Dietary and Nutrition Recommendations in Pediatric Primary Care: A Call to Action

Sayward E. Harrison, PhD1; Deborah Greenhouse, MD, FAAP2

1
From the SC SmartState Center for Healthcare Quality, Department of Health Promotion,
Education, and Behavior, Arnold School of Public Health, University of South Carolina.
Columbia, South Carolina.
2
From the Palmetto Pediatric & Adolescent Clinic, Columbia, South Carolina.

Corresponding Author:
Dr. Sayward Harrison
SC SmartState Center for Healthcare Quality
Department of Health Promotion, Education, and Behavior
Arnold School of Public Health
University of South Carolina
915 Greene St.
Columbia, SC 29208
harri764@mailbox.sc.edu

The authors have no financial disclosures to declare and no conflicts of interest to report.

This work was supported by the University of South Carolina Office of the Vice President for
Research through the ASPIRE: Advanced Support for Innovative Research Excellence grant
(#11540-16-41739).

The authors have no commercial or proprietary interest in any drug, device, or equipment
mentioned in this manuscript.

The authors would like to thank Molly Beman and Grace Whitbeck for their assistance with
literature review.
Brief Description:

Counseling and interventions targeting diet and nutrition are key components of childhood

obesity prevention, and clear guidelines exist for incorporating these practices into pediatric

primary care. This paper presents a “call to action” for primary care providers to devote

increased attention to incorporating diet and nutrition into their practice and reviews current

evidence and guidelines on the integration of diet/nutrition counseling into pediatric primary

care.

Key Points:

1. Pediatric primary care is an opportune setting to provide counseling and interventions

targeting diet and nutrition—key components of current efforts to prevent and reduce childhood

obesity.

2. Assessment of children’s diet/nutrition habits should be a routine part of primary care and

specific recommendations offered to all families to encourage the development of healthy habits

and prevent excess weight gain.

3. Despite recommendations for universal dietary/nutrition assessment and counseling, providers

report limited engagement in these practices; substantial efforts are needed to better incorporate

diet and nutrition into pediatric primary care.

Key Words:

diet; nutrition; primary care; pediatrics; childhood obesity prevention

Abstract

Childhood obesity increases risk for numerous negative health outcomes and frequently creates a

pathway to adult obesity and its multiple morbidities. Diet and nutrition play a key role in

maintaining an individual’s energy balance and preventing weight gain, yet numerous barriers

exist to integrating diet and nutrition into primary care. Pediatric primary care providers should

be aware of scientific evidence supporting the incorporation of dietary/nutrition counseling into

pediatric preventive visits. Thus this review offers providers an overview of current diet and

nutrition prevention recommendations and presents a “call to action” to make diet and nutrition

assessment, counseling, and intervention routine aspects of pediatric primary care.

 Diet and nutrition have major impacts on the growth and development of children, and

recommendations and interventions that target diet and nutrition are key components of

childhood obesity prevention.1 Primary care providers (PCPs) play a critical role in these efforts,

yet few studies have examined their involvement in providing dietary and nutrition

recommendations and engaging families in intervention in these key areas. This dearth of

research is particularly problematic in the Southern United States, given the disparately high

rates of childhood obesity within the region. Thus we present a “call to action” to urge PCPs to

devote increased attention to incorporating diet and nutrition into their practice. In this paper, we

provide a brief overview of the evidence supporting the integration of diet/nutrition counseling

into pediatric primary care, review current diet and nutrition prevention recommendations, and

identify opportunities to increase these important preventive practices.

Current State of Childhood Obesity

Though there is some suggestion that childhood obesity rates have begun to plateau, the

prevalence of childhood obesity increased rapidly in past decades to epidemic levels, with recent

estimates suggesting that 31.8% of US children are overweight or obese (Body Mass Index

[BMI] > 85th percentile).2 Childhood obesity is a predictor of multiple negative health outcomes,

including adult obesity, premature death, type 2 diabetes, hypertension, coronary heart disease,

stroke, and cancer.3 In addition, obese children are at risk for numerous negative psychosocial

outcomes. They are more likely than non-obese peers to experience depressed mood, be bullied,

face discrimination, and have poor self-esteem.4

Children in the Southern United States are particularly at risk for obesity. Eight of the 10

states with the highest prevalence of obesity for children and adolescents are located within the

South, and states from the “Deep South” including Mississippi, South Carolina, and Louisiana
consistently lead the nation in childhood obesity rates.5 Childhood obesity disparities in the

South are partly rooted in structural and policy factors. The South has higher rates of

demographic groups at increased risk for obesity, including rural residents and those from

racial/ethnic minority backgrounds.6,7 In the United States, children who are raised in low-

income homes are more likely to be overweight or obese, and the South has the nation’s highest

rates of poverty, as well as lowest median household incomes.8 The region also has the nation’s

highest rates of individuals who lack health insurance, and policies that limit insurance coverage

and/or restrict the expansion of supplemental nutrition programs (e.g., Special Supplemental

Nutrition Program for Women, Infant, and Children [WIC]) can further exacerbate obesity

disparities.9 Finally, socio-cultural norms surrounding diet and physical activity may encourage

“obesogenic” environments in Southern communities and partially account for the phenomenon

of intergenerational transmission of obesity.10-12

Prevention of Childhood Obesity in Primary Care Settings

Many of the observed disparities in adult obesity are thought to be strongly influenced by

factors that operate in infancy and early childhood, highlighting the importance of targeting

children early in life.13 For the first time, obesity prevalence among children aged 2 to 5 years

old decreased from 13.9% in 2004 to 9.4% in 2014, cause for some optimism that better

outcomes for the youngest and most vulnerable can be achieved.14 Preventing obesity early in

life is critical as overweight children are significantly more likely to become overweight adults.15

Though adult weight loss through modifying exercise and eating habits is possible, weight loss in

adulthood is frequently not sustained and there is some evidence that the risks of obesity can

remain, even when excess weight has been lost.16,17 Thus intervening early and targeting systems
that are most influential during infancy and early childhood—namely caregivers—may offer the

most promise to reduce the risk of adult obesity and its correlated morbidities.

At first glance, obesity prevention is deceptively simple: individuals should engage in

physical activity and follow a healthy diet to maintain a state of energy balance in which energy

intake (i.e., calories in) does not exceed energy expenditure (i.e., calories out).12 However,

individuals reside within complex systems (e.g., socio-cultural, political, environmental) that

create vast challenges to maintaining energy balance. To reduce these challenges, coordinated

approaches are needed across multiple levels, including individuals, families, communities, and

the larger society.18

Primary care is an opportune setting to promote energy balance and create healthier

environments for children and families. Nearly all children in the US (~96%) have an established

health care provider, and most (~75%) report having had contact with a physician in the past six

months.19,20 This type of access enables obesity prevention and intervention programming to

reach a high percentage of infants and children. In recent years, a number of primary care-based

interventions to prevent and treat childhood obesity have been developed, evaluated, and found

to have modest evidence-base.21 However, even primary care settings that are not equipped to

support specific obesity programming can adopt evidence-based practices into general preventive

care. Clear recommendations for PCPs on how to incorporate obesity prevention into primary

care practices have been established. In 2007, an Expert Committee led by members of the

American Medical Association, the Health Resources and Service Administration, and the

Center for Disease Control and Prevention, and comprised of representatives of 15 health

organizations, as well as various scientists and clinicians, produced the Expert Committee
Recommendations (ECR), a set of specific actions and recommendations related to the

prevention, assessment, and treatment of childhood obesity in primary care.1

Recommendations for Incorporating Diet/Nutrition in Pediatric Primary Care

The ECR provide universal guidelines for incorporating childhood obesity prevention

into all well-child visits and encourage collaboration among families, schools, communities, and

healthcare providers to create healthier environments. As one of its core missions, the Expert

Committee established specific diet and nutrition recommendations (Table 1) that pediatric PCPs

should convey to families at preventive visits. Specifically, PCPs are urged to guide families to

develop healthy diet and nutrition habits as early as possible to prevent excess weight gain. Key

diet and nutrition behaviors should be recommended to families at routine visits including the

importance of limiting sugar-sweetened beverages, limiting fast food and other energy-dense

food options, promoting family meals and daily breakfast, and encouraging appropriate portion

sizes.1 A number of other specific nutrition strategies were also recommended (see Table 1 for

full list).

----------------------------------------TABLE 1 ABOUT HERE--------------------------------------------

When a child’s BMI and/or other family and child risk factors warrant intervention,

providers are recommended to use patient-centered communication practices to identify

modifiable behaviors and implement behavior change strategies. Specifically, motivational

interviewing is recommended as an evidence-based technique to assess a family’s readiness for

change, identify particular beliefs and values that are important to the family, increase

motivation, and assist with formulating a behavior change plan.22,23 Using this framework,

pediatric PCPs can utilize a brief five-step obesity prevention protocol to alert caregivers to their

child’s obesity risk and engage them in behavior change. This protocol involves sharing key risk
information with caregivers, eliciting their concerns, assessing obesity-related health behaviors,

identifying an opportunity for behavior change, assessing the family’s motivation to change,

mutually developing a plan for action, and scheduling follow-up.1 Recent randomized controlled

trials of motivational interviewing in pediatric primary care have yielded statistically significant

and clinically meaningful reductions in children’s BMI percentiles and highlight the feasibility

and promise of implementing obesity prevention and intervention efforts in the primary care

setting.24,25

Expanding beyond prevention, the Expert Panel also established a 4-stage model of

childhood obesity treatment/care that begins with brief counseling appropriate for the primary

care setting and progresses to tertiary care involving a multidisciplinary intervention team.1

These proposals align with recent recommendations on diet/nutrition from the Institute of

Medicine, American Medical Association, and the American Academy of Pediatrics (AAP) that

highlight the importance of working with families to promote a diet rich in foods with low

caloric density and poor in foods with high caloric density.18,26,27 The AAP also has recently

provided recommendations for practical strategies to manage a family’s food environment,

including keeping healthy alternatives to sugar-sweetened drinks and energy-dense foods readily

available at all times and in plain sight; decreasing the size of household dishes and serving

utensils; and eliminating eating prepackaged foods or foods directly from the packaging.27

Adopting these recommendations into primary care may be a key ingredient to reduce childhood

obesity rates to the established goal of 5% in 2030.28,29 However, the role of primary care in

prevention and treatment of childhood obesity, particularly in the Southern United States is

relatively unstudied.20,30

Current Practices in Adopting Diet/Nutrition Recommendations in Primary Care

 In the first published study to investigate changes in primary care following release of the

ECR,31 data from the National Center for Health Statistics were analyzed to calculate the

frequency with which PCPs reported engaging in obesity prevention efforts during pediatric

preventive visits over a 4-year period, encompassing years both before and after release of the

ECR recommendations. Providers reported providing counseling on topics related to

food/beverage consumption and general diet/nutrition health at a minority of preventive visits.

Specifically, providers’ self-reported frequencies of offering diet/nutrition recommendations at

preventive visits showed a declining trend (i.e., 40% in 2006; 35% in 2007; 34% in 2008; and

31% in 2009).31 Of additional concern, sub-group analysis indicated that children from

socioeconomic disadvantage were less likely to receive diet and nutrition counseling, despite

their increased risk for obesity.31 Other subgroups, including non-Hispanic black children, were

also significantly less likely to receive diet/nutrition counseling, with only 22% being provided

with diet/nutrition counseling at well-child visits in 2008-2009.31

These findings are consistent with available national data on weight-related care of

children by pediatricians and family physicians. In 2008, a joint project between the National

Institutes of Health and the Centers for Disease Control was launched to survey a nationally

representative group of pediatricians and family physicians to establish baseline data on how

frequently PCPs were engaged in energy balance assessment and counseling.32,33 Only 68.0% of

pediatricians and 38.5% of family physicians reported regularly assessing children’s BMI

percentiles.32 Few PCPs (18.3%) reported often or always referring children for further

evaluation when needed, and a minority (42.0%) reported systematically tracking patients’

weight over time.32 With regard to regional differences, pediatric PCPs in the South were

significantly less likely to engage in general obesity counseling and significantly less likely to
provide guidance on diet/nutrition to families than their counterparts in the Northeast.32 Though

most PCPs (>90.0%) occasionally engaged in general assessment of children’s food intake,

fewer (56.6%) reported specifically asking about dietary components.32

Barriers to Integrating Obesity Prevention into Pediatric Primary Care

Providers’ lack of compliance with ECR recommendations has complex origins that may

include limited awareness of the recommendations or lack of knowledge of evidence-based

practices, lack of provider training, discomfort in discussing obesity with families, and other

systemic barriers (e.g., lack of time, lack of adequate reimbursement for prevention services). In

one of the few studies investigating physician’s self-reported barriers to engaging in obesity

prevention,34 primary care physicians (i.e., specialties of family medicine or pediatrics) from

southern Appalachia were surveyed to assess provider attitudes and perceived barriers to

engaging in childhood obesity prevention. Thought providers recognized the importance of

prevention and intervention efforts, they reported frequently not engaging in the Expert Panel’s

recommended practices. For instance, only 25.7% of providers discussed childhood obesity with

parents of children not currently overweight (i.e., universal prevention).34 Even for children who

were already overweight/obese, nearly a third of providers (29.4%) did not currently discuss

eating and physical activity habits with families and did not (80.6%) share tools needed to make

changes in these habits.34 Rates of using recommended behavioral change techniques (e.g.,

determining parents’ readiness for change, identifying barriers to change) were poor, and

providers cited a number of barriers that prevented them from engaging in the recommended

practices including lack of parental involvement, lack of patient motivation, lack of time, and

lack of support services.34

 Data also suggest that significant gaps exist in the training of medical school students to

provide competent diet and nutrition services.35,36 A recent survey found that US medical schools

averaged 19.6 hours of required nutrition instruction (range=0 to 70 hours) and only 27% met the

minimum of 25 hours of nutrition instruction recommended by the National Academy of

Sciences, a recommendation set in 1985—long before the peak of the obesity epidemic.37

Primary care providers also report a need for continuing education in diet/nutrition, with priority

areas including the role of nutrition in general weight management; information on herbals,

botanicals, and other complementary and alternative medicines; and vitamin/mineral

supplements.38

Without comprehensive training in diet and nutrition, providers may lack confidence in

their ability to offer recommendations and guide children and families in modifying their

behaviors. A recent survey of pediatricians found that nearly half (46%) lacked confidence in

their ability to obtain a child’s diet history using 24-hour recall, food record, or food frequency

methods, a majority (61%) felt incompetent in using motivational interviewing to elicit behavior

change among families, and one in five (20%) lacked confidence in their ability to collaborate

with registered dieticians or refer to community nutrition resources when necessary.39

Opportunities for Integrating Diet/Nutrition Recommendations into Practice

There is increasing recognition that substantive changes are needed to shift our nation’s

healthcare system away from its current reductionist, reactionary model of chronic disease care

and toward a model of integrated prevention and health promotion.40 Primary care providers will

play a critical role in this shift, and incorporating diet and nutrition into their practice is one step

toward accomplishing this. To improve current rates of compliance with the ECR

recommendations on diet and nutrition, we offer the following recommendations. First, better
education and training are needed on issues of diet and nutrition, as well as their links to wellness

and disease prevention. Currently, a minority of medical training programs provide the

recommended amount of instruction in diet and nutrition, leaving providers with knowledge gaps

and limited confidence in their ability to incorporate diet and nutrition counseling into their

practice. Improved curricula and opportunities for continuing professional development in

diet/nutrition will be helpful to ensure that providers have ample background knowledge and

confidence in their ability to recommend evidence-based diet and nutrition practices to the

families they serve.

Secondly, there is a need for increased commitment to interdisciplinary efforts to prevent

childhood obesity. Its etiology is complex and multi-faceted, and thus childhood obesity

prevention and intervention efforts must be as well. Integrated care frameworks that make

dieticians and nutritionists a part of the primary care team offer promise, and such

multidisciplinary teams in primary care are recognized as essential by the American College of

Physicians for implementing patient-centered care.41,42 Incorporating dieticians and nutritionists

into primary care may reduce some of the barriers (i.e., lack of time, lack of training) that

providers currently report hinder their efforts.43 Integrating dietary counseling into pediatric

primary care is also associated with a range of benefits for primary care practice, including

lowered rates of referrals to hospitals and specialty clinics.44

Resources and Future Directions

Pediatric PCPs who wish to improve their current diet and nutrition counseling practices

have a number of resources at their disposal. In addition to reviewing the provided ECR

guidelines, providers should consult the newest Dietary Guidelines for Americans45 that are

endorsed by the AMA and provide a review of scientific evidence on diet as well as key
recommendations for shifting the nation to healthier patterns of eating. The Association of

American Medical Colleges offers a number of diet/nutrition training resources at their

MedEdPortal including a guide for integrating nutrition assessment and counseling into

outpatient care.46 The AAP provides numerous resources for PCPs through their Bright Futures

National Center, including a free, downloadable nutrition pocket guide for health professionals

that reviews key diet/nutrition recommendations at each developmental stage, provides guiding

questions to use with families when assessing diet/nutrition health, and offer responses to

families’ common diet and nutrition concerns.47 Providers may also benefit from becoming

familiar with federal and state food assistant programs (e.g., WIC, Supplemental Nutrition

Assistance Program [SNAP]) to understand available diet/nutrition resources, as well as the

limitations that families may face when trying to implement changes in these areas.27

Specific characteristics of providers’ practice settings should also be examined to

determine whether system variables such as electronic medical records and reminder systems

facilitate obesity prevention efforts. For instance, primary care practices that utilize electronic

health records have been found to be more likely to engage in obesity prevention practices than

those that use paper records, perhaps due to greater ease in tracking BMI over time and making

prompt referrals when needed.33 On a larger level, statewide and national advocacy is needed to

push for increased reimbursement for preventative diet/nutrition services and to incentivize

evidence-based prevention practices. Together, such integrated and multi-level efforts will be

necessary, particularly in the Southern United States, to ensure that all children have access to

the care and resources necessary to achieve a healthful diet and reduce their risk for childhood

obesity.
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