The Application of Telemedicine to Pediatric Obesity: Lessons from the Past Decade

Abstract

Background:

Telemedicine has been utilized to deliver pediatric weight management care in both rural and urban communities. This method of health care delivery may provide a solution to the many logistical obstacles to pediatric obesity management, including time, finances, and distance to programs.

Objectives:

This review examines all studies in the past decade that employed telehealth communication directly between families and obesity specialists to treat pediatric obesity. To assess the practical use of such programs, studies that surveyed family satisfaction with this method of health care are also included.

Methods:

A comprehensive electronic database search was conducted in PubMed/MEDLINE, Scopus, CINAHL, and Cochrane Library databases.

Results:

All studies demonstrated noninferiority in clinical efficacy as measured by weight status improvement in participants of either the telehealth cohort or the in-person cohort. Attrition rates were also not statistically significant between groups. Patient satisfaction with telemedicine delivery was high across studies. Lack of statistical significance in outcomes of these studies can be attributed to infrequent visits, limited duration of programs, and study size.

Conclusions:

Future research is needed to evaluate the effect on health outcomes as well as compliance when direct to consumer telemedicine visits are integrated in pediatric weight management clinics with more frequency and for longer duration. This method of telemedicine would allow for increased contact with patients and families in between face-to-face encounters. Telehealth provides the potential to create more robust, accessible, and effective pediatric weight management programs.

Introduction

Current obesity statistics from the recent NHANES cycle data (2015–2016) indicate a prevalence of pediatric obesity of 18.5%. Unfortunately, there has been a positive trend in the prevalence of obesity in all age groups between 2 and 19 years.¹ Effective treatment of this population to prevent concomitant comorbidities such as diabetes mellitus, cardiovascular disease, hypertension, sleep apnea, fatty liver disease, depression, and stroke,² which begin to develop in childhood,³ is an important public health endeavor. Telehealth has been used effectively in the field of adult obesity management,^4,5 which raises hope for its utility in pediatric weight management.

Adherence to 2007 Expert Committee Recommendations⁶ on pediatric obesity management within primary care has been limited and rendered difficult by lack of time and resources in the primary care setting.⁷ The recent U.S. Preventive Services Task Force Recommendation Statement on obesity in children and adolescents endorses intensive behavioral counseling with a goal of at least one contact hour every 2 weeks per year to effectively achieve improved weight status.⁸ Clinicians often site lack of access to dieticians and weight management clinics as obstacles to the treatment of childhood obesity.^9,10 Access to pediatric weight management clinics may facilitate guideline-based weight management care; however, logistical barriers to specialty obesity clinics impede the delivery of care.

Overall, attrition rates range from 27% to 73% in pediatric weight management clinics.¹¹ In a recent retrospective study of patient encounters to two busy pediatric weight management programs, 53% of children returned for a follow-up visit after their initial encounter and only 29% of children returned after the second visit.¹² Logistical obstacles such as difficulty with the time commitment required by a program, absence from school and work, parking expenses, and travel distance are cited as common reasons for noncompliance.¹³ Interestingly, obesity programs with the lowest attrition rates offer frequent monthly visits, which may increase patient engagement.¹⁴ Data also suggest that the frequency of visits with a dietician is more closely associated with successful body mass index (BMI) reduction than a specific dietary intervention.¹⁵

Telemedicine holds great promise as a tool to overcome many of the obstacles to the effective delivery of pediatric obesity care. Additionally, telemedicine transcends geographical limits to care in regions of the country where weight management centers are not available. This selective review focuses specifically on published literature on pediatric obesity management via videoconferencing between patients and medical providers over the past decade.

Methods

DATA ACQUISITION

A comprehensive electronic database search was conducted between June 4 and July 4, 2019, using the following databases: PubMed/MEDLINE, Scopus, CINAHL, and Cochrane Library. With the help of three librarians, the following MeSH search terms were created: pediatric obesity and telemedicine. Additionally, an advanced PubMed search was performed with the same terms. A sample PubMed advanced search can be found in Table 1, and a sample PubMed MeSH search can be found in Table 2. After the initial search, article titles and abstracts were reviewed for inclusion and exclusion criteria. Selected articles and systematic reviews were closely examined for inclusion criteria and were also cross-referenced for additional articles. Results were further filtered to publications written in English and published within the past 10 years. Only articles published in 2009 and forward were included in this review. (A final review of the literature was performed on December 19, 2019.)

Table 1.

Sample PubMed Advanced Search Builder

TERM 1		TERM 2		TERM 3
Pediatric or paediatric or child or children or adolescent^*	AND	Obesity or obese or overweight	AND	Telemedicine or telephone or telehealth

Table 2.

Sample PubMed MeSH Search

CONCEPT 1		CONCEPT 2
Pediatric obesity	AND	Telemedicine

INCLUSION AND EXCLUSION CRITERIA

All articles were published in a peer-reviewed journal and met the following criteria: participants defined as pediatric were ≤18 years old; patients enrolled in the study were overweight or obese (defined as a BMI ≥85% or BMI ≥95%, respectively); studies involved the use of telemedicine technology between patients and obesity specialists; and outcome measures included change in BMI, weight loss, patient/family satisfaction, or attrition. Both qualitative and quantitative studies were included in this review.

Studies were excluded if the primary intervention was based on internet modules, text messaging, self-monitoring systems, only telephone calls, or physical activity gaming technology since the focus of this article was videoconferencing. The search initially yielded 904 potentially relevant articles for abstract review. Using the above criteria, 10 quantitative studies and 2 qualitative studies on patient satisfaction were included in this review. One additional study, which is in process, was also included in this review.

Results

GROUP TELEMEDICINE SESSIONS: SCHOOL-BASED

At the University of Kansas, Davis et al. have conducted multiple studies to explore the feasibility and utility of group telemedicine in the delivery of pediatric weight management to rural communities. An initial feasibility study demonstrated the satisfaction and ease of delivery of telemedicine to rural Kansas families. In the telemedicine arm, four group video calls at local schools were conducted over the course of 8 weeks. In the control group, families met with their pediatrician once to review a similar curriculum. Although no significant change in BMI, diet, or exercise was noted in either group at the end of the study, families reported being highly satisfied with the telemedicine experience.¹⁶

A larger similar trial randomized patients to either group telemedicine or an individual physician encounter and also demonstrated no statistical difference in BMI, behavior, diet, or activity between the intervention group and the control physician group; however, all participants did have improvement in these outcome parameters. The telemedicine arm participated in 8 weekly group meetings with a trained psychologist or graduate students, followed by 6 monthly meetings. Participants in the control arm met with their own primary care physicians who were given specific topics to review with patients.¹⁷

More than 200 families were invited to participate in this study; however, only a small group was interested in enrolling. The authors concluded that there was still a significant burden of participation with the need to go to weekly group sessions at the school.¹⁸ Davis et al. also reported equivalent feasibility and satisfaction between group telephone and telemedicine encounters. Children and parents were enrolled in either group telemedicine or group telephone encounters, which were conducted at the local schools. There was no difference in change in BMI z-score or change in diet and nutrition between the groups; however, several parents in the telephone group reported a desire for telemedicine visits or face-to-face visits to increase the benefits of the program.¹⁹ Limited program size, duration, and the group nature of the sessions may have contributed to the lack of a statistical advantage in telemedicine in these studies.

TELEMEDICINE INTERVENTIONS WITHIN RURAL AND URBAN CLINICS

In North Carolina, the TeleFIT program installed telemonitors in local rural clinics to improve access for rural patients to specialty pediatric obesity care in the Brenner FIT program, a tertiary care weight management program. Patients enrolled in the telemedicine intervention group had their first visit in person at the main hospital and then had a telemedicine visit in a local clinic every 2–4 weeks with clinicians from the Brenner FIT program. Further in-person visits were scheduled every 4 months. Enrollment increased significantly among rural patients with the advent of this telemedicine option. Decrease in BMI z-score as well as attrition was comparable to patients who had all their visits in person in the Brenner FIT program.²⁰

Lipana et al. compared outcomes in patients who participated in more than one encounter with a weight management specialist in a Telemedicine Weight Management Clinic within rural clinics in the community with patients who received in-person care in the Weight Management Clinic at the University of California (UC) Davis Medical Center. The telemedicine group had more success in improving nutrition, activity, and decreasing screen time compared with those who presented for face-to-face visits. Positive weight outcomes including weight maintenance, decrease, or a slowing of weight gain were also more common in the telemedicine group. Statistical significance or adjustment for frequency of visits was not published for this study.²¹

Slusser et al. reported family satisfaction and improved outcome measures with a telemedicine endeavor in two urban clinics in Los Angeles, California. Before a telemedicine visit, an initial face-to-face evaluation was performed for all patients with a pediatric obesity specialist. A majority (93%) of patients felt satisfied with their subsequent telehealth appointment and 96% found their telemedicine appointment to be more convenient than travelling to the main urban hospital. In a chart review, 82% of telemedicine patients achieved either a stabilization or a decrease in BMI z-score at in-person follow-up. Although there was no control group for comparison, this study demonstrated successful implementation of telemedicine within an urban environment.²²

DIRECT TO CONSUMER TELEMEDICINE INTERVENTION

Fleischman et al. randomized patients to either in-person primary care visits as well as individual obesity specialist televisits in their home (Group 1) or in-person visits with their primary care providers (PCP) who received teleconsultations on pediatric obesity management (Group 2). A crossover protocol was used so that Group 2 received PCP visits and specialist televisits for the second 6 months, whereas Group 1 received only PCP visits during the second 6 months. Obesity specialists, alternating between a dietician and a psychologist, conducted direct to consumer telemedicine visits with the patient and parent every week for 6 weeks and then every 2 weeks for the remainder of the 6 months. Individualized treatment plans were created for each family. At the 3-month mark, after the intensive phase of direct to consumer telemedicine visits, there was a significant decrease in BMI in Group 1 compared with Group 2 who participated in only primary care visits. At 12 months, there was a statistically significant decrease in BMI within each group from baseline but not between groups.²³ This study demonstrated that a therapeutic model utilizing direct communication between the obesity specialists and patients holds promise for effective specialty care within the context of a weight management program.

In Canada, Coles et al. conducted an observational cohort study in which one group of adolescents with obesity received only in-clinic counseling after an initial 6-month weight management program, whereas the intervention group received on average 4.9 telemedicine visits in addition to face-to-face encounters over the 2 years. Attendance, cancellations, and no-show visits were similar between the usual care group and intervention group. No difference was found in BMI or weight change between the two groups during interval assessments or at the conclusion of the study. The authors concluded noninferiority in the telemedicine arm in delivering continued health care. Infrequent visits via telemedicine was postulated as the etiology for the absence of a significant decrease in BMI in the telemedicine arm.²⁴ This study demonstrated the feasibility of embedding telemedicine visits within the usual care of a tertiary obesity management program with adolescents.

Tripicchio et al. conducted a 3-arm study with all participants receiving weekly nutrition education and physical activity for 12 weeks within a family-based behavioral group (FBBG). Approximately one third of participants also received a digital tablet with a fitness application (FITNET). Another one third of participants received SKYPE telemedicine sessions every other week in addition to education and physical activity. BMI z-score dropped significantly in the group receiving telehealth sessions at the conclusion of the 12-week study; however, there was not a significant difference between groups. The authors postulated that the study size may have prevented the detection of a statistical significance in BMI z-score difference between the three groups.²⁵

Taveras et al. explored the benefit of telehealth coaching within an enhanced primary care obesity intervention program. The Connect for Health trial randomized overweight and obese children to either an enhanced primary care program or an enhanced primary care, and contact with a health coach via videoconferencing, telephone, or face-to-face encounters every other month for a year. Although the BMI z-score decreased in both groups, there was no statistical difference in BMI z-score between the groups. The lack of a significant difference between the two groups was attributed to the robust nature of the enhanced primary care program and the infrequent coaching sessions.²⁶ Again, direct to consumer telehealth encounters integrated into an existing pediatric weight management program appear logistically feasible, although significant benefit over standard intensive care has not been clearly demonstrated (Table 3).

Table 3.

Summary of Telemedicine Studies

AUTHOR	STUDY POPULATION	RANDOMIZED/CONTROL	GROUP VERSUS INDIVIDUAL TELEMEDICINE	DURATION/FREQUENCY	PROVIDER TYPE	RESULTS	CONCLUSIONS
Davis et al.^S1	17 Participants (all 5th graders); BMI ≥85%	Yes/yes	Group TM versus physician visit	Four 1-h group sessions over 8 weeks or a single visit with physician	PhD level psychologist from tertiary care center	Provider and parent satisfaction with TM; no change in BMI percentile between either group	Highly feasible method of obesity care delivery; no impact likely due to limited number of visits
Davis et al.^S2	27 Physician intervention, 31 telemedicine; BMI ≥85% (5–11 years)	Yes/yes	Group telemedicine versus physician visit	Weekly group for 8 weeks, monthly for 6 months and 30–45 individual coaching sessions every other week	Licensed psychologist or graduate-level fellows	Improvements in BMI z-score and diet and physical activity; no difference in these outcomes between groups	No difference in outcome between a single visit with physician given a curriculum to review and group TM program; specific list of topics for PCP may have increased primary care efficacy in weight management
Davis et al.^S3	42 Telemedicine, 61 telephone; BMI >85% (5–12 years)	Yes/no	Group telemedicine with video communication or Group telephone with speakerphone	8 Weekly group meetings followed by 6 monthly group meetings	Clinical member of the research team met with parent group; on-site representative (nurse, gym teacher, computer teacher) met with children	No change between groups in diet or physical activity; no difference in level of satisfaction between groups; no difference in BMI z-score between groups	High satisfaction and low attrition noted between both groups; both methods are effective in the delivery of pediatric weight management care
Irby et al.^S4	35 Telemedicine, 259 in-person visits; BMI ≥95% (2–18 years)	No/no	Individual Telemedicine in pediatrician's office (patient/parent and provider)	Initial in-person visits, then every 2–4 weeks by TeleFIT (in person every 4 months)	Brenner FIT team	BMI z-score decreased in both groups, no difference between groups; attrition rates the same in both groups	Increased enrollment in program with telemedicine option; comparable BMI outcome measures
Lipana et al.^S5	49 Telemedicine clinic, 63 face to face	No/yes	Individual Telemedicine in clinic (patient/parent and provider)	Greater than two visits over 5-year course of study	Pediatrician and registered dietician	Improved nutrition, increased activity, decreased screen time in telemedicine group; more patients with slowing, decreasing, or maintaining of weight gain in telemedicine group	Possible to achieve outcomes equivalent and even superior to face-to-face care
Slusser et al.^S6	32 Patients	No/no	Individual Telemedicine in an urban clinic	Over 3 years	Fit Clinic provider, pediatrician	Patient satisfaction: 96% easier to get to, 89% similar to face-to-face encounter; 82% with stabilization or decrease in BMI z-score; improved blood pressure among those with elevated blood pressure initially	Telemedicine enable tertiary care to be more accessible in an urban community; acceptability and satisfaction similar to an in-person visit
Fleischman et al.^S7	40 Patients; BMI ≥95% (10–17 years)	Yes/yes (crossover)	Individual Telemedicine visit between patient and obesity specialist	6 Months and then crossover for another 6 months/every week for 6 weeks and then twice a month	Dietician or psychologist	BMI z-score lower in Group 1 at 3 months but not significantly between the two groups at 6 or 12 months	Integrated care model between primary care and specialty care using telemedicine effective in achieving BMI reduction
Coles et al.^S8	100 (50/50); BMI ≥95% with comorbidity or BMI ≥99%	No/yes	Individual Telemedicine visit (started after 6 months in face-to-face program)	2 Years/average 4.9 visits (after in-person session)	Dietician, exercise, therapist, psychologist, nurse	No change in BMI or weight between groups	Telemedicine can be integrated successfully in a weight management program; infrequent visits contributed to the absence of superior effect of telemedicine arm
Tripicchio et al.^S9	64 Patients; BMI ≥85%	No/yes	Group 1: Family-based behavioral group program (FBBG); Group 2: FBBG and (FITNET) physical activity via tablet; Group 3: FBBG, physical activity via tablet and five individual telehealth coaching sessions	12 Weeks, five telehealth sessions	Trained health coaches	No BMI z-score change in first two groups; Telehealth group (Group 3) with statistically significant BMI z-score change, but not between groups	Telehealth sessions were a good way to reinforce FBBG content; statistical significance between groups not present because of small study size
Taveras et al.^S10	721 Patients; BMI ≥85%; 361: enhanced primary care; 360: enhanced care with coaching	Yes/yes	Telemedicine health coaching and/or enhancing primary care	Contact every other month via telephone, videoconferencing or face-to-face encounters	Trained health coaches	No statistical difference in BMI z-score between groups	Statistical difference not seen because enhanced care was such a robust program and inadequate coaching sessions; no change in percentage of children with severe obesity in either group

BMI, body mass index; PCP, primary care provider; TM, telemedicine.

QUALITATIVE TELEMEDICINE STUDIES

Qualitative articles on the use of telemedicine in pediatric obesity management support equivalent parent satisfaction with in-person visits. Mulgrew et al. compared satisfaction between parents who participated in direct to consumer telemedicine encounters with an obesity specialist with those parents who had face-to-face encounters at a pediatric obesity clinic at UC Davis. The surveys demonstrated no difference in overall parent satisfaction between telemedicine care and traditional face-to-face care. Although families receiving telemedicine care reported interest in further telemedicine visits, they felt slightly less confident in understanding topics pertaining to their child's health than those who received these discussions in person. Sample size was believed to be the reason for the lack of a statistical difference in satisfaction between the two groups.²⁷ As part of the Connect for Health Study, parent satisfaction with videoconferencing for coaching visits was surveyed. A majority (98%) of parents who participated in a telemedicine visit would recommend this form of interaction with a health provider. Savings in time, cost, and the ability to have a face-to-face interaction were cited as the benefits of a video visit. Most parents did not report any technical difficulties with the video calls.²⁸

ONGOING STUDIES

Davis et al. are implementing a trial exploring the utility of direct to consumer telemedicine in the delivery of pediatric weight management care to children in rural Kansas. The study involves group sessions weekly for 8 weeks and then monthly for 6 months between families and a psychologist or dietician. Families participate in these sessions from home. In addition, families will receive individual health coaching via telemedicine every other week. The control group in this study receives monthly newsletters with content similar to that which is delivered in the telehealth sessions.²⁹ This study will not only eliminate the requirement of going to a school for a group encounter but will also provide patients private and tailored interactions with a specialist at home with a high frequency of visits during the course of the study.

Discussion

Telemedicine studies included in this review do not demonstrate a consistently significant benefit to pediatric weight outcomes over in-person visits; however, none of the studies indicated that BMI outcomes were inferior in children and adolescents who received care via telemedicine and patient satisfaction was quite high with this method of health care delivery.²⁸ The lack of statistical significance in the different studies may be attributed to study size, frequency of visits, content of the visit, and patient engagement in the program. This review can inform future strategies in developing the effective use of telemedicine in pediatric obesity management.

Frequency of contact between providers and patients was associated with a statistically significant larger decrease in BMI than controls. For example, immediately after the 6-week intensive phase of telemedicine visits in Fleischman's study, there was a statistically significant difference in BMI z-score in those children who had weekly telehealth visits compared with those children who only met with a PCP. This difference was attenuated at 6 months after twice a month visits were instituted.²³ Most of the other programs had even less frequent telemedicine encounters, which may be the reason no superior clinical benefit of telemedicine visits was demonstrated.^21,24,25 Future programs should examine the positive effect on weight outcomes with more frequent visits for an extended duration.

Access to a telemedicine program at a local clinic conveys benefits in compliance and a decrease in attrition to a pediatric weight management program.²⁰ Integrating direct to consumer telemedicine into an existing pediatric weight management program holds great promise as a method of increasing contact with families with even less burden of participation and decreased operational costs than programs at local clinics or schools.

Future studies need to evaluate the use of direct videoconferencing as an established component of long-term participation in a pediatric weight management program. Direct to consumer visits instead of group visits enable obesity medicine specialists to provide personalized care to families at their convenience in the privacy of their own home. Telemedicine can be utilized to enable more frequent contact with patients after the family has been engaged in a comprehensive in-person initial encounter. Interval face-to-face visits allow providers to monitor BMI outcomes and comorbidities of obesity as well as assess efficacy of participation in a program. Achieving more frequent contact via telehealth circumvents many of the causes of attrition such as financial restraints and time limitation in pediatric weight management programs and may lead to improved outcomes as well as more widespread delivery of pediatric obesity care.

Footnotes

Authors' Contributions

S.D. and S.S.V. conceptualized and designed the review, coordinated and supervised data collection, participated in interpretation of review, drafted the initial article, critically reviewed and revised the article, and approved the final article as submitted.

Acknowledgments

We would like to acknowledge the efforts of Dr. Eduardo Fox and Dr. Nazrat Mirza to the editing of this article. Additionally, we would like to thank the librarians at George Washington University School of Medicine and Health Sciences and Children's National Medical Center for their assistance with our literature search.

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

The authors have no financial relationships relevant to this article to disclose.

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