RESEARCH LETTER Fitwits MDTM: An Office-Based Tool and Games for Conversations about Obesity with 9- to 12-Year-Old Children Ann L. McGaffey, MD, Diane J. Abatemarco, PhD, MSW, Ilene Katz Jewell, MSHyg, Susan K. Fidler, MD, and Kristin Hughes, MFA Background: Physician feelings of ineffectiveness and family-related barriers hamper childhood obesity discussions. Physicians desire appealing, time-efficient tools to frame and sensitively address obesity, body mass index, physical activity, nutrition, and portion size. Our university design-led coalition co- developed tools and games for this purpose. Methods: In this feasibility study, we evaluated physician-level counseling of 9- to 12-year-old chil- dren and their parents/caretakers using Fitwits MD (Carnegie Mellon University School of Design, Pitts- burgh, PA), a brief, structured intervention with flashcards and take-home games. Residency-based phy- sicians in three low- to mid-level socioeconomic urban offices provided self-report data over 8 months through surveys, comment cards, and interviews. Results: We recruited 33 physicians and 93 preadolescents and families. Child-centered key mes- sages resulted in 7-minute conversations, on average. For those physicians who used Fitwits MD, 96% felt improved comfort and competence and 78% noted barrier reduction. Conclusions: Fitwits MD improved residency-based physician self-efficacy and emphasized important health education topics regarding office-based childhood obesity discussions with preadolescents and parents/caretakers. ( J Am Board Fam Med 2011;24:768 –771.) Keywords: Body Mass Index, Communication, Health Literacy, Obesity, Portion Size Though the health dilemma of excess weight is widely known, not all physicians and families dis- cuss childhood obesity in a forthright, understand- able way. Many physicians perceive the following as barriers: time pressure; insufficient training for nu- trition-based and body mass index (BMI) counsel- ing; treatment futility; home and neighborhood environments that undermine recommendations; and insufficient reimbursement, support services, and patient educational materials. Clinicians under-utilize BMI. Often, families do not perceive that a problem exists and may not be motivated, have low literacy and numeracy skills, or have aver- sion to the term “obesity” and to perceived criti- cism of parenting skills.1–5 For these reasons, we co-developed counseling tools and games to com- municate weight-related concerns and health guid- ance. In June 2008, a Carnegie Mellon University design team led seven physicians and two registered dietitians through a participatory design workshop. The resulting Fitwits MD flashcards included a This article was externally peer reviewed. Submitted 18 November 2010; revised 15 March 2011; accepted 21 March 2011. From the Department of Behavior and Community Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (DJA); the Center for Health Pro- motion Research, Case Western Reserve University, Cleve- land, OH (IKJ); Primary Care Sports Medicine Fellowship Program, Thomas Jefferson University Hospital, Philadel- phia, PA (SKF); University of Pittsburgh Medical Center, St. Margaret Family Medicine Residency Program, Pitts- burgh, PA (SKF, AM); and Carnegie Mellon University School of Design, Pittsburgh, PA (KH). Current affiliation: Thomas Jefferson University, School of Population Health, Philadelphia, PA (DJA); and Ambler Medical Associates, Ambler, PA (SKF). Funding: This study was funded by The Heinz Endow- ments, the St. Margaret Foundation, and the Allegheny County Medical Society Foundation. Conflict of interest: none declared. Corresponding author: Ann McGaffey, MD, University of Pittsburgh Medical Center, St. Margaret Bloomfield Gar- field Family Health Center, 5475 Penn Avenue, Pittsburgh, PA 15206 (E-mail: mcgaffeyal@upmc.edu). 768 JABFM November–December 2011 Vol. 24 No. 6 http://www.jabfm.org o n 5 A p ril 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://w w w .ja b fm .o rg / J A m B o a rd F a m M e d : first p u b lish e d a s 1 0 .3 1 2 2 /ja b fm .2 0 1 1 .0 6 .1 0 0 2 7 8 o n 1 5 N o ve m b e r 2 0 1 1 . D o w n lo a d e d fro m http://www.jabfm.org/ simple definition of obesity, BMI charts with Fit- wits and Nitwits characters and color-coded ranges, and friendly interrogatives about personal and family history. Self-management cues include 60 minutes of daily exercise, foods and beverages con- taining large amounts of sugar and fat, healthy alterna- tives, and a hand-based portion guide (Figure 1; http:// www.fitwits.org). In addition, we provided to families the Fitwits School take-home games.6 Methods Residency-based physicians in three western Penn- sylvania low- to mid-level socioeconomic urban offices provided self-report data mid-November 2008 through July 2009. We recruited convenience samples of physicians, parents/caretakers, and 9- to 12-year-old children presenting for well child/mi- nor illness visits, regardless of BMI. The Carnegie Mellon University and University of Pittsburgh institutional review boards approved all study pro- cedures. Fitwits team residents trained physicians using flashcards, best-evidence recommendations, and games practice in a 1-hour training session. Absent physicians were provided with one-on-one instruc- tion. Participants were instructed to use Fitwits MD in lieu of traditional office discussions. We used a pre- and posttest observational design. Be- fore training, physicians completed a 10-question survey with Likert-scale questions and comment areas concerning comfort and competence levels, patient health education, perceived discussion length, and physician barriers. Questions after the study period included percentage of intervention use; Likert scale change in comfort, competence, and barrier reduction; and perceived discussion length. Physicians completed open-ended com- ment cards after each office visit intervention. In- depth audio-recorded and transcribed interviews with randomly selected physicians provided addi- tional qualitative data. The comment cards and interviews were analyzed by two evaluation team coders (DJA, IKJ). Quantitative data were analyzed using SPSS software, version 14.0 (SPSS Inc., Chi- cago, IL). Results Ninety-three families participated. Of 39 eligible physicians, 33 (13 in postgraduate year 2, 11 in postgraduate year 3, two fellows, and seven faculty) were recruited, 32 completed the study, and eight were interviewed. At baseline, almost all physicians reported that they discussed obesity prevention (93.8%), nutrition (87.9%), and exercise (97.0%); only 21.2% discussed portion size. More than half of physicians reported feeling somewhat to very comfortable (59.4%) and competent (62.6%). All physicians identified barriers, notably time (51.5%) and parent/child issues (54.7%). Figure 1. The Fitwits MD flashcards use simple visual representations with accompanying health terms. The cards use characters called the “Fitwits and Nitwits” to clarify body mass index charts, ask open-ended questions, and give self-management information. doi: 10.3122/jabfm.2011.06.100278 Fitwits MDTM: An Office-Based Tool and Games 769 o n 5 A p ril 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://w w w .ja b fm .o rg / J A m B o a rd F a m M e d : first p u b lish e d a s 1 0 .3 1 2 2 /ja b fm .2 0 1 1 .0 6 .1 0 0 2 7 8 o n 1 5 N o ve m b e r 2 0 1 1 . D o w n lo a d e d fro m http://www.jabfm.org/ After the intervention (Table 1), 40.7% of phy- sicians used Fitwits MD at half or more visits, whereas 21.9% did not use it. Physicians who used Fitwits MD reported increased comfort (96.2%), enhanced competence (96.3%), and fewer barriers (77.7%). The average perceived discussion time doubled from 3.6 minutes before the intervention to 7.0 minutes using Fitwits MD. Interviewed phy- sicians appreciated the nonjudgmental characters, visual cues, portion size demonstrations, bidirec- tional fun conversations, and the standardized in- tervention for all patients, not just obese children. Ninety-three comment cards indicated children’s excitement about the games and that Fitwits MD facilitated discussion about fast food and soda con- sumption, family meals, activity levels, and screen (TV, video and computer) time. Discussion Brief tools are needed to guide childhood obesity counseling.1,7 In this feasibility study, the Fitwits MD intervention improved residency-based physi- cians’ comfort and competence levels and reduced barriers. Visual literacy, simplified health terms, child-centered messages, and take-home games en- couraged physicians to invest in the health of pa- tients ages 9 to 12 years, regardless of BMI. Three built-in components emphasized important health education topics: BMI charts, the term “obesity” simply defined, and hand-based portion sizes.3– 6 Limitations included some differences in survey questions before and after the intervention, some bias from leading questions, sample size, lack of validity or reliability of measures, a control group, and data from experienced clinicians. Future re- search will address these limitations and assess health outcomes. We thank Lindsey Detwiler Barton, RD, Megan McQuaide Montag, RD, Stephen A. Wilson, MD, MPH, and design and additional physician participants for help with developing the Fitwits tool; Fitwits office champion and resident teams: Laura Macbeth MPH, CHES, Melissa Williams, Rosia L Williams, RN, Stacey L. Brown, MD, Jill Haltigan, MD, Kristen A. Scopaz, MD, and Michelle N. Stalter, DO. Contributions to data analysis were provided by Chrissy A. Lopez. Amy Haugh, MLS, and Jennifer L. Middleton, MD, MPH, reviewed the manuscript, and Paula Preisach helped with manuscript prepa- ration. References 1. Perrin EM, Flower KB, Garrett J, Ammerman AS. Preventing and treating obesity: pediatricians’ self-Ta bl e 1. R es ul ts of Po st in te rv en ti on Ph ys ic ia n Su rv ey Q ue st io ns fo r W el l Ch il d Vi si ts w it h 9- to 12 -Y ea r- O ld Ch il dr en (N � 32 ) Q ue st io ns R es po ns e C at eg or ie s A pp ro xi m at el y w ha t % of vi si ts di d yo u us e F it w it s? N on e � 10 % 11 % to 30 % 31 % to 50 % 51 % to 70 % � 71 % N um be r (% ) 7 (2 1. 9) 4 (1 2. 5) 4 (1 2. 5) 4 (1 2. 5) 10 (3 1. 3) 3 (9 .4 ) A ft er us in g F it w it s, ar e yo u m or e or le ss co m fo rt ab le di sc us si ng ob es it y pr ev en ti on ? N o ch an ge M uc h le ss /a lit tl e le ss co m fo rt ab le In th e m id dl e So m ew ha t m or e co m fo rt ab le M uc h m or e co m fo rt ab le N um be r (% ) 1 (3 .8 ) 0 0 13 (5 0. 0) 12 (4 6. 2) H as th e F it w it s of fi ce to ol im pr ov ed ho w co m pe te nt yo u fe el di sc us si ng nu tr it io n, ex er ci se , an d po rt io n he al th ed uc at io n? N o ch an ge M uc h le ss /a lit tl e le ss co m pe te nt In th e m id dl e So m ew ha t m or e co m pe te nt M uc h m or e co m pe te nt N um be r (% ) 0 1 (3 .7 ) 0 11 (4 0. 7) 15 (5 5. 6) W he n us in g F it w it s, ar e an y ba rr ie rs to di sc us si ng ob es it y pr ev en ti on , nu tr it io n, ex er ci se , an d po rt io ns w it h fa m ili es re du ce d? N o F ew ch an ge s In th e m id dl e So m e ch an ge s M an y ch an ge s N um be r (% ) 2 (7 .4 ) 4 (1 4. 8) 0 10 (3 7. 0) 11 (4 0. 7) T ot al s do no t ne ce ss ar ily eq ua l 32 be ca us e of m is si ng in fo rm at io n. P er ce nt ag es ar e ba se d on on ly th os e re sp on de nt s w ho pr ov id ed an an sw er . 770 JABFM November–December 2011 Vol. 24 No. 6 http://www.jabfm.org o n 5 A p ril 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://w w w .ja b fm .o rg / J A m B o a rd F a m M e d : first p u b lish e d a s 1 0 .3 1 2 2 /ja b fm .2 0 1 1 .0 6 .1 0 0 2 7 8 o n 1 5 N o ve m b e r 2 0 1 1 . D o w n lo a d e d fro m http://www.jabfm.org/ efficacy, barriers, resources, and advocacy. Ambul Pediatr 2005;5(3):150 – 6. 2. van Gerwen M, Franc C, Rosman S, Le Vaillant M, Pelletier-Fleury N. Primary care physicians’ knowl- edge, attitudes, beliefs and practices regarding child- hood obesity: a systematic review. Obes Rev 2009; 10:227–36. 3. Sesselberg TS, Klein JD, O’Connor KG, Johnson MS. Screening and counseling for childhood obesity: results from a national survey. J Am Board Fam Med 2010;23(3):334 – 42. 4. Ben-Joseph EP, Dowshen SA, Izenberg N. Do par- ents understand growth charts? A national, internet- based survey. Pediatrics 2009;124(4):1100 –9. 5. Barlow SE and the Expert Committee. Expert com- mittee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120(Suppl 4):S164 –92. 6. McGaffey A, Hughes K, Fidler SK, D’Amico FJ, Stalter MN. Can Elvis Pretzley and the Fitwits im- prove knowledge of obesity, nutrition, exercise, and portions in fifth graders? Int J Obes (Lond) 2010; 34(7):1134 – 42. 7. Woolford SJ, Clark SJ, Ahmed S, Davis MM. Feasibility and acceptability of a 1-page tool to help physicians assess and discuss obesity with parents of preschoolers. Clin Pediatr (Phila) 2009; 48(9):954 –9. doi: 10.3122/jabfm.2011.06.100278 Fitwits MDTM: An Office-Based Tool and Games 771 o n 5 A p ril 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://w w w .ja b fm .o rg / J A m B o a rd F a m M e d : first p u b lish e d a s 1 0 .3 1 2 2 /ja b fm .2 0 1 1 .0 6 .1 0 0 2 7 8 o n 1 5 N o ve m b e r 2 0 1 1 . D o w n lo a d e d fro m http://www.jabfm.org/