Childhood Obesity Research Demonstration: Efforts to Identify Effective Strategies for Low-Income Children

Childhood obesity affects nearly 14 million children aged 2 to 19 years in the United States. Children in low-income families are disproportionately affected, with about 1 in 5 having obesity. Studies suggest that children with obesity are likely to become adults who are overweight or have obesity, which can contribute to poorer health and higher health care expenditures. CDC was designated as the agency to design and manage the project and has awarded grants in three separate phases.

GAO was asked to examine the CORD Project, including what has been learned regarding strategies to reduce childhood obesity. In this report, GAO describes 1) the extent to which CDC changed the design of the CORD Project between grant phases, 2) the results of the CORD Project and factors that have affected implementation, and 3) efforts by CDC and others to disseminate results and lessons learned.

To conduct this work, GAO reviewed planning and grant documentation for the three CORD phases, published articles about the design of CORD phase 1 and 2, and documentation describing the results of CORD phase 1. GAO also interviewed CDC officials, CORD phase 1 and 2 grantees, and officials from other HHS agencies involved in the design of the CORD Project.

HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.

The Centers for Disease Control and Prevention (CDC) has made four key changes to the design of the Childhood Obesity Research Demonstration (CORD) Project between each of the three grant phases. Established by law in 2009, the project provides research grants to develop and implement strategies to reduce obesity among low-income children. One of CDC's design changes, for example, was to modify the scope of the project (i.e., type of strategies implemented by grantees). After CORD phase 1, CDC officials shifted the scope from prevention—through the implementation of strategies in community settings, such as schools, and in health care settings—to the treatment of children who were overweight or had obesity. According to CDC officials, the agency made this change due to the shorter time frame for implementing CORD phase 2 and in response to existing national recommendations related to childhood obesity. CDC also changed the purpose of the project's study design prior to phase 3. Whereas CORD phases 1 and 2 were intended to build knowledge and evidence of effective strategies, CDC modified CORD phase 3 to focus on translating effective strategies into routine use by converting them into a package of materials that others could replicate.

To evaluate the effectiveness of CORD phase 1—the only phase that is complete—CDC awarded a grant to an independent entity to aggregate results across the three grantees, and each grantee conducted their own evaluation. The evaluation center and the grantees reported some improvements in children who received CORD 1 strategies. For example, the evaluation center reported small but positive changes in outcomes measured, which included body mass index and fruit and vegetable consumption. These improvements were most often observed among

children who received primary care strategies, such as individualized counseling, and

children who participated in public health strategies, such as an evidence-based nutritional program, in addition to the primary care strategies.

CDC and grantees identified several factors during the first two phases that affected the ability to implement strategies to reduce obesity among low-income children. For example, grantees noted that the preexistence of programs and policies that promoted healthy behaviors positively affected their implementation of CORD strategies. CDC officials identified the turnover of principals and other school or clinic staff as negatively affecting the implementation and suggested that future researchers incorporate staff retraining costs into their strategies as a way to help mitigate this challenge.

CDC has taken steps to share CORD design materials and results through published literature, websites, and conferences. It has also coordinated with other Department of Health and Human Services (HHS) offices and agencies to promote the wider adoption of CORD strategies in low-income communities. For example, CDC has collaborated with an office in HHS to fund a project to increase the use of a specific weight management program used in CORD phase 1.

The prevalence of childhood obesity—defined as body weight higher than  what is considered a healthy weight for a given height—in the United  States was about 19 percent from 2015 through 2016, affecting  approximately 14 million children and teens aged 2 to 19, according to the  Centers for Disease Control and Prevention (CDC). Childhood obesity  disproportionally affects children from low-income families. For example,  CDC data show that the obesity rate for children in families with incomes  below the federal poverty threshold was 21 percent from 2013 through  2016, which was about 71 percent higher than the rate for children in  families with the highest incomes. There are both numerous negative  health outcomes and financial consequences related to childhood obesity.  For example, researchers have found that childhood obesity is associated  with a number of health disorders including high blood pressure and high  cholesterol, type 2 diabetes, and asthma. Studies suggest that children  with obesity are likely also to become adults who are overweight or have  obesity, which can contribute to increased health care expenditures over  their lifetimes.

The Children’s Health Insurance Program Reauthorization Act of 2009  (CHIPRA) authorized the Secretary of the Department of Health and  Human Services (HHS) to establish the Childhood Obesity Research  Demonstration (CORD) Project. Specifically, CHIPRA authorized HHS to  award grants to universities and other eligible entities to implement  activities to reduce childhood obesity among low-income children, such  as those who are eligible for Medicaid or the Children’s Health Insurance  Program (CHIP). HHS designated CDC as the agency responsible for  designing, awarding, and managing the grants. Subsequent laws— including the 2018 reauthorization of CHIP—appropriated funding for, and  further extended, the CORD Project. With this funding, CDC established  two additional CORD Project phases—CORD 2 and CORD 3—which  awarded additional grants and used different design approaches. CORD  phase 1 concluded in September 2016; as of September 2019, phases 2  and 3 were ongoing.

You asked us to review HHS’s processes for designing and evaluating  the CORD Project and determine what has been learned regarding  different strategies to support healthy behaviors and reduce childhood  obesity. In this report, we describe  1. the extent to which CDC changed the design of the CORD Project between the grant phases, 2. the results of the demonstration projects and any factors that have affected their implementation, and 3. efforts by CDC and others to disseminate results and lessons learned from the CORD Project.

To describe the extent to which CDC’s design of the CORD Project  changed between the three grant phases, we reviewed relevant laws and  CDC documentation and interviewed officials from CDC, other HHS  agencies, and CORD grantees from phases 1 and 2. We did not interview  CORD phase 3 grantees, as those grants were just beginning at the time  of our review. To ascertain the purpose and research objectives for each  phase of the CORD Project, we reviewed relevant laws; the CORD  Project Plan developed by HHS, which provided parameters for designing  the CORD Project; the funding opportunity announcements for all three  CORD phases; and the grant award documentation, which describes the  responsibilities and requirements grantees had to fulfill. We also  interviewed CDC officials to obtain information about design decisions for  the CORD Project, as well as their interaction with grantees and other  HHS agencies. We interviewed officials from the National Institutes of  Health, the Health Resources and Services Administration, the Agency  for Healthcare Research and Quality, and the Centers for Medicare &  Medicaid Services (CMS) to understand their involvement in the CORD  Project. Finally, we interviewed officials representing the entities to which  CDC awarded grants to implement demonstration projects under CORD  phases 1 and 2 (hereafter referred to as implementing grantees) and the  University of Houston (hereafter referred to as the evaluation center),  which conducted a cross-site evaluation of the three demonstration  projects. We asked these officials about their interactions with CDC, other  HHS officials, and other grantees.

To describe the results of the demonstration projects and factors that  have affected implementation, we reviewed CORD phase 1 evaluation  reports and progress reports by the evaluation center and implementing  grantees, which contained information on progress made as well as  information about the challenges grantees experienced in implementing  them. We also reviewed final reports by CORD phase 1 grantees that  summarized the results of the implemented strategies. We examined the  CORD phase 2 progress reports available at the time of our review, which  contain information on the progress CORD phase 2 grantees reported  regarding their implementation of the strategies but do not contain  information on the results of the implemented strategies. Additionally, we  reviewed studies the grantees published in peer-reviewed journals as of  April 2019 to obtain information about the results of the implemented  strategies and other lessons learned regarding approaches for reducing  obesity in low-income children. As of April 2019, the CORD phase 2  grantees had published studies that described the design and evaluation  approaches grantees planned to use but had not published any studies  describing the results of the implemented strategies. Finally, we  interviewed CDC officials and CORD phase 1 and 2 grantees to obtain  their perspectives on the lessons learned from the CORD Project.

To describe efforts by CDC and others to disseminate results and lessons  learned from the CORD Project, we reviewed the CDC CORD Project  websites, which present information about the CORD grantees and  published articles about the design and the strategies implemented, and  reviewed materials from conference presentations provided or facilitated  by CDC officials. We interviewed CDC officials to understand how they  disseminated the results from the implemented strategies and to learn  about the information they intended to include in the report to Congress  about CORD phases 1 and 2 that they were drafting at the time of our  review. In addition, we interviewed officials from other HHS agencies to  determine the extent to which they have coordinated with CDC on the  CORD Project and interviewed CORD phase 1 grantees to understand  the extent to which the CORD strategies have been sustained in the  communities in which they implemented them.

We conducted this performance audit from July 2018 to October 2019 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

The primary purpose of the CORD Project is to develop and implement  strategies for reducing obesity among low-income children. According to  CDC, strategies that have been used to prevent and manage obesity  include screening patients using body mass index (BMI), so children and  their parents understand their risks; supporting healthy behaviors—such  as eating vegetables and promoting physical activity—in early care and  education centers and schools; and educating parents on how to  reinforce healthy living habits at home. BMI is used to determine  overweight and obesity (see sidebar).

Percentiles are calculated from the Centers  for Disease Control and Prevention (CDC)  growth charts developed from national survey  data collected between 1963 and 1994.

Funding for the CORD Project was first made available through the  enactment of the Patient Protection and Affordable Care Act, about one  year after the CORD Project was authorized. In January 2011, CDC  published the funding opportunity announcement—which outlined the  goals of the grant as well as the eligibility criteria and other  requirements—and, in September 2011, the first demonstration projects  began. Congress subsequently appropriated additional funding for the  CORD Project in April 2015 and January 2018, bringing the total amount  appropriated to $65 million for fiscal years 2010 through 2023. CDC  officials told us that during this time period the CORD Project was the  primary source of CDC funding for childhood obesity research focused on  low-income children. CDC implemented the CORD Project in three  separate grant phases, with different design approaches and grantees.  (See fig. 1.)

Across the three CORD Project phases—only the first of which is  complete—CDC has awarded ten grants to entities to implement  demonstration projects aimed at reducing obesity in low-income  children. (See table 1.) In the first phase of the CORD Project, CDC also  awarded a grant to the evaluation center to conduct a cross-site  evaluation of the implementing grantees’ demonstration projects.

CDC Has Made Four Key Changes to the CORD Project Design in Response to Lessons Learned and National Recommendations

CDC Made Four Key Design Changes to the CORD Project between Each Grant Phase

CDC made four key design changes between the three CORD phases.  CDC changed the scope of the project (i.e., type of strategies  implemented), the type of evaluations (i.e., how it evaluated the  strategies), the purpose of the study design, and the extent of  participation by state Medicaid or CHIP programs. (See fig. 2.) CDC  officials designed the CORD Project based on the language and  requirements in CHIPRA and the CORD Project Plan developed by HHS,  according to CDC officials. For CORD phases 2 and 3, CDC officials  modified elements of the design in response to lessons learned, time  frames for implementation, and recommendations related to childhood  obesity made by national organizations such as the U.S. Preventive  Services Task Force (hereafter referred to as the Task Force).

Scope of CORD Project. After CORD phase 1, CDC officials shifted the  scope of the CORD Project from prevention to the treatment of children  who are overweight or have obesity, according to CDC officials.  Specifically, CDC designed CORD phase 1 to require grantees to  implement demonstration projects that integrated public health and  primary care strategies by promoting children and their families’ use of  healthy behaviors and by modifying community environments. CORD  phase 1 grantees implemented strategies in two types of settings: (1)  community and (2) health care settings. Public health strategies are  activities and programs delivered in community settings, such as schools  and early care and education centers. Grantees also implemented  primary care strategies, which in general are BMI screenings or other  activities implemented in health care settings, such as during physician  visits in federally qualified health centers. While CORD 1 grantees  implemented strategies in both types of settings, the specific strategies  that each CORD phase 1 grantee implemented varied. (See text box and  app. I for additional information about the strategies CORD 1 grantees  implemented.)

Examples of Strategies Childhood Obesity Research Demonstration Phase 1  Grantees Implemented  California Demonstration Project

Public health strategies implemented included training staff at early care and  education centers on health behavior change strategies and providing centers  with large self-service water containers to promote increased water intake.

Primary care strategies implemented included body mass index (BMI)  screenings for children participating in early care and education centers. BMI is a  measure used to determine overweight and obesity.

Public health strategies implemented included training teachers in participating  elementary schools on how to implement evidence-based health education  curricula that encouraged learning about nutrition and physical activity.

Primary care strategies implemented included establishing a healthy weight  clinic located in the participating health centers.

Public health strategies implemented included providing classroom-based  nutrition and gardening curricula in the early care and education centers.

Primary care strategies included modifying electronic health records systems to  increase provider awareness and action related to maintaining healthy weight,  such as prompting clinicians to refer children who were overweight or had obesity  to additional services.

Pediatric Weight Management  Interventions  The Centers for Disease Control and  Prevention (CDC) defines pediatric weight  management interventions as intensive  behavioral interventions designed to address  excess weight through child and parental  counseling on diet, physical activity, or  behavior change management. The U.S.  Preventive Services Task Force refers to  these as interventions for weight management  interventions.

For CORD phases 2 and 3, CDC shifted the scope of the CORD Project  to the treatment of children who are overweight or have obesity.  Specifically, CDC modified the scope to only focus on implementing  pediatric weight management interventions, one type of primary care  treatment strategy (see sidebar). CDC officials told us they changed the  scope of CORD phase 2 in response to the shorter, 2-year funding period  authorized by law. CDC officials stated that unlike CORD phase 1, the  shorter time frame for CORD phase 2 did not allow for a planning year to  establish and solidify community relationships across multiple community  settings while also enabling sufficient time to implement the strategies  and analyze outcome and other data.

CDC also modified the scope for CORD phase 2 and 3 to focus on  pediatric weight management interventions in response to existing  national recommendations related to childhood obesity, according to CDC  officials. The Task Force recommended that primary care providers  screen children 6 years and older for obesity and offer, or refer children  with obesity to, pediatric weight management interventions. In making  its recommendation, the Task Force found that pediatric weight  management interventions should involve at least 26 hours of contact  between the provider and the child, family, or both over a period of 2 to 12  months. According to CDC’s funding opportunity announcement for  CORD phase 2, a 2007 expert committee convened by the American  Medical Association similarly recommended that all health care providers  address weight management and lifestyle issues with children at least  once a year and provide behavior counseling on key obesity-related  behaviors. CDC officials stated they designed CORD phase 2 to meet  the guidelines and standards outlined in these recommendations.

After Congress extended the CORD Project for a 6-year period beginning  in fiscal year 2018 and appropriated additional funding, CDC designed  the scope of CORD phase 3 as a 5-year grant to continue efforts to  implement pediatric weight management interventions only. CDC  officials stated they considered returning to an integration of public health  and primary care strategies for CORD phase 3, similar to CORD phase 1,  but decided that the best use of resources was to focus on integrating  pediatric weight management interventions into communities, which  includes linking families with resources already available in the  community, such as low-cost physical activity offerings.

Common Outcome Measures for  Childhood Obesity Research  Demonstration (CORD) Phase 1  Frequency of fruit and vegetable consumption   Frequency of sugar-sweetened beverage  consumption  Physical activity   Sleep time  Screen time (e.g., watching television and  playing video games)  Body mass index  Quality of life (e.g., physical, emotional, and  social)

Type of evaluations. In CORD phase 1, CDC awarded a grant to  another entity—the evaluation center—to conduct a cross-site evaluation  to aggregate results of the three implementing grantees’ demonstration  projects. In designing CORD phases 2 and 3, CDC did not award grants  to independent entities to conduct cross-site evaluations of the  implementing grantees’ demonstration projects. In CORD phase 1, the  cross-site evaluation was intended to help inform national policy decision- making, including recommendations regarding the applicability of CORD  strategies in other communities. To assess the effectiveness of CORD  phase 1, CDC designed the cross-site evaluation to examine the  demonstration projects using a set of common outcome measures, which  the evaluation center developed in collaboration with CDC officials and  implementing grantees (see sidebar).

CDC officials told us they removed the cross-site evaluation component  for CORD phases 2 and 3 in part due to challenges executing the cross- site evaluation in CORD phase 1. Officials explained, for example, that  the difficulty in developing common outcome measures that could be  analyzed across the three demonstration projects that were both valid  and specific enough to the strategies was a challenge given the variation  in the strategies implemented by each grantee, data collection time  frames, and methodologies. In addition, CDC officials stated the  implementing grantees had sufficient capacity to conduct their own  evaluations. For these reasons, CDC officials said they concluded that  the cross-site evaluation was not an efficient use of resources. The  CORD phase 1 grantees also identified the following challenges related to  the cross-site evaluation:

Grantees told us there was insufficient time to develop the common  outcome measures prior to implementing the strategies. One grantee  noted this resulted in them needing to collect some data  retrospectively instead of collecting it in real time.

Grantees also collected data at different time frames from each other,  which resulted in limited data for measuring outcomes via the  common measures. Evaluation center officials stated that the lack of a  common timeline for collecting data resulted in them only being able  to analyze changes in common outcomes measures at the two  common time points across all three grantees—baseline and 12  months—even though some grantees collected data at later time  points (e.g., 24 months after implementation began). Thus, evaluation  center officials said they were unable to determine whether changes  in outcomes observed were sustained 24 months after  implementation.

Grantees reported challenges in creating valid common outcome  measures applicable across the varying age ranges, locations, and  strategies implemented for the three demonstration projects that  affected results of the cross-site evaluation. For example, only the  Massachusetts demonstration project chose to implement strategies  in the Special Supplemental Nutrition Program for Women, Infants  and Children offices, making any data collected about that strategy  unable to be included in the cross-site evaluation.

CDC required the implementing grantees in all CORD phases to conduct  their own evaluations and report on outcomes associated with the  strategies implemented under their demonstration projects. Specifically,  CDC expected the grantee-specific evaluations to measure health  outcomes—such as changes to BMI, nutrition, and physical activity—and  quality of life, and to report information on the processes, outcomes, and  costs of the individual demonstration projects in the evaluations.

Purpose of study design. While CDC designed CORD phases 1 and 2  to build knowledge and evidence on strategies for reducing obesity  among low-income children, CDC designed CORD phase 3 to focus on  translating strategies proven to reduce childhood obesity into routine use  for low-income families. More specifically, for CORD phases 1 and 2,  CDC required grantees to use or adapt strategies that previously had not  been rigorously tested in low-income children. For example, in CORD  phase 2, the Arizona demonstration project adapted a preexisting  program—which was aimed at preventing child behavior issues through  motivational interviewing techniques and parent education—to improve  weight-related health behaviors in low-income children. By comparing  low-income participants receiving the strategies with those who did not,  the Arizona demonstration project aims to develop evidence about  whether or not these strategies work to reduce obesity in low-income children. Arizona officials told us that while the CORD phase 2 study  design is appropriate for helping to expedite the translation of knowledge  into practice, it has nonetheless been challenging to implement the  demonstration project in a 2-year period. The officials explained 2 years is  a short period of time for this type of demonstration project.

For CORD phase 3, CDC is requiring grantees to take an existing  evidence-based pediatric weight management intervention and convert it  into a user-friendly package of information, containing all materials clinical  or community-based entities would need to easily, efficiently, and  completely replicate the pediatric weight management intervention.  Materials may include implementation manuals, training curricula,  technical assistance, and evaluation materials. CORD phase 3 grantees  are required to partner with clinical or community entities that will then  use the package to implement the set of pediatric weight management  interventions in their community. Additionally, CORD phase 3 grantees  are required to make edits to the packaged materials based on the results  of the implementation and develop sustainability and dissemination plans  to implement the pediatric weight management intervention at additional  locations.

CDC officials and agency documentation outlined multiple reasons why  they modified the study design for CORD phase 3. For example, in its  funding opportunity announcement for CORD phase 3, CDC noted that  there have been challenges in moving research-based, national  recommendations, like Task Force recommendations, into practice.  According to CDC officials, this challenge is especially great in low- income communities, where there are a limited number of available  pediatric weight management interventions that are rigorous enough to  meet the standards outlined by the Task Force. Additionally, officials  noted that when these interventions are available, families are generally  charged for the services. CDC officials told us that, according to the  literature, it can take many years for evidence-based clinical interventions  to make it into mainstream practice. Thus, by designing CORD phase 3  to package evidence-based pediatric weight management interventions  that will be targeted to communities with low-income families, CDC  officials told us they hope to reduce the number of years before adoption  of such treatment strategies is prevalent.

Participation by state Medicaid or CHIP program officials. In the  design for CORD phase 1, implementing grantees were not required to  develop relationships with officials from their state Medicaid or CHIP  offices or with other payers, but these relationships were encouraged,  according to CDC officials. At each subsequent CORD phase, CDC  modified its expectations of grantees regarding the involvement of state  Medicaid and CHIP program officials in the demonstration projects.  Specifically, CDC added a requirement that the implementing grantees  form a payer advisory board with representatives from state Medicaid or  CHIP offices and encouraged grantees to collaborate with other relevant  health care stakeholders, such as private payers, to foster discussions  about how to obtain reimbursement for CORD strategies.

Noting the importance of establishing these types of relationships, CDC  officials told us that grant funding and in-kind donations—which CDC  encouraged grantees to identify and use to supplement CORD grant  funding—are not sustainable sources of funding for continued  implementation of childhood obesity programs. As a result, the officials  told us reimbursement from insurers, such as Medicaid or CHIP, is  necessary to sustain the implemented strategies at the level of intensity  required by the Task Force recommendations. For example, in CORD  phase 2, officials from the Arizona demonstration project told us they  included representatives from United Healthcare’s private and Medicaid  health plans and also a representative from Mercy Care, a not-for-profit  Medicaid plan, on their payer committee. Arizona demonstration project  officials stated they were working with representatives of the state  Medicaid program and private health plans to determine what kind of  evidence payers would need to reimburse for obesity-related services.

Reimbursement is a key focus in CORD phase 3, and CDC officials told  us they plan to assist grantees in determining which services provided  within the pediatric weight management interventions may be  reimbursable. Specifically, CDC officials stated they will coordinate  opportunities for information sharing, technical assistance, and  networking between CORD phase 3 grantees, states, and CMS in order  to explore broader Medicaid and CHIP coverage options for the services  delivered through the grants. CMS officials noted that medical services  provided under the grant could be reimbursable under states’ Medicaid  and CHIP programs, including under the Early and Periodic Screening,  Diagnostics and Treatment benefit.

CDC Used a Similar Approach to Grantee Management in the First Two CORD Phases

While CDC changed some design elements of the CORD Project  between the phases, according to CDC officials, the agency used a  consistent approach in managing grantees. Specifically, CDC officials told  us that in CORD phases 1 and 2 they promoted collaboration between  themselves and the grantees, as well as among the grantees, and  monitored the grantees through regular interactions with them. CDC  officials told us they used a team of personnel with different expertise to  oversee the CORD phase 1 and 2 grants. For example, the team included  a project officer who specialized in program management to oversee the  day-to-day operations, as well as subject matter experts, including one  experienced in evaluation design. CDC officials told us they interacted  with CORD phase 1 and 2 grantees on regular conference calls and  conducted annual site visits to each grantee. Grantees stated that CDC’s  site visits aided them in implementing their demonstration projects by  keeping them and their community partners accountable. In addition,  grantees told us that CDC collaborated with them to provide expertise on,  or troubleshoot the design of, the implementation of their demonstration  projects. For example, Arizona demonstration project officials told us that CDC officials helped them to figure out how to best achieve their desired  sample size for a strategy they were implementing. CDC officials told us  they plan to continue a similarly collaborative management approach for  CORD phase 3.

CDC officials stated they also monitored CORD phase 1 and 2 grantees  by requiring grantees to regularly report on their efforts and generally plan  to monitor CORD phase 3 grantees the same way. For example, CDC  required CORD phase 1 grantees to submit annual progress reports at  least 90 days before the end of the budget period that included  descriptions of progress made towards the research goals, information on  expenditures, and a detailed budget justification for the new budget  period. CDC also required CORD phase 1 grantees to submit both annual  progress reports and a final progress report. CORD phase 1 grantees told  us that CDC officials were helpful in providing administrative support that  ensured grant paperwork was completed consistent with requirements.

Evaluations Show Some Improvements for the Completed Demonstration Projects and CDC and Grantees Identified Factors Affecting Implementation

Evaluation Center and Grantees Reported Some Improvements for Children Receiving the Strategies in the First Phase of the CORD Demonstration Projects

The evaluation center’s cross-site evaluation and the implementing  grantees’ evaluation findings reported some improvements in BMI and  other outcomes measured among children who received CORD phase 1  strategies. Specifically, the evaluation center reported that positive  changes on these outcomes were observed most often among the  following groups of children, providing some evidence of the effectiveness  of the strategies delivered:

Children who received primary care strategies, such as individualized  counseling.

Children who received public health strategies, such as an evidence- based nutritional program, in addition to the primary care strategies.

In evaluating the CORD 1 demonstration projects, the evaluation center  did not examine which specific strategies were the most effective. The  primary objective of the cross-site evaluation was to determine if there  was evidence that an integrated approach had any advantage over  implementing either public health only or primary care only strategies.  The evaluation center examined the extent to which the three CORD 1  demonstration projects collectively were associated with positive changes  over time in behavior or reductions in BMI. Because of the considerable  variation in each of the three demonstration projects, the evaluation  center grouped the various strategies implemented by the three grantees  into two categories for the analysis: public health and primary care plus.  Next, the evaluation center categorized children by the types of strategies  they received (public health only, primary care plus only, or both public  health and primary care plus) and by age (2 to 5 years, 6 to 8 years, and  9 to 12 years). The evaluation center tested whether each of the  possible combinations of strategy and age showed improvement over a  12-month period for each common measure.

Using this approach, the evaluation center found some improvements for  all of the common outcomes measured; however, improvements were not  observed for each strategy or age group. Specifically, of the 81 possible  combinations of strategy and age, 52 demonstrated some improvement  over the 12-month period; however, only 16 of them showed a statistically  significant improvement. (See fig. 3.) For example, BMI improved for  children over the 12-month period in three of the strategy and age  combinations, but the improvement was statistically significant for just one  of those combinations. Among the 52 groups that showed improvements  at 12 months, most of the differences observed were very small. For  example, from the start of the intervention to 12 months after the  intervention, there was about a 1 percent increase in the percentage of  children who reported they were physically active for 60 minutes at least  one day a week.

The implementing grantees—each of which conducted their own  evaluations—also reported some improvements in the children who  received CORD phase 1 strategies. Similar to the evaluation center’s  findings, the implementing grantees did not report improvements for all  participating age groups or all outcomes they examined. Among their  findings, the grantees reported the following:

Children at participating early care and education centers in Texas,  who were exposed to strategies such as classroom-based nutrition  and gardening curricula, demonstrated modest improvements in BMI  over a 2-year period when compared with children who did not receive  these Texas demonstration project strategies. The Texas  demonstration project also reported improvements in BMI for some  children who participated in a weight management program  administered in YMCAs compared with a different weight  management program administered in primary care clinics.  Specifically, researchers found that the YMCA program was more  effective in reducing BMI for low-income children at 3 months but not  at 12 months after implementation of the program.

Children who received both public health and primary care strategies  under the California demonstration project experienced some  improvement on some outcome measures when compared to children  who only received one type of strategy. For example, children who are  overweight or have obesity who received both public health and  primary care strategies reported playing less hours of video games  during the week than those who only received the primary care  strategies.

During CORD phase 1, the Massachusetts demonstration project  observed some improvements over time in the children who received  CORD strategies. For example, the percentage of seventh grade  students with obesity decreased from the start of implementation  compared with 24 months after implementation in the two  communities where the strategies were implemented. However,  these results were modest; the decrease in the percentage of  students with obesity was less than 3 percent in both communities.

CDC officials, implementing grantees, and the evaluation center noted  that modest or no effects were likely in part due to small sample sizes  because of recruitment issues. Regarding recruitment, CDC officials told  us that two of the three CORD phase 1 demonstration projects had issues  with recruitment that caused sample size issues and ultimately statistical  power issues. Specifically, when there is a smaller sample size, a study  may be underpowered, which means that statistically significant effects  are less likely to be detected even when differences exist. CDC officials  explained that having limited statistical power affects the ability for more  specific modeling or analysis to determine for whom the strategies works  best (e.g., those with obesity or severe obesity). Grantees and CDC  officials told us that when faced with recruitment issues, grantees made  changes to their recruitment strategies. For example, grantees reduced  the minimum BMI required for children participating in the demonstration  projects in an attempt to increase participation. However, grantees told us  they were still not able to reach their anticipated number of participants.  Additionally, an official from the evaluation center told us some common  outcome measures used in the cross-site evaluation were limited. The  official explained that, had the grantees had more time to reach  consensus on how to collect the data for the common outcome measures,  or had the common outcome measures been identified in advance of the  implementing grantees developing their own evaluations using measures  specific to their demonstration projects, the evaluation center might have  had more precise data to demonstrate improvements among participants.

In planning for CORD phase 1, CDC officials acknowledged that the  demonstration projects might not result in significant changes for some  outcomes. CDC’s funding opportunity announcement noted that changes  in health indicators, such as BMI, are long-term objectives, and that the  period of funding for the projects might be too short to demonstrate  significant improvement in these outcomes. A CDC official stated that  although strong results were not found across each of the demonstration  projects, the results of the implemented strategies provided evidence that  these strategies could be implemented in a real-world setting. Thus, they  noted the lack of stronger and larger effects does not mean that the  demonstration projects were not successful.

CORD phase 1 grantees told us they continue to analyze the data and  expect to publish additional findings, even though the grant period has  concluded. For example, the evaluation center told us they had enough  data from the CORD Project to continue publishing for many years and  planned to publish studies examining how existing community policies— such as physical activity policies—affected the outcomes of the  implemented strategies. One of the implementing grantees also told us  that having more time to fully analyze, use, and publish results from the  data was needed.

CDC and Grantees Identified Several Factors Affecting the Implementation of Strategies to Reduce Obesity among Low- Income Children

CDC officials and CORD grantees identified several factors that affected  grantees’ ability to implement strategies to reduce childhood obesity  among low-income children. According to CDC officials, policymakers and  researchers should consider these factors when implementing similar  strategies in the future. CDC officials or implementing grantees identified  the following factors they observed across the CORD grantees:

Staff turnover. CDC officials told us that the turnover of principals  and other administrative personnel trained to provide the strategies is  one factor that negatively affected the implementation of the  strategies in schools or clinics. For example, CDC officials noted that  in the Massachusetts demonstration project, researchers had to  establish a relationship with a new principal of one of the participating  schools when the other principal left, which delayed progress in  implementation at that location. Similarly, the Arizona demonstration  project also experienced staff turnover at the clinics, which led to a  need for retraining and challenges in staff flows. CDC officials  suggested that future research should consider incorporating staff  retraining costs in the design of public health strategies to help  mitigate this challenge.

Family support. CDC officials told us that grantees had to provide  more support than initially anticipated to families to better ensure their  participation. CDC officials told us that grantees addressed this  challenge by allowing siblings to also attend or participate in the  activities or by holding activities on weekends or after school to  accommodate parents’ work obligations. Strategies should be  designed to be flexible for families, as there are competing demands  on the families participating in the demonstration projects, CDC  officials explained.

Pertinent programs and policies. Implementing grantees noted that  the preexistence of programs or policies that promoted healthy  behaviors in the public health and primary care sectors positively  affected their implementation of CORD strategies. For example,  Massachusetts demonstration project officials told us that the  strategies they implemented complemented an existing statewide  program that promoted opportunities for healthy eating and active  living in the communities, schools, childcare centers, and businesses.  Grantee officials attributed the organizational commitment and  motivation they observed in participating schools to these preexisting  activities.

Commitment from partner organizations. Implementing grantees  found that the commitment of partner organizations, such as schools,  was an important factor affecting implementation. According to  implementing grantees, determining the willingness and ability of an  organization to implement the strategies is important—by identifying,  for example, leaders who support the strategies and can help ensure  staff commitment to execute them. The Massachusetts demonstration  project reported that 90 percent of the stakeholders they worked with  noted the presence of leadership and administrative support for the  project reduced feelings of conflict between program implementation  and other priorities. Alternatively, the California demonstration project  identified the lack of a strong supporter in a leadership position as a  barrier to implementation.

Parental stresses. Implementing grantees found that parental  stresses related to social economic status (e.g., food insecurity or  accessibility challenges, including transportation to intervention sites)  was a major factor negatively affecting family participation and the  implementation of the strategies. Grantees explained that  understanding the effect of these stresses on a family’s ability to focus  on the strategies to reduce childhood obesity is important and  grantees should plan for ways to mitigate those stresses.

CDC told us that the CORD phase 3 demonstration projects may be able  to help mitigate some of the challenges identified from prior CORD  experiences, as noted above. For example, CDC officials told us they  plan to work with CORD phase 3 grantees to find ways to mitigate  challenges associated with staff turnover, which could include taping  trainings or allowing for virtual opportunities for retraining. Additionally,  the CORD phase 3 grants are implementing pediatric weight  management interventions in different settings—some in clinical settings  and some in community settings—which CDC officials said may provide  parents with additional flexibility to participate in the strategies.

CDC and Others Have Taken Steps to Disseminate CORD Results and Continue to Promote the Use of CORD Strategies in Low-Income Communities

CDC has taken steps to share CORD phases 1 and 2 design materials  and available results with researchers and others. For example, CDC  shared on its website information for CORD phases 1 and 2, including  project summaries, background information about the grantees, and  published literature describing the project designs and results. In  addition, CDC shared lessons learned about the CORD Project and  evidence-based childhood weight management programs during a series  of webinars. According to CDC officials, the intended audience for the  webinars included public health practitioners and researchers; local,  state, and federal government agency officials; health care professionals;  policy analysts; and community health workers. CDC officials also told us  they have presented CORD results and lessons learned at conferences  and at meetings organized by other HHS agencies. Specifically, a CDC  official and grantees summarized results from the first phase of the  CORD Project at the American Academy of Pediatrics’ Annual  Conference in 2016. CORD phase 1 results were also presented at the  2018 Annual Meeting for the Association of State Public Health  Nutritionists. Additionally, in November 2017, CORD phase 1 grantees  met with researchers from the National Institutes of Health’s Childhood  Obesity Prevention and Treatment Research program to share lessons  learned from their respective research.

To further disseminate CORD results, CDC officials highlighted their  planned report to Congress, as required by CHIPRA, which was  subsequently issued in September 2019. The report describes the findings for CORD phase 1 and provides brief descriptions of the CORD  phase 2 grantees and their demonstration projects, since the results of  those projects are not yet available. The report identifies CORD phase 1  findings, including information about the costs of implementing the  strategies. CDC officials noted that the implemented public health  strategies, such as providing classroom-based nutrition and gardening  curriculum or programs that promote physical activity, cost less than  primary care strategies. Specifically, CDC reported that the costs of public  health strategies in early care and education centers ranged from $26 to  $96 per child, the costs of some primary care strategies ranged from  $164 to $181 per child, and the cost of more intensive family-based  weight management programs ranged from $2,107 to $2,220 per child.

CDC, in collaboration with other HHS agencies, has also taken some  steps to promote the wider adoption of CORD strategies in low-income  communities. For example, CDC and CMS have had preliminary  discussions about how CMS could help CORD grantees understand how  Medicaid and CHIP programs could reimburse for the obesity-related  strategies they are implementing as part of the CORD Project, which  CDC officials told us could help to sustain and expand these strategies to  other low-income communities. CMS officials told us they are considering  whether to issue guidance to state Medicaid and CHIP programs that  explains how some states have been able to reimburse entities for the  provision of overweight- and obesity-related services. CDC officials told  us that after discussions with CMS officials, they provided information to  CMS in October 2018 that could be used for a possible CMS information  bulletin to state Medicaid and CHIP officials on childhood obesity.

In addition, CDC and the Office of the Assistant Secretary for Planning  and Evaluation within HHS have awarded a cooperative agreement to the  National Association of Community Health Centers to increase the  implementation of an evidence-based childhood weight management  program—Mind, Exercise, Nutrition, Do It!—by federally qualified health  centers. According to HHS officials, the National Association of  Community Health Centers is assisting 14 federally qualified health  centers in five states (Arizona, Florida, Illinois, Mississippi, and North  Carolina) to implement this intervention and, based on lessons learned,  plans to develop an implementation guide to support the expansion of this  strategy to other health centers. CDC officials also told us they are  coordinating with the National Cancer Institute within the National  Institutes of Health to share knowledge with CORD phase 3 grantees  about how to develop business models to support the expansion of  successful strategies, which aligns with one of CDC’s goals for CORD  phase 3 to determine how to increase the adoption of successful  strategies beyond the CORD intervention sites.

CDC officials and implementing grantees provided us some examples of  CORD strategies and materials that continue to be used in the states  where they were implemented or have been implemented in other low- income communities.

Officials from the Massachusetts demonstration project told us that  some of the primary care strategies they developed during CORD  phase 1 are still provided in the healthy weight clinics that participated  in the project.

Officials from the Arizona demonstration project told us they have  received funding from the U.S. Department of Agriculture to develop a  new training module for health care providers interested in  implementing the project’s pediatric weight management intervention.  They explained that the new training module will include information  on parenting strategies specific to child health behaviors (e.g.,  monitoring of physical activity) and examples of stories from the  families who participated in the Arizona demonstration project.

CDC officials also told us that materials that CORD grantees used as  part of their strategies are publically available for use by researchers  and other communities. These materials include a primary care  resource guide developed in collaboration with the American  Academy of Pediatrics, the Coordinated Approach to Child Health  early childhood kit, and a healthy weight clinic implementation guide.

We provided a draft of this report to HHS for comment. HHS provided  technical comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  Secretary of Health and Human Services, the appropriate congressional  committees, and other interested parties. In addition, this report will be  available at no charge on the GAO website at http://www.gao.gov.

If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or dickenj@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. Major contributors to this report are listed in  appendix II.

Appendix I: Childhood Obesity Research Demonstration Grantees

The Children’s Health Insurance Program Reauthorization Act of 2009  (CHIPRA) authorized the Department of Health and Human Services  (HHS) to establish the Childhood Obesity Research Demonstration  (CORD) Project. CHIPRA specified that HHS provide project grants to  universities or other eligible entities to implement activities to reduce  childhood obesity among low-income children. HHS designated the  Centers for Disease Control and Prevention (CDC) as the agency  responsible for designing, awarding, and managing the grants.  Subsequent laws provided additional funding and extended the CORD  Project for two more phases.

The first phase of the CORD Project began in September 2011 and was  completed in September 2016. The purpose of CORD phase 1 was to  determine whether implementing strategies in public health sectors,  including early care and education centers, schools and community  organizations, and primary care sectors, such as health care clinics, could  improve low-income children’s risk factors for obesity. CDC funded three  implementing grantees: San Diego State University, the Massachusetts  State Department of Public Health, and the University of Texas Health  Science.

CORD phase 2 started in June 2016. The purpose of this phase was to  further test if strategies implemented in the primary care sector would  reduce the body mass index (BMI) in children with obesity, or who were  overweight with risks including medical and behavioral risks and family  history. CDC funded the following grantees: the Massachusetts State  Department of Public Health and Arizona State University. As of July  2019, CORD phase 2 was ongoing.

The California demonstration project was led by San Diego State University. The demonstration project was implemented in three rural communities—Brawley, El Centro, and Calexico—in Imperial County, California. Imperial County, California, is located on the U.S.-Mexico border, and had an estimated 174,528 residents, 77 percent of whom were of Mexican origin—including 32 percent who were foreign born—in 2010. Three-quarters of all residents reported speaking a language other than English at home. The median household income was $39,402, compared to $61,632 in the state, and income disparities are reflected further in the differential poverty rates (23 percent in Imperial County versus 14 percent in California as a whole).

Early care and education centers (23 centers)  Collected height and weight for children aged 2-5 years.  Trained center staff on health behavior change strategies to use at their centers.  Provided centers with large self-serve water containers and cooking kits with  child-friendly cooking and serving items.

Elementary schools (13 schools)  Worked with school nurses and trainees to collect BMI measurements from  kindergarteners, third graders, and fifth graders in the El Centro Elementary  School District; and kindergarteners, second graders and fifth graders in the  Brawley Elementary School District.  Provided schools physical activity equipment.

Installed water jets and other water containers to provide self-serving access by  students.  Developed lesson plans promoting sleep for grades kindergarten through sixth  grade.

Community (three community organizations and three independent restaurants)

Provided a water dispenser at two community recreations centers in Brawley and  El Centro and at one Boys and Girls Club in Brawley.  Developed community gardens at the Boys and Girls Club in Brawley and a  recreation center in El Centro.

Introduced healthy children’s menu items in three restaurants.

The grantee conducted a non- randomized study which sought to  determine whether strategies  implemented in both public health  sectors and primary care sectors  would be more effective at preventing  and controlling childhood obesity when  compared with strategies implemented  in public health sectors only, primary  care sectors only, or when strategies  were not implemented.

Community health clinics (three clinic sites)

Modified the clinics’ electronic health record systems to improve health care  provider screening and treatment of childhood obesity including through the use  of alerts and prompts. To facilitate the adoption of the system changes, a patient  care coordinator was hired to work across the participating clinics.

Hired community health workers and a community health worker coordinator to  administer the Family Wellness Program, a 12-month program that delivered  wellness and physical activity workshops, motivational interviewing, and  newsletters.

The Massachusetts demonstration project was a led by the Massachusetts Department of Public Health. The demonstration project was implemented in the cities of Fitchburg, located in north-central Massachusetts, and New Bedford, in southeast Massachusetts. In 2010, the population of these two cities was about 40,000 and 95,000, respectively, and was predominantly non-Hispanic white (about 68 percent). Both communities had higher percentages of low-income residents than the state of Massachusetts, according to 5-year estimates from the 2008-2012 American Community Survey. Specifically, the percentage of families with children whose incomes were less than the federal poverty level was about 24 percent in Fitchburg and 27 percent in New Bedford versus 12 percent in the state.

Early care and education centers (nine centers)  Trained mentors to provide support to staff to implement evidence-based programs  on nutrition and physical activity.

Schools and after school programs (six schools and 17 after school programs)  Provided evidence-based health education curricula and training to teachers to  encourage student learning about nutrition and physical activity.  Implemented a nutrition curriculum for after-school program staff to use with children  aged 5 to12 years.

Community  Implemented a communications campaign, including text messaging, small  billboards, transit ads, and handouts, to spread the demonstration project’s brand and  to change community norms and practices in physical activity and healthy eating.

Special Supplemental Nutrition Program for Women, Infants and Children (one  program in each community)  Collaborated with the Special Supplemental Nutrition Program for Women, Infants  and Children to implement intervention activities including training nutritionists and  nutrition assistants in best practices on assessment and counseling for childhood  obesity prevention and developing an obesity counseling toolkit for providers.

The grantee used a combination of pre- post time series and quasi- experimental designs to examine the extent to which the interventions resulted in changes in BMI, individual- level lifestyle behaviors, satisfaction with health care services, and quality of life among children, as well as to health policies, programs, and environments in the two intervention cities compared to another city.

Health centers (two centers)  Modified existing electronic health records to deploy a computerized, point-of-care  decision support alert at the time of a well-child care visit for a child who is overweight  or has obesity. The alert prompted clinicians to document weight status, nutrition and  physical activity counseling, and place referral to the on-site healthy weight clinic for  weight management support.  Implemented a healthy weight clinic in each participating health centers. Each healthy  weight clinic was staffed with a physician, a nutritionist, and a community health  worker who met with each patient and family. Patients participating in the healthy  weight clinics engaged in dietary and physical activity assessment, goal setting, and  were connected to community resources to support healthy lifestyles.

The Texas demonstration project was led by the University of Texas Health Science Center in Houston. The demonstration was implemented in two catchment areas in Houston and Austin, Texas. The data collected at the beginning of the project from participating early care and education centers, schools, and clinics indicated that families were low-income, with most parents reporting an annual household income of $25,000 or less. The population was predominantly Hispanic (73 to 83 percent), with approximately 44 to 55 percent predominately Spanish-speaking.

Early care and education centers (28 centers)  Provided classroom materials on nutrition and gardening and bilingual parent tips  sheets on nutrition, activity, and screen time.  Provided physical activity equipment to participating centers.

Schools (40 schools)  Trained school staff on a nutrition and physical education classroom curricula.  Sent text messages in English or Spanish to participants once a week that  emphasized program concepts and linked families to resources.

Community  Provided training sessions to teach community health workers, teachers, parents,  physicians, and others stakeholders about advocacy and the implementation of  environmental changes for healthy eating and active living.

Health care clinics (11 clinics)  Provided BMI screening for children who are overweight or have obesity, which  included decision supports to integrate guidelines for the appropriate clinical  screening, evaluation and treatment into day-to-day practice.  Modified electronic health records to identify children who were overweight and  had obesity, provide prompts for treatment, and provide clinicians with access to  referral information for weight management.

The Texas demonstration project  implemented and evaluated a primary  and secondary obesity prevention  program. In the primary prevention  intervention, the grantee collected data  on risk factors and the utilization of  health care services and community  programs. This intervention was  focused on the entire community, with  the goal of preventing the  development of obesity. The  secondary prevention program  consisted of a randomized control trial,  targeted to children who were already  overweight or had obesity. Children  and their families were randomly  assigned to either a community  centered or a primary care centered  weight management program.

The Arizona demonstration project is  led by Arizona State University. The  purpose of the project is to implement  an adapted program in three pediatric  primary care clinics located in  Maricopa County, Arizona. These  clinics serve a minority patient  demographic of about 60 to 65  percent, of which the largest groups  are Mexican American and American  Indian.

Program adaptation: Adaptation began by assessing the needs and capacity of a  primary care organization and the families they serve. The program was then  pilot-tested in a general pediatrics clinic and a clinic for children with advanced  obesity to determine feasible delivery modifications as well as enhanced content  for obesity management and prevention. During and at the end of the pilot trial,  feedback was solicited from stakeholders and families. A draft of the adapted  version of the program was then developed, additional feedback was sought from  experts and stakeholders and a second pilot-testing phase was completed.  Feedback was again collected from families who received the intervention and  from stakeholders who participated in the pilot. The intervention protocol and  content were further refined to implement in the three pediatric primary care  clinics.

The Arizona demonstration project implemented an adapted program that was designed to target health behavior change in children ages 5 and one half to 12 years by improving family management practices and parenting skills, with the goal of preventing obesity and excess weight gain. The program is designed to tailor services based on a family assessment and to increase parent motivation. The project included a randomized control trial to evaluate the effectiveness of the adapted program within three primary care clinics in two federally qualified health centers and a children’s hospital.

Effectiveness study: Participants were identified during clinic well- and sick-child  visits and through queries of electronic health records. After completing a family  health assessment, families were randomly assigned to the adapted program or  services as usual. Participating families completed routine assessments about  family health behaviors, child health behaviors, family well-being and support,  and other topics. Following the assessments, feedback sessions were initiated.  The first feedback session focused on understanding (a) the caregivers’  perception of their needs; (b) their child’s health, adjustment, and behavior; and  (c) the caregivers’ motivation to change parenting and family management  practices in support of health behavior change. Additionally, over a 6-month  period, families participated in eight to 16 parenting sessions tailored to the  specific needs identified in the family health routine assessment and focused on  a specific behavior change goal, such as setting limits on snacking between  family meals or monitoring children’s sedentary and physical activity time. In the  second and third feedback sessions, the coordinator began by checking in with  the family about their progress, discussing barriers they experienced, and  exploring the ways that the previous feedback and parenting sessions were  helpful for them in catalyzing and supporting healthy lifestyle behavior change.  Additionally, coordinators provided families with referrals to existing resources in  the community. In weeks where a face-to-face session was not scheduled or did  not occur, the coordinator conducted a 15- to 30-minute phone-based coaching  session. The purpose was to maintain contact with the family and help problem- solve challenges, reinforce positive achievements, and continually address  motivation to change and barriers to engagement.

The Massachusetts demonstration project for CORD phase 2 is led by the Massachusetts State Department of Public Health and Massachusetts General Hospital. The demonstration project was implemented in the cities of Holyoke and New Bedford, Massachusetts.

Primary care screening and assessment of child BMI: Children were referred to  the demonstration project by their primary care provider during a health care visit  where a height and weight was obtained and it was determined that the child was  overweight or had obesity. After the referral was made, parents were mailed an  introductory letter and fact sheet by the study team. A bilingual study coordinator  contacted parents by phone and explained that the research study was to  examine strategies to improve the care that is provided for children who require  weight management. The coordinator obtained verbal informed consent from the  parent and administered a 20-minute baseline survey.

The demonstration project implemented a randomized trial that compares the effects of a pediatric weight management program delivered in the healthy weight clinics of two federally qualified health centers with a weight management program delivered at two YMCAs. Eligible children were overweight or had obesity, ages 6 to 12 years, and received primary care at the two federally qualified health centers.

Child assigned to intervention: After the parent completed the survey, the child  was randomly assigned to a healthy weight clinic in one of the two federally  qualified health centers or to the weight management program delivered at one  of the two YMCAs. Each of the two intervention groups received an intensive 6- month intervention, followed by a 6-month maintenance period that delivered 30  or more hours of contact time over one year. In addition, children in both  intervention groups were exposed to quality of care improvements in their  federally qualified health centers, which included primary care provider weight  management training and text messages to participating families for self-guided  behavior change support.

Healthy weight clinic: This intervention was clinic-based and used a  multidisciplinary team, including, a pediatrician, community health worker,  dietician, and access to behavioral/mental health providers, as needed. The  team was trained to deliver motivational interviewing and behavioral  modification techniques to engage families in setting and following through  on healthy eating and activity goals. Visits alternated between group visits  with other children and families in the program and individual visits for the  first 6 months and individual visits in the second 6 months. During the first   6 months of the intervention, the community health worker or dietitian made  bi-weekly phone calls to the family on weeks they did not have an in person  visit. During the second 6 months, they provided once-monthly calls.

YMCA weight management program: This intervention was a community- based intervention where staff at two local YMCAs were trained to implement  the program. Two YMCA group leaders provided support, education and  activities during sessions, which included goal setting and action planning, a  parent discussion, and 60 minutes of physical activity for the children. The  program was delivered over 12 months, which included 16 weekly sessions,  followed by four sessions delivered every other week and concluded with five  monthly sessions.

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Shannon Slawter Legeer  (Assistant Director), Deitra H. Lee (Analyst-in-Charge), and Kristen M.  Pinnock made key contributions to this report. Also contributing were  Krister Friday, Richard Lipinski, Laurie Pachter, Ethiene Salgado- Rodriguez, and Emily Wilson Schwark.

According to the CDC, obesity affects about 14 million U.S. children aged 2 to 19, with higher rates in children from low-income families. CDC awarded grants to universities and others to implement strategies for reducing childhood obesity in low-income families.

The grants were awarded in three phases; the first of which is complete. In that phase, grantees found some small but positive changes, such as lower body mass index and more fruits and vegetables in the children’s diets. Across grantees, participating children who received health care services, such as individual counseling, showed progress more often than those who did not.