Reference: JAMA. 2024 Dec 24;332(24):2068-2080
Practice Point: Childhood obesity in marginalized communities is neither inevitable nor purely genetic and may be reduced with a smartphone-based intervention in infancy.
EBM Pearl: When something appears to be low cost, low risk, and highly effective, sometimes we can act on imperfect evidence.
Childhood obesity, like many modern public health threats, is a slow-moving but deadly scourge. When we see children with overweight or obesity in marginalized communities, it’s hard to appreciate that this form of malnutrition can be just as deadly as underweight or failure to thrive. (For example, the prevalence of pediatric type 2 diabetes significantly increased during the stressful years of the COVID-19 pandemic.) A pragmatic intervention that reduces childhood obesity in underserved populations would be most welcome.
The Greenlight study collaboration, a six-center U.S.-based academic pediatric consortium, recently published results of a randomized trial comparing standard counseling about healthy diet and nutrition versus counseling plus real-time digital feedback for families with newborns. Although one criterion for enrollment was owning a smartphone, the study purposefully included socioeconomically diverse families. Spanish was the first language in about 35% of households, the primary caregiver was assessed as having limited health literacy about 57% of the time, and about 15% of participants reported having food insecurity at baseline. A total of 900 children were randomized (451 in counseling-only and 449 in counseling-plus-intervention groups). All families received initial counseling on healthy diet and activity, a series of English or Spanish booklets, and several physical tools (sippy cups, divided plates, labeled food storage cups). The digital group also had access to a smartphone app allowing for real-time feedback on the child’s weight-for-length as well as analysis of diet and activity habits such as screen time. Notably, the app was customizable based on primary language and caregiver health literacy.
The digital intervention worked, particularly for those most at risk. At 24 months, the group with digital interventions had lower rates of obesity (an adjusted risk ratio of 0.56 [95% CI 0.36-0.88] based on the CDC criteria of BMI ≥ 95th percentile or 0.46 [95% CI 0.24-0.89] based on the WHO criteria of a BMI z-score > 3). More than half of text messages sent in the intervention group elicited a response from caregivers. Note that 24 months of age is the generally accepted point to stop considering weight-for-length (kg/m) and start considering BMI criteria for overweight measurements. Interestingly, the results were far stronger in socially disadvantaged groups such as people who identified as Hispanic and/or Black, those with food insecurity, and those with lower health literacy.
Suffice it to say, this study is a “treat,” as it were. This is an intervention that, particularly in the age of smartphone ubiquity, might be scalable to large populations with tools most people already have. The lack of blinding in the study is problematic, as blinding is a key component for validity in randomized clinical trials and could theoretically have been performed here with apps that emphasize diet or activity or some other mechanism to give equal attention to both groups. Attention bias, once embedded into a study, is almost impossible to adjust for with statistical maneuvers. Sometimes we feel like researchers say “more research is needed” as often as pediatricians say “kids aren’t just small adults,” but in this case we wonder if action is possible before more definitive research is performed. Sometimes an intervention makes so much sense we should just go ahead and do it while we wait for more studies. We generously applied that maxim during the COVID-19 pandemic because it was perceived to be an emergency. Do the massive and increasing inequities in childhood obesity also count as an emergency? Is this one of those times when we should “just do it”?
For more information, see the topic Prevention of Obesity in Children and Adolescents in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Dan Randall, MD, MPH, FACP, Senior Deputy Editor at DynaMed. Edited by Alan Ehrlich, MD, FAAFP, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Katharine DeGeorge, MD, MS, Senior Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia; McKenzie Ferguson, PharmD, BCPS, Senior Clinical Writer at DynaMed; Rich Lamkin, MPH, MPAS, PA-C, Clinical Writer at DynaMed; Matthew Lavoie, BA, Senior Medical Copyeditor at DynaMed; Hannah Ekeh, MA, Senior Associate Editor II at DynaMed; and Jennifer Wallace, BA, Senior Associate Editor at DynaMed.