title: Exploring innovative approaches and patient-centered outcomes from positive outliers in childhood obesity.
abstract: OBJECTIVE
  New approaches for obesity prevention and management can be gleaned from positive outliers-that is, individuals who have succeeded in changing health behaviors and reducing their body mass index (BMI) in the context of adverse built and social environments. We explored perspectives and strategies of parents of positive outlier children living in high-risk neighborhoods.
  
  
  METHODS
  We collected up to 5 years of height/weight data from the electronic health records of 22,443 Massachusetts children, ages 6 to 12 years, seen for well-child care. We identified children with any history of BMI in the 95th percentile or higher (n = 4007) and generated a BMI z-score slope for each child using a linear mixed effects model. We recruited parents for focus groups from the subsample of children with negative slopes who also lived in zip codes where >15% of children were obese. We analyzed focus group transcripts using an immersion/crystallization approach.
  
  
  RESULTS
  We reached thematic saturation after 5 focus groups with 41 parents. Commonly cited outcomes that mattered most to parents and motivated change were child inactivity, above-average clothing sizes, exercise intolerance, and negative peer interactions; few reported BMI as a motivator. Convergent strategies among positive outlier families were family-level changes, parent modeling, consistency, household rules/limits, and creativity in overcoming resistance. Parents voiced preferences for obesity interventions that include tailored education and support that extend outside clinical settings and are delivered by both health care professionals and successful peers.
  
  
  CONCLUSIONS
  Successful strategies learned from positive outlier families can be generalized and tested to accelerate progress in reducing childhood obesity.
authors.affiliation: Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Mass. Electronic address: msharifi@partners.org.
authors.forename: Mona
authors.initials: M
authors.lastname: Sharifi
authors.affiliation: Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Mass.
authors.forename: Gareth
authors.initials: G
authors.lastname: Marshall
authors.affiliation: Warren Alpert Medical School, Brown University, Providence, RI; Harvard School of Public Health, Boston, Mass.
authors.forename: Roberta
authors.initials: R
authors.lastname: Goldman
authors.affiliation: Obesity Prevention Program, Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Mass.
authors.forename: Sheryl L
authors.initials: SL
authors.lastname: Rifas-Shiman
authors.affiliation: Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Mass.
authors.forename: Christine M
authors.initials: CM
authors.lastname: Horan
authors.affiliation: Obesity Prevention Program, Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Mass.
authors.forename: Renata
authors.initials: R
authors.lastname: Koziol
authors.affiliation: Harvard Vanguard Medical Associates, Boston, Mass.
authors.forename: Richard
authors.initials: R
authors.lastname: Marshall
authors.affiliation: Harvard Vanguard Medical Associates, Boston, Mass; Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass; Department of Health Care Policy, Harvard Medical School, Boston, Mass; Partners Healthcare System, Boston, Mass.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Sequist
authors.affiliation: Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Mass; Obesity Prevention Program, Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Mass.
authors.forename: Elsie M
authors.initials: EM
authors.lastname: Taveras
mesh_terms: D000886:Anthropometry; D001294:Attitude to Health; D015992:Body Mass Index; D002648:Child; D057286:Electronic Health Records; D005260:Female; D017144:Focus Groups; D015438:Health Behavior; D006801:Humans; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D010290:Parents / Q000523:psychology; D063766:Pediatric Obesity / Q000453:epidemiology* / Q000517:prevention & control*; D036301:Qualitative Research
keywords: attitude to health; obesity; overweight; parents; positive deviance; qualitative