Successful Virtual Delivery of a Group Childhood Healthy Weight Program

Background

We recently described the development and evolution over 5 years of Get Up & Go, a 10-week healthy weight program for children ages 6–14 years, offered free to families, which resulted in improved weight status and healthy lifestyle behaviors. At each weekly class, two coaches, with backgrounds ranging from nutrition, physical therapy, wellness coaching, and teaching, provide nutrition education, fun physical activity that engages children and adults, goal setting, and a healthy snack. Between classes, program staff check in with families about their goals.

We reported that 2/3 of registered families attended at least one session, about 70% of attenders met graduation criteria, and among those completers, %BMI_p95 change was −2.34 (SD = 4.19). ¹ When the COVID-19 pandemic emerged, the Get Up & Go program instituted the option of a virtual class, delivered synchronously to the participating families. This report's aim is to evaluate the observed participation and effectiveness of the virtual implementation in comparison with concurrent in-person delivery.

Methods

Beginning June 2020, referred parents could choose either an in-person session, delivered at a YMCA of Metropolitan Dallas site near their home, or a live video session. Families in the virtual delivery could connect from their homes. Both settings delivered the same curriculum over 10 weeks, with sessions offered weekday evenings or on a weekend day, and with the option for sessions delivered in Spanish. Most in-person sessions were bilingual, and all virtual sessions were monolingual (English or Spanish).

Implementation of virtual sessions differed from in-person in several ways. The in-person classes restricted participation to one parent and one child, a change from before the pandemic, when the program encouraged attendance by the whole family. Each virtual class was delivered by a single coach, rather than two, and lasted about 1 hour in contrast to the 90 minutes in-person classes. In the virtual delivery, families received a phone tripod to facilitate virtual interaction between the coaches and family members when the family's internet access was limited to a smart phone. The families in the virtual class did not receive a healthy snack. Coaches provided links for weekly recipes rather than passing out hard copies.

Extra effort was made to maintain engagement during the distant learning. At the start of each session and with reminders throughout, the coaches emphasized the importance of parent as well as child participation. The virtual classes did not have a standard physical activity component, but the coaches could intersperse “brain break” videos from the free GoNoodle site (www.gonoodle.com), which contains short (about 3 minutes) videos of fun dancing and movement, designed for schools and families. When coaches in the virtual classes drew on posters to make a point, they asked participants to draw along with them, and they encouraged families to go their own pantry and refrigerator to find nutrition labels and other props.

Virtual participants picked up curriculum material and had weight and height measured at YMCA of Metropolitan Dallas sites near their homes before session start and then returned for postsession measures. BMI was calculated from weight and height and then expressed as percent above the 95th percentile (%BMI_p95). Experts recommend this metric, among others, for BMI >97th percentile rather than CDC BMI percentile or z score, because the compressed distribution of percentile and z metrics in the high BMI range means relatively large weight differences result in no or very small differences in percentile or z score.^2–4 This metric is used to categorize childhood obesity into Class 1 [BMI ≥95th percentile (obesity cut point) to <120% BMI_p95], Class 2 (BMI_p95 ≥120%–139.9%), and Class 3 (BMI_p95 ≥140%).

Severe obesity is defined as Class 2 and above, and the prevalence of Class 1, 2, and 3 obesity among children 2–19 years nationally is 16.4%, 5.2%, and 1.5%, respectively. ⁵

All parents completed the Behavior Assessment Questionnaires (BAQs) ⁶ before and after their session. BAQ contains 10 questions about frequency of nutrition behaviors (fruit and vegetable intake, and sugar-sweetened beverages and other unhealthy eating patterns), physical activity, and screen time, and scores can range from 0 to 100, with higher scores indicating healthier behaviors. Because virtual participants did not complete the Progressive Aerobic Cardiovascular Endurance Run, this outcome measure is not reported here.^7,8

The Human Studies committee at the University of Texas Southwestern Medical Center determined that this report did not require IRB oversight.

Results

Over 3 quarterly cycles, 116 families registered for virtual and 107 registered for in-person delivery. Fewer families who registered for the virtual option participated (defined as attending ≥ one session) vs. those who registered for in-person delivery (60.3% vs. 78.5%, respectively, p = 0.003). Over the 3 cycles, the program delivered 41 sessions: 20 bilingual in-person, 2 English in-person, 9 Spanish virtual, and 10 English virtual. At baseline, children who participated in virtual (n = 70) vs. in-person (n = 84) were similar in age [11.1 (SD 2.4) vs. 10.7 (SD 2.2) years], gender (37.1% vs. 46.4% male) and severe obesity status, defined as BMI_p95 ≥120% (77.5% vs. 77.5%). Virtual classes had a higher proportion of Spanish-speaking families (41.4% vs. 22.6%, p = 0.01). The BAQ scores were similar at baseline [34.8 (SD 12.7) vs. 36.5 (SD 12.5)], and the proportion of families meeting graduation criteria of at least six classes, not including orientation, was similar (77.1% for virtual vs. 65.5% for in-person).

Table 1 displays the change from baseline for BMI_p95 and BAQ scores among the graduates in the two groups. The measures in both groups improved in the expected direction, with a greater decrease in BMI_p95 among the virtual group compared with the in-person group, although the difference did not reach significance.

Discussion

Live virtual delivery of group classes of Get Up & Go, an established community-based healthy weight program, resulted in improvement in BMI_p95, with trend toward superior effect compared with concurrent in-person delivery, with >80% of eligible children undergoing evaluation. Improvements in BAQ scores were similar in both groups. Although the families registered for virtual delivery had a lower participation rate, the children in the two groups who did participate were similar in age, gender, and degree of obesity, and had similar graduation rates.

During the pandemic, the rate of BMI increase in children markedly rose. ⁹ The media has reported the struggles parents experienced maintaining healthy routines for their children during the pandemic, ¹⁰ and surveys have confirmed decreased physical activity and unhealthy changes in snacking during this time.^11,12 In this environment, it is notable that participation and outcomes of Get Up & Go during the pandemic, including both virtual and in-person groups, were similar to the prepandemic findings in the recent published report.

We have found no existing reports of virtual live delivery of a group weight management program to children and families who participate from their home. One program, deployed in a rural setting, gathered participants at a local site where they connected as a group to distant program deliverers, ¹³ but this approach is contrary to the social distancing that prompted the Get Up & Go virtual format. The reasons for lower participation among registrants for the virtual delivery compared with in-person are unknown but could include lower sense of commitment to a virtual class; family and work demands, which may have led to the choice of virtual delivery; and technological problems. Further study is needed on this question.

The reasons Spanish-speaking families preferred virtual to in-person delivery were not examined. Spanish-speaking families had access to the bilingual in-person classes, delivered throughout the metropolitan area. Spanish-speaking families may have preferred the monolingual Spanish delivery in the virtual platform, or the choice may reflect disparity in transportation, need for child care for other family members, or concerns about infection exposure. Further study in this area as well is needed.

In conclusion, the virtual delivery of Get Up & Go classes resulted in better BMI_p95 improvement with similar retention compared with the standard in-person format. Our virtual synchronous implementation has been an effective response to the pandemic challenges. We also suggest that nonpandemic use of this format would expand access to families with transportation or other barriers to in-person participation.