New Study Finds Obesity Can Be Prevented in Very Young Children

A new study shows that adding text messaging to traditional in-clinic health counseling for parents about feeding habits, playtime and exercise prevents very young children from developing obesity and potentially lifelong obesity-related problems.

Findings from the study, co-led by Kori Flower, MD, MS, MPH, division chief of General Pediatrics and Adolescent Medicine at the UNC School of Medicine, were published in JAMA. The work stems from decades of research showing that having obesity in early childhood significantly increases the risk of lifetime obesity, cardiovascular disease, diabetes and other serious diseases, particularly in low-income and minority populations. Samantha Schilling, MD, MSHP, associate professor in the Division of General Pediatrics and Adolescent Medicine at UNC, was also a co-investigator on the study.

About 1 in 5 school-aged children were affected by obesity in 2017–18, according to the U.S. Centers for Disease Control and Prevention — rates that have only increased during and since the COVID-19 pandemic. Efforts to reduce the rate have relied heavily on in-person interventions by pediatric providers, with limited success.

In an earlier study, also co-led by Flower, investigators demonstrated that a “health literacy-informed” primary care-based intervention called the Greenlight Program, which Flower and colleagues at other medical centers developed for parents, improved healthy growth in newborns until 18 months of age, but found that improvements were not sustained at age 2 years.

In an effort to extend the improvements through 2 years of age, when pediatrics office visits become less frequent, the new study focused on adding text messaging to reinforce elements of the Greenlight Program, which previously only consisted of written materials and health counseling during primary care visits.

“Parents and pediatricians have told us how much they enjoy using the materials, which are available in both English and Spanish, and are designed to meet the needs of diverse families,” said Flower.

Building on that knowledge, to conduct the new study, which was co-led by UNC and five other academic medical institutions, the researchers recruited nearly 900 parent-infant pairs between October 2019 and January 2022 from newborn nurseries or pediatric primary care clinics at Duke University, University of Miami, New York University/Bellevue Hospital Center, Stanford University and Vanderbilt University Medical Center. Johns Hopkins University also collaborated in the study.

At the start of the trial, all babies were 21 days old or younger, born after 34 weeks gestation, at a healthy weight, and with no chronic medical conditions that might affect weight gain.

The participants were about 45% Hispanic, 20% white and nearly 16% Black. More than 55% were considered to have limited health literacy based on the Newest Vital Sign, a widely used health literacy screening tool developed by researchers at the University of Arizona, and nearly 16% reported household food insecurity, meaning limited access to healthy food choices.

The infant-parent pairs were randomly sorted into two groups. Both groups received Greenlight Program education, with counseling on healthy nutrition and behaviors from their primary care providers, along with eight educational booklets matching the child’s age at regular well visits, with guidance and goal-setting tips in English or Spanish on feeding, physical activity, sleep and screen time.

Next, half (449) of the infant-parent pairs received personalized, interactive text messages from a fully automated system to support health behavior goals.

Goals (such as fewer sugar-sweetened beverages or less screen time) were texted in English or Spanish every two weeks until 2 years of age. Those texts were followed by five automated check-in messages throughout the two weeks. Parents were asked to self-rate their goal progress.

Based on parents’ responses, the automated digital intervention system then provided immediate feedback, tips for addressing challenges and encouragement based on progress.

The researchers found that children of parents who received the digital intervention as well as personal counseling had healthier weight-for-length growth curves over the first two years of life than children of parents who had counseling only, which resulted in an estimated reduction of 0.33 kg/m at the 24-month time point. Researchers say while this doesn’t sound like a lot, it’s consistent with the U.S. Preventive Services Task Force target for effective obesity trials. Also, obesity prevention for the digital group was significant. Some 7% of the digital intervention group had obesity, compared with nearly 13% of the clinic-only group, which is a nearly 45% adjusted relative reduction.

The researchers conclude that their digital intervention led to healthier weight-for-length paths and reduced the incidence of obesity at 2 years of age when added to in-person health counseling.

“It’s unusual to be able to prevent obesity in children, and we’re thrilled to have an intervention that has evidence behind it and can be implemented widely,” said Flower.

The investigators say the digital services were effective in populations that traditionally experience the highest risk of obesity, and “could have significant impact” if implemented on a broader scale.

Moreover, they concluded “the intervention effect” occurred as early as 4 months and sustained throughout the two years. The researchers say this study may be one of the first ever to prevent early childhood obesity, particularly in a large group of diverse participants.

Finally, the researchers say the digital intervention had a greater effect on children from households with food insecurity, on Hispanic and non-Hispanic Black children, and those with lower health literacy.

The researchers hope to be able to follow children as they become older to determine if the reduction in obesity is sustained over time.

Additional authors include William Heerman, Russell Rothman, Jonathan Schildcrout, Aihua Bian, Laura Adams and Evan Sommer from Vanderbilt University Medical Center; Lee Sanders from Stanford University; Alan Delamater from University of Miami; Melissa Kay from Wake Forest University; Charles Wood from Duke University; Eliana Perrin from Johns Hopkins University; Rachel Gross and H. Shonna Yin from New York University; and other Greenlight investigators.

This work was supported by the Patient-Centered Outcomes Research Institute (AD-2018C1-11238). Study data were collected and managed using REDCap electronic data capture tools hosted at Vanderbilt University Medical Center and supported by the National Center for Advancing Translational Sciences/National Institutes of Health (UL1 TR000445).