Addressing Health Literacy and Numeracy to Prevent Childhood Obesity

In 2003, Surgeon General Richard Carmona stated that low health literacy was "one of the
largest contributors to our nation's epidemic of overweight and obesity." This assertion is
supported by recent studies which have found that low health literacy or numeracy is
associated with poorer caregiver breastfeeding knowledge, incorrect mixing of infant formula,
difficulty understanding food labels and portion sizes, and higher Body Mass Index (BMI) in
adults and children. Of particular concern is the impact of the obesity epidemic on our
youngest children. Over 26% of preschool children are now overweight (BMI≥85%) or obese
(BMI≥95%) (based on 2007 Health and Human Services/Centers for Disease Control Expert Panel
definitions). Rates of obesity in preschool children have doubled over the past decade, with
the highest increases among low income and minority children-- the same communities most
affected by low health literacy.

To date, clinical efforts to prevent or treat childhood obesity have had limited efficacy.
Efforts need to start early, because children who are overweight by age two are five times as
likely to become overweight adolescents, and subsequently at higher risk for obesity-related
complications including early-onset Type-2 Diabetes and cardiovascular disease. No published
clinical studies have rigorously addressed obesity prevention prior to age 2 with a specific
low-literacy and numeracy focus. Addressing caregiver health literacy in early childhood is
an innovative strategy to promote healthy nutrition and activity among these families and
prevent unhealthy weight gain across the child's life, which would have great public health
significance by preventing both child and adult chronic illness.

The proposed study is a multi-site randomized, controlled trial to assess the efficacy of a
low-literacy/numeracy-oriented intervention designed to promote healthy family lifestyles and
to prevent early childhood obesity. The intervention will be delivered through pediatric
resident physicians in primary care settings in under-resourced communities. Four academic
medical centers will be randomized: Vanderbilt University, the University of Miami, the
University of North Carolina at Chapel Hill, and New York University. Two centers will
receive the intervention, while the other two centers will receive an active control. At each
site, a cohort of 250 English- or Spanish-speaking caregiver-child dyads will be enrolled and
followed from the child's 2 month well-child visit through the 24-month well-child visit. The
intervention will include a low-literacy-oriented toolkit for pediatric residents to use with
families and clear health communication training for the pediatric residents. At control
sites, pediatric residents will provide "usual care" with respect to lifestyle counseling,
but they will also receive an injury-prevention education program to act as an attention
control. The primary hypotheses are that the intervention will improve family dietary and
physical activity behaviors and that it will reduce the rate of childhood overweight
(BMI≥85%) at age 24 months.

Specific Inclusion Criteria at the parent-child dyad level will include:

- Consent from a primary caregiver (i.e., parent or legal guardian)

- Caregiver's ability to speak English or Spanish

- Infant presenting for a 2 month well-child visit (child is 6 ≥ 12 weeks old)

- Caregiver agrees to participate in the study, and agrees to bring their child to all
well-child care visits until their 2 year well-child care visit.

Specific Exclusion Criteria at the parent-child dyad level will include:

- Child born prior to 32 weeks' gestational age or with a birth weight < 1500 grams

- Child with weight/length < 3rd percentile at 2 months of age

- Child with a diagnosis of failure to thrive or with weight that has dropped ≥ 2
percentile curves since the previous well child visit

- Child with known medical problems that may affect their ability to thrive or requires
a special diet (e.g. metabolic disease, uncorrected congenital heart disease, renal
disease, lung disease)

- Caregiver with significant mental or neurologic illness likely to impair their ability
to participate

- Caregiver age < 18 years

- Caregiver with known plans to move out of the immediate area during the study period

- Caregiver with poor visual acuity (i.e. vision worse than 20/50 with Rosenbaum Pocket
Screener as assessed at the time of recruitment)

Specific Inclusion Criteria at the Pediatric Resident level will include:

- Participation in the medical center's pediatric resident training program

- Providing regular care (> 3 sessions per month) in the pediatric resident primary care
clinic; AND

- Consent to participate in the study

Specific Exclusion Criteria at the Pediatric Resident level will include:

- Providing no regular care in the pediatric resident primary care clinic (e.g.,
transitional-year resident, Medicine/Pediatrics resident); OR

- Known plans to leave the training program during the ensuing 6 months