The Childhood Obesity Research Demonstration Project: Linking Public Health Initiatives and Primary Care Interventions Community-Wide To Prevent and Reduce Childhood Obesity

Childhood obesity is a serious national health problem with 17% of American youth living with obesity. ¹ In 2010, the Patient Protection and Affordable Care Act (ACA) appropriated $25 million for a 4-year community-based study to determine whether an integrated model of primary care and public health services can improve underserved children's risk factors for obesity. In response, the CDC established the Childhood Obesity Research Demonstration (CORD) to meet the requirements of the ACA and address the call by expert groups for comprehensive, multilevel, multisetting approaches to prevent and reduce childhood obesity. ² This commentary introduces the nine articles in this issue that describe the research collaboration funded by the CDC.

Obesity-related health behaviors, such as nutrition and physical activity, are shaped by multiple sources of influence and environments, including the home, early care and education, school, healthcare, and other community settings. Therefore, a host of setting stakeholders who influence these settings, including government, education, the private setting, nonprofit organizations, and families, have a role to play in creating healthier communities. CORD will add to the limited research available on comprehensive, community-wide models for childhood obesity prevention. A recent comparative effectiveness review of the peer-reviewed childhood obesity prevention literature in developed countries found there is a need for more studies that include results from interventions occurring in multiple settings. ³ The systematic review found a very limited number of articles with multiple settings and only one community-based, multiple-setting, early childhood obesity prevention study that measured weight and had at least 1 year of follow-up. ⁴ In school-aged youth in the United States, Shape Up Somerville has been novel in its results of reducing BMI over 2 years through a community-based participatory research approach that met the community's interests and strengths and interventions that could be included into existing “platforms” (schools, afterschool, and community). ⁵

The collection of articles in this supplement to Childhood Obesity describes how CORD builds on each community's existing work, uses its stakeholders' perspectives of problems and feasible solutions, and leverages state and local infrastructure in three states: Imperial County, California; Fitchburg and New Bedford, Massachusetts; and Austin and Houston, Texas. Each of the three demonstration sites serves children ages 2–12 years and their families in communities with high childhood obesity rates.

While we wait for final evaluation data from each of the demonstration sites, we are learning about novel ways that public health and primary care can work together to embed healthy eating and active living in the daily routines of children and families. CORD is increasing healthy eating and active living opportunities for young children and their families by supporting change at the individual, system, and community levels. Interventions in each setting include those reviewed and described by Foltz and colleagues on population-based research and practice-tested strategies for improving obesity-related behaviors. ⁶

The article in this collection by Foltz and colleagues ⁷ describes the common framework called the CORD model and identifies similarities across the demonstration sites. All CORD sites leverage existing systems, such as schools and clinics, and engage stakeholders, such as parents, teachers, and pediatricians, to deliver research-tested interventions. Sites also provide quality training and resources for key individuals in children's lives, such as parents, pediatricians, early care and education providers, teachers, restaurateurs, and park managers, to increase their capacity to promote and support obesity prevention health behaviors. More intensive interventions are used for children who are already overweight or have obesity and their families. For example, each site is involving community health workers (CHWs) as a bridge or connector between public health and primary care. The article by Williams and colleagues ⁸ describes the model of technical support provided to demonstration sites by the CDC, including a team approach comprised of a scientific intervention expert, evaluation expert, project officer, and scientific team coordinator.

CORD includes a cross-site evaluation, led by the University of Houston. The cross-site evaluation plan, described in the article by O'Connor and colleagues, ⁹ establishes a suite of common data elements to document changes in organizational environments (i.e., early care and education settings), behavioral outcomes, and changes in weight status. Other outcomes include parenting skills, healthcare satisfaction, children's quality of life, and measures of cost and program sustainability beyond the funded intervention period. In this supplement, the demonstration sites also provide an overview of their evaluation strategy.^10,11

The California CORD (CA-CORD) site Our Choice/Nuestra Opción is featured in an article by Ayala and colleagues ¹² that describes the unique partnership among San Diego State University, the Imperial County Public Health Department, and the Clínicas de Salud Del Pueblo, Inc. (CDSDP), who are working together in the US-Mexico border region. CDSDP is a private, nonprofit, federally qualified health center that provides primary and preventive healthcare for underserved residents of Imperial and Riverside counties through health clinics, women, infants, and children (Special Supplemental Nutrition Program for Women, Infants and Children; WIC) programs, and community health programs. CA-CORD interventions were shaped by the University team's previous work as well as systematic reviews of childhood obesity interventions specific to Latino populations^13,14 and the advice of an Imperial County Community Advisory Committee. The Community Advisory Committee was a key partner in planning the CA-CORD work in schools, early care and education centers, community health centers, and the community at large by identifying assets in Imperial County and its areas of need.

Articles from the Texas CORD (TX-CORD) site describe their robust systems-based approach to reducing childhood obesity, as well as a novel approach for using geographical information science to select the intervention and comparison catchment areas (Hoelscher and colleagues ¹⁵ ; Oluyomi and colleagues ¹⁶ ). These articles describe TX-CORD's development and use of the Cooridinated Approach To Child Health (CATCH) Early Childhood program for preschool children in Head Start and other early care and education settings. This program complements the more well-known CATCH for schools. ¹⁷ In addition, the TX-CORD articles describe the family-centered, intensive, secondary prevention program for helping children attain a healthy weight based at the YMCA. As part of this program, families are connected to the healthcare system through peer paraprofessionals, including CHWs.

Massachusetts's CORD project, Mass in Motion Kids, builds on a state public health department community-level obesity prevention initiative, Mass in Motion. ¹⁸ Taveras and colleagues ¹⁹ describe how Mass in Motion Kids is delivering evidence-based obesity prevention interventions in pediatric primary care, WIC programs, early care and education settings, schools and afterschool programs, and community-wide initiatives, including messaging and media. Evidence-based strategies in schools and afterschool programs are based on randomized trials in Massachusetts showing improvements in policies and obesity-related behaviors.^20,21 To ensure effective healthcare approaches, local teams from pediatric practices and community organizations are provided advanced training on childhood obesity treatment, quality care improvement strategies, and motivational interviewing. The project also integrates CHWs into primary care and Healthy Weight Clinic Teams. To further better support management of pediatric obesity, Mass in Motion Kids modified the existing electronic health records in two community health centers to create a BMI decision support tool. This point-of-care alert provides pediatricians with patient weight status diagnosis, recommendations and codes for nutrition and physical activity counseling, referral mechanisms for the on-site Healthy Weight Clinic, and orders for obesity-related laboratory studies.

CORD sites have adapted evidence-based interventions in multiple settings using the strengths of the existing community contexts and strong community input. CORD and the NIH-supported Childhood Obesity Prevention and Treatment Research (COPTR trials) ²² are structured to add significantly to the field's knowledge about effective, sustainable interventions to prevent and reduce childhood obesity. Understanding the challenges in program delivery, fidelity across various settings, and the associated intervention costs are vital for planning and delivering programs beyond the research phase. Although the three CORD sites all implemented the CORD model in communities with high percentages of low-income and ethnic minority residents and high childhood obesity rates, they each used slightly different approaches of supporting infrastructure and systems changes within setting and in support of families. What we learn from CORD will benefit children and families in many diverse communities across the nation.