight. Overweight/obese children were less likely to be perceived as overweight in the later survey years. More than three quarters of parents perceived overweight children as “about the right weight.” The study authors surmised a generational shift in mismatched parent perceptions with current heavier child weights and a related growing challenge to prevent childhood obesity.33

Correct recognition by parents of their child's BMI percentile after the intervention showed an overall improvement, most notably for obese and overweight children. However, some parents continued to incorrectly identify their child's BMI. Choosing an incorrect BMI category could represent ≥1 or more belief or cultural or social factors, including low acceptance by parents of their child's BMI status on a chart compared with the parent's strong notion of a child as underweight, healthy, or, at most, overweight.3 This comment corresponds to this: “Mother very resistant to BMI as a useful measure in children.” Many cultural attitudes correlate health and/or sports prowess with increased weight.34,35 It is common for parents to feel that an overweight child is “fine,” despite a physician's concern,34 as in this comment from a physician regarding an obese boy: “Mom feels he is normal compared with family and wants him to play football….” It is also common for a parent to worry that a healthy child is too thin.8,27 Some parents have competing priorities, feel too overwhelmed to adopt a new concern, or express low confidence in controlling the food and behavior environment, including child-rearing by extended family members.28,35 The new childhood “norm” of excess body weight makes it difficult for parents and youth to know what healthy children look like.33,36 Although the Institute of Medicine (2005) and the American Academy of Pediatrics (2007) endorsed the term obesity in child BMI percentile determinations,34,37,38 some of the pediatric literature finds it pejorative or insensitive for family discussions and shows preference for terms such as unhealthy weight.22,39⇓–41 Providers agree on health-supporting, culturally attuned, and motivating discussions.42,43 Our physicians were trained and accustomed to using the flashcard term obesity, defined as “too much weight for height.” Physician comments on the lack of parental engagement indicated fatigue and distraction from listening during real-world office conditions: “Mom was very sleepy and not very engaged but was appreciative.” Some of these factors may have influenced parental misidentification of BMI.

In studies that included agreement on a corrective plan, families lauded weight-related discussions that partner the child, parent, and physician; set specific goals over successive visits; and provide simplified and correct nutrition information.21,25,28,34,35,44 Most responses to 9 behavioral questions before the intervention (Table 2) suggested high consumption of sweetened beverages and junk food, prolonged screen time, and a television in the child's bedroom. These survey questions set the tone of behavioral messages for the coming Fitwits discussion. The most popular behavior change goals selected by parent-child dyads after the intervention (Table 4) correlated with visual images on the Fitwits cards and physician training cues. Parent comments supported physician-led Fitwits conversations as age-appropriate and motivating: “Very nice and explained everything so it could be understood by the children”; “This visit has been informative and goal inspiring.” Fitwits games were given for use at home, with implied permission to engage further in lifestyle changes, as per this trio of comments: “Mother ready to share in dietary improvements” (from a physician); “We will do this together” (from a parent); “I understood everything the doctor told me” (from a child).

Limitations

Our study was promoted by an interested team of residents and may not translate to a busy primary care practice. It is, however, a brief conversation that can replace usual discussions about BMI, nutrition, and activity. The demographics of our study population (mostly African American) may limit the generalizability of the findings.

Conclusions

Given prevalent underrecognition of children's weight status, physicians need to develop clinical skills and be given brief tools to foster productive discussions of BMI and awareness of health by children and parents.9,20,21,45⇓⇓⇓–49 Our study measured communication between physicians, preadolescents, and parents, starting with an ordinary well-child office visit and mediated by a child-friendly tool, to test correct understanding of BMI—a known gap in parent-child readiness to pursue health-attaining behavioral goals. This well-child visit tested the Fitwits office tool for joint discussions among physicians, parents, and 9- to 12-year-olds about their understanding and identification of BMI category (underweight, healthy weight, overweight, or obese). Overall correct identification of BMI improved from 50% before to 60.6% after the intervention, with positive movement between the overweight (34.5% to 51.7%) and obese (4.4% to 24.4%) categories. Continuing underrecognition or acknowledgment of overweight/obese children and some healthy children was noted. This highlights the difficulties of educating parents to identify BMI status in the new “normal” environment of heavier children, even with a dedicated intervention.33 The behavioral management suggestions for nutrition, portion size, and activity changes built in to the Fitwits flashcards were reflected in the 2 goals most often chosen by the parent-child dyads. The majority of comments by parents were appreciative of the physician interaction, Fitwits flashcards, and information. Further results pending analysis include longitudinal 12-month surveillance of correct BMI category choices and BMI trajectories, with an opportunity to improve with the use of Fitwits at 3 follow-up visits.

Acknowledgments

The authors thank all the participants and supporters of this study at the University of Pittsburgh Medical Center, St. Margaret Family Medicine Residency Program. They are grateful for the formative work of Fitwits team members Jeremy Alland, MD, LaShonna M. Austin, Scott Bragg, PharmD, Gregory Castelli, PharmD, Matthew Harbaugh, MD, and Danielle York, MD; article review by Susan K. Fidler, MD, and J. Dustin Williams, MLIS; the literature contributions from Amy Haugh, MLS; survey construction assistance from Abigail A. Jacobsen, MLIS, and J. Dustin Williams, MLIS; photography by Andrea Karsh, LCSW, BCD; and article preparation by Paula Preisach.

Notes

  • This article was externally peer reviewed.

  • Funding: This research was supported through grants from the Allegheny County Medical Society Foundation, the Auxiliary Board of St. Margaret Foundation, the St. Margaret Foundation Family Health Center Fund, and the A.J. and Sigismunda Palumbo Charitable Trust.

  • Conflict of interest: none declared.

  • To see this article online, please go to: http://jabfm.org/content/30/2/178.full.

  • Received for publication August 30, 2016.
  • Revision received December 8, 2016.
  • Accepted for publication December 23, 2016.

References

  1. 1.↵
    1. Barlow SE
    . Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120(Suppl 4):S164–92.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Fitzgibbon ML,
    2. Beech BM
    . The role of culture in the context of school-based BMI screening. Pediatrics 2009;124(Suppl 1):S50–62.
    OpenUrlAbstract/FREE Full Text
  3. 3.↵
    1. Harris CV,
    2. Neal WA
    . Assessing BMI in West Virginia schools: parent perspectives and the influence of context. Pediatrics 2009;124(Suppl 1):S63–72.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    1. Klein JD,
    2. Sesselberg TS,
    3. Johnson MS,
    4. et al
    . Adoption of body mass index guidelines for screening and counseling in pediatric practice. Pediatrics 2010;125:265–72.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. O'Brien SH,
    2. Holubkov R,
    3. Reis EC
    . Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics 2004;114:e154–9.
    OpenUrlAbstract/FREE Full Text
  6. 6.↵
    1. Dorsey KB,
    2. Wells C,
    3. Krumholz HM,
    4. Concato JC
    . Diagnosis, evaluation, and treatment of childhood obesity in pediatric practice. Arch Pediatr Adolesc Med 2005;159:632–8.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Dilley KJ,
    2. Martin LA,
    3. Sullivan C,
    4. Seshadri R,
    5. Binns HJ
    . Identification of overweight status is associated with higher rates of screening for cormorbidities of overweight in pediatric primary care practice. Pediatrics 2007;119:e148–55.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Lundahl A,
    2. Kidwell KM,
    3. Nelson TD
    . Parental underestimates of child weight: a meta-analysis. Pediatrics 2014;133:1–15.
    OpenUrlFREE Full Text
  9. 9.↵
    1. Woolford SJ,
    2. Clark SJ,
    3. Strecher VJ,
    4. Gebremariam A,
    5. Davis MM
    . Physicians' perspectives on increasing the use of BMI charts for young children. Clin Pediatr (Phila) 2008;47:573–7.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Huang TT,
    2. Borowski LA,
    3. Liu B,
    4. et al
    . Pediatricians' and family physicians' weight-related care of children in the U.S. Am J Prev Med 2011;41:24–32.
    OpenUrlCrossRefPubMed
  11. 11.↵
    1. Ben-Joseph EP,
    2. Dowshen SA,
    3. Izenberg N
    . Do parents understand growth charts? A national, internet-based survey. Pediatrics 2009;124:1100–9.
    OpenUrlAbstract/FREE Full Text
  12. 12.↵
    1. Patel AI,
    2. Madsen KA,
    3. Maselli JH,
    4. Cabana MD,
    5. Stafford RS,
    6. Hersh AL
    . Underdiagnosis of pediatric obesity during outpatient preventive care visits. Acad Pediatr 2010;10:405–9.
    OpenUrlCrossRefPubMed
  13. 13.↵
    1. Cook S,
    2. Weitzman M,
    3. Auinger P,
    4. Barlow SE
    . Screening and counseling associated with obesity diagnosis in a national survey of ambulatory pediatric visits. Pediatrics 2005;116:112–6.
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Rhee KE,
    2. Phan T-L,
    3. Barnes RF,
    4. Benun J,
    5. Wing RR
    . A delayed-control trial examining the impact of body mass index recognition on obesity-related counseling. Clin Pediatr (Phila) 2013;52:836–44.
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. McGaffey A,
    2. Hughes K,
    3. Fidler SK,
    4. D'Amico FJ,
    5. Stalter MN
    . Can Elvis Pretzley and the Fitwits improve knowledge of obesity, nutrition, exercise, and portions in fifth graders? Int J Obes (Lond) 2010;34:1134–42.
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Hughes K,
    2. Fidler S,
    3. McGaffey A,
    4. Audenried C
    . Fitwits: designed to help physicians start conversations with families about obesity. Paper presented at the 2009 Icograda Education Network Conference, Icograda World Design Congress, Beijing, China (October 24–30, 2009). repository.cmu.edu/cgi/viewcontent.cgi?article=1000&context=design. Accessed April 16, 2016.
  17. 17.↵
    1. McGaffey AL,
    2. Abatemarco DJ,
    3. Jewell IK,
    4. Fidler SK,
    5. Hughes K
    . Fitwits MD™: an office-based tool and games for conversations about obesity with 9- to 12-year-old children. J Am Board Fam Med 2011;24:768–71.
    OpenUrlAbstract/FREE Full Text
  18. 18.↵
    1. Wislo VMP,
    2. McGaffey A,
    3. Scopaz KA,
    4. et al
    . Fitwits: preparing residency-based physicians to discuss childhood obesity with preteens. Clin Pediatr (Phila) 2013;52:1107–17.
    OpenUrlCrossRefPubMed
  19. 19.↵
    1. Haemer M,
    2. Cluett S,
    3. Hassink SG,
    4. et al
    . Building capacity for childhood obesity prevention and treatment in the medical community: call to action. Pediatrics 2011;128(Suppl 2):S71–7.
    OpenUrlAbstract/FREE Full Text
  20. 20.↵
    1. Perrin EM,
    2. Skinner AC,
    3. Steiner MJ
    . Parental recall of doctor communication of weight status: national trends from 1999 through 2008. Arch Pediatr Adolesc Med 2012;166:317–22.
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Vine M,
    2. Hargreaves MB,
    3. Briefel RR,
    4. Orfield C
    . Expanding the role of primary care in the prevention and treatment of childhood obesity: a review of clinic- and community-based recommendations and interventions. J Obes 2013;2013:172035.
    OpenUrl
  22. 22.↵
    1. Dietz WH,
    2. Story MT,
    3. Leviton LC
    . Introduction to issues and implications of screening, surveillance, and reporting of children's BMI. Pediatrics 2009;124(Suppl 1):S1–2.
    OpenUrlFREE Full Text
  23. 23.↵
    1. Perrin EM,
    2. Jacobson Vann JC,
    3. Benjamin JT,
    4. Skinner AC,
    5. Wegner S,
    6. Ammerman AS
    . Use of a pediatrician toolkit to address parental perception of children's weight status, nutrition, and activity behaviors. Acad Pediatr 2010;10:274–81.
    OpenUrlCrossRefPubMed
  24. 24.↵
    1. Woolford SJ,
    2. Clark SJ,
    3. Ahmed S,
    4. Davis MM
    . Feasibility and acceptability of a 1-page tool to help physicians assess and discuss obesity with parents of preschoolers. Clin Pediatr (Phila) 2009;48:954–9.
    OpenUrlCrossRefPubMed
  25. 25.↵
    1. Daniels SR,
    2. Hassink SG
    . The role of the pediatrician in primary prevention of obesity. Pediatrics 2015;136:e275–92.
    OpenUrlAbstract/FREE Full Text
  26. 26.↵
    1. Sylvetsky-Meni AC,
    2. Gillepsie SE,
    3. Hardy T,
    4. Welsh JA
    . The impact of parents' categorization of their own weight and their child's weight on healthy lifestyle promoting beliefs and practices. J Obes 2015;2015:307381.
    OpenUrl
  27. 27.↵
    1. Tschamler JM,
    2. Conn KM,
    3. Cook SR,
    4. Halterman JS
    . Underestimation of children's weight status: views of parents in an urban community. Clin Pediatr (Phila) 2010;49:470–6.
    OpenUrlCrossRefPubMed
  28. 28.↵
    1. Brown L,
    2. Dolisca SB,
    3. Cheng JK
    . Barriers and facilitators of pediatric weight management among diverse families. Clin Pediatr (Phila) 2015;54:643–51.
    OpenUrlCrossRefPubMed
  29. 29.↵
    1. Rattay KT,
    2. Ramakrishnan M,
    3. Atkinson A,
    4. Gilson M,
    5. Drayton V
    . Use of an electronic medical record system to support primary care recommendations to prevent, identify, and manage childhood obesity. Pediatrics 2009;123(Suppl 2):S100–7.
    OpenUrlAbstract/FREE Full Text
  30. 30.↵
    1. Keehbauch J,
    2. Miguel GS,
    3. Drapiza L,
    4. Pepe J,
    5. Bogue R,
    6. Smith-Dixon A
    . Increased documentation and management of pediatric obesity following implementation of an EMR upgrade and education. Clin Pediatr (Phila) 2012;51:31–8.
    OpenUrlCrossRefPubMed
  31. 31.↵
    1. Coleman KJ,
    2. Hsii AC,
    3. Koebnick C,
    4. et al
    . Implementation of clinical practice guidelines for pediatric weight management. J Pediatr 2012;160:918–22.
    OpenUrlCrossRefPubMed
  32. 32.↵
    1. Sesselberg TS,
    2. Klein JD,
    3. O'Connor KG,
    4. Johnson MS
    . Screening and counseling for childhood obesity: results from a national survey. J Am Board Fam Med 2010;23:334–42.
    OpenUrlAbstract/FREE Full Text
  33. 33.↵
    1. Hansen AR,
    2. Duncan DT,
    3. Tarasenko YN,
    4. Yan F,
    5. Zhang J
    . Generational shift in parent perceptions of overweight among school-aged children. Pediatrics 2014;134:481–8.
    OpenUrlAbstract/FREE Full Text
  34. 34.↵
    1. Bolling C,
    2. Crosby L,
    3. Boles R,
    4. Stark L
    . How pediatricians can improve diet and activity for overweight preschoolers: a qualitative study of parental attitudes. Acad Pediatr 2009;9:172–8.
    OpenUrlCrossRefPubMed
  35. 35.↵
    1. Ganter C,
    2. Chuang E,
    3. Aftosmes-Tobio A,
    4. et al
    . Community stakeholders' perceptions of barriers to childhood obesity prevention in low-income families, Massachusetts 2012–2013. Prev Chronic Dis 2015;12:140371.
    OpenUrl
  36. 36.↵
    1. Maximova K,
    2. McGrath JJ,
    3. Barnett T,
    4. O'Loughlin J,
    5. Paradis G,
    6. Lambert M
    . Do you see what I see? Weight status misperception and exposure to obesity among children and adolescents. Int J Obes (Lond) 2008;32:1008–15.
    OpenUrlCrossRefPubMed
  37. 37.↵
    1. Koplan JP,
    2. Liverman CT,
    3. Kraak VI
    ; Institute of Medicine Committee on Prevention of Obesity in Children and Youth. Preventing childhood obesity: health in the balance. Washington, DC: National Academies Press; 2005.
  38. 38.↵
    1. Krebs NF,
    2. Himes JH,
    3. Jacobson D,
    4. et al
    . Assessment of child and adolescent overweight and obesity. Pediatrics 2007;120(Suppl 4):S193–228.
    OpenUrlCrossRefPubMed
  39. 39.↵
    1. Dutton GR,
    2. Tan F,
    3. Perri MG,
    4. et al
    . What words should we use when discussing excess weight? J Am Board Fam Med 2010;23:606–13.
    OpenUrlAbstract/FREE Full Text
  40. 40.↵
    1. Puhl RM,
    2. Peterson JL,
    3. Luedicke J
    . Parental perceptions of weight terminology that providers use with youth. Pediatrics 2011;128:e786–93.
    OpenUrlAbstract/FREE Full Text
  41. 41.↵
    1. Katz DL,
    2. Murimi M,
    3. Pretlow RA,
    4. Sears W
    . Exploring effectiveness of messaging in childhood obesity campaigns. Child Obes 2012;8:97–105.
    OpenUrlPubMed
  42. 42.↵
    1. Dietz WH,
    2. Story MT,
    3. Leviton LC
    . Issues and implications of screening, surveillance, and reporting of children's BMI. Pediatrics 2009;124(Suppl 1):S98–101.
    OpenUrlFREE Full Text
  43. 43.↵
    1. Perrin EM,
    2. Finkle JP,
    3. Benjamin JT
    . Obesity prevention and the primary care pediatrician's office. Curr Opin Pediatr 2007;19:354–61.
    OpenUrlCrossRefPubMed
  44. 44.↵
    1. Kwapiszewski RM,
    2. Lee Wallace A
    . A pilot program to identify and reverse childhood obesity in a primary care clinic. Clin Pediatr (Phila) 2011;50:630–5.
    OpenUrlCrossRefPubMed
  45. 45.↵
    1. Perrin EM,
    2. Flower KB,
    3. Garrett J,
    4. Ammerman AS
    . Preventing and treating obesity: pediatricians' self-efficacy, barriers, resources, and advocacy. Ambul Pediatr 2005;5:150–6.
    OpenUrlCrossRefPubMed
  46. 46.↵
    1. Perrin EM,
    2. Jacobson Vann JC,
    3. Lazorick S,
    4. et al
    . Bolstering confidence in obesity prevention and treatment counseling for resident and community pediatricians. Patient Educ Couns 2008;73:179–85.
    OpenUrlCrossRefPubMed
  47. 47.↵
    1. Rausch JC,
    2. Perito ER,
    3. Hamatz P
    . Obesity prevention, screening, and treatment: practices of pediatric providers since the 2007 expert committee recommendations. Clin Pediatr (Phila) 2011;50:434–41.
    OpenUrlCrossRefPubMed
  48. 48.↵
    1. Wolff MS,
    2. Rhodes ET,
    3. Ludwig DS
    . Training in childhood obesity management in the United States: a survey of pediatric, internal medicine-pediatrics and family medicine residency program directors. BMC Med Educ 2010;10:18.
    OpenUrlCrossRefPubMed
  49. 49.↵
    1. Lenders CM,
    2. Deen DD,
    3. Bistrian B,
    4. et al
    . Residency and specialties training in nutrition: a call for action. Am J Clin Nutr 2014;99:1174S–83.
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top

In this issue

The Journal of the American Board of Family     Medicine: 30 (2)
The Journal of the American Board of Family Medicine
Vol. 30, Issue 2
March-April 2017
  • Table of Contents
  • Table of Contents (PDF)
  • Cover (PDF)
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on American Board of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
FitwitsTM Leads to Improved Parental Recognition of Childhood Obesity and Plans to Encourage Change
(Your Name) has sent you a message from American Board of Family Medicine
(Your Name) thought you would like to see the American Board of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
1 + 1 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
FitwitsTM Leads to Improved Parental Recognition of Childhood Obesity and Plans to Encourage Change
Bethany A. Edwards, Jonathan R. Powell, Ann McGaffey, Valerie M. P. Wislo, Elaine Boron, Frank J. D'Amico, Linda Hogan, Kristin Hughes, Ilene Katz Jewell, Diane J. Abatemarco
The Journal of the American Board of Family Medicine Mar 2017, 30 (2) 178-188; DOI: 10.3122/jabfm.2017.02.160274

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
FitwitsTM Leads to Improved Parental Recognition of Childhood Obesity and Plans to Encourage Change
Bethany A. Edwards, Jonathan R. Powell, Ann McGaffey, Valerie M. P. Wislo, Elaine Boron, Frank J. D'Amico, Linda Hogan, Kristin Hughes, Ilene Katz Jewell, Diane J. Abatemarco
The Journal of the American Board of Family Medicine Mar 2017, 30 (2) 178-188; DOI: 10.3122/jabfm.2017.02.160274
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • Notes
    • References
  • Figures & Data
  • References
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Content Usage and the Most Frequently Read Articles of 2017
  • Correction to "FitwitsTM Leads to Improved Parental Recognition of Childhood Obesity and Plans to Encourage Change"
  • Improving Family Medicine with Thoughtful Research
  • Google Scholar

More in this TOC Section

  • Associations Between Modifiable Preconception Care Indicators and Pregnancy Outcomes
  • Perceptions and Preferences for Defining Biosimilar Products in Prescription Drug Promotion
  • Evaluating Pragmatism of Lung Cancer Screening Randomized Trials with the PRECIS-2 Tool
Show more Original Research

Similar Articles

Keywords

  • Body Mass Index
  • Body Weight
  • Childhood Obesity
  • Health Literacy
  • Portion Size
  • Surveys and Questionnaires

Navigate

  • Home
  • Current Issue
  • Past Issues

Authors & Reviewers

  • Info For Authors
  • Info For Reviewers
  • Submit A Manuscript/Review

Other Services

  • Get Email Alerts
  • Classifieds
  • Reprints and Permissions

Other Resources

  • Forms
  • Contact Us
  • ABFM News

© 2025 American Board of Family Medicine

Powered by HighWire