Primary care providers’ perspectives on initiating childhood obesity conversations: a qualitative study

Abstract

Background

Primary care physicians (PCPs) are in a critical position for identifying, preventing and treating childhood obesity. However, a one-size-fits-all approach does not exist for having conversations about weight with families. A better understanding of how PCPs can address paediatric patients’ weight concerns is needed in order to develop effective guidelines and trainings.

Objective

To describe PCPs preferences and behaviours regarding weight-related conversations with paediatric patients’ and their families.

Methods

Twenty PCPs affiliated with the University of Minnesota, USA, were recruited to participate in semi-structured interviews. Transcripts were analysed using inductive thematic analysis.

Results

PCP’s identified well-child visits as the most appropriate time for weight-related discussions with families. Physicians described what approaches/elements they perceived to work best during conversations: collaboration, empathy, health-focused and objective measures.

Conclusions

Overall, PCPs were more comfortable with weight-related discussions during annual well-child visits and rarely initiated them during an acute visit or the first encounter with a patient. Objective measures, such as growth charts, were often utilized to start discussions. Considering a large proportion of well-child visits are missed, alternative opportunities to have discussions about healthy lifestyle behaviours should be explored. The integral role PCPs play in paediatric obesity warrants further research.

Key Messages.

• Well-child visits are the preferred setting to discuss weight-related topics.

• Primary care providers use objective measures to prompt discussions about weight.

• Successful conversations about weight are collaborative and health-focused.

Introduction

Childhood obesity is a significant public health challenge in the USA, putting an estimated 18.5% of children at risk for poor health outcomes and obesity-related conditions during their youth and later in life (1–4). Interventions designed to treat childhood obesity have spanned the spectrum of methodologies and settings, with promising but limited success (5–7). While primary prevention of childhood obesity may be the most suggested approach, identifying and treating the many existing cases remains a priority (8). Popularized by a 2007 Expert Committee report (9), primary care physicians (PCPs) have a critical role in identifying, preventing and treating childhood obesity (10–13). Consistent check-ups, development of trust and long-term follow-ups allow PCPs to partner with families to screen early and often, and address weight management concerns. The US Preventive Services Task Force’s recommendation for addressing childhood obesity in the primary care setting is screening children 6 years and older (14,15). Annual screenings with a body mass index (BMI) calculation are recommended, preferably at well-child, health maintenance or equivalent appointments (9). Recent evidence suggests the majority of PCPs are adhering to the US Preventative Services Task Force screening guidelines, but there is a lack of follow-up in referrals and/or counselling (16).

In order to effectively improve PCPs childhood obesity-related practices, it is necessary to understand and address the barriers PCPs are facing. Guo et al. summarize PCPs barriers as time, self-efficacy, language, training and reimbursement (17). Language, and more generally communication, has been observed to be a critical component in weight management (18–20). However, there is not a one-size-fits-all approach for having conversations about weight with families and negative, unintended consequences may occur if the conversation is approached inappropriately (20). While guidelines suggest PCPs screen for and discuss childhood obesity early and often, the impact and best context remain unclear: should conversations occur at all well-child visits regardless of child weight status and/or comorbidities, concurrent with an associated diagnosis or when a particular BMI is reached (9,14,20,21). Moreover, there is no consensus on how to help PCPs navigate weight-related conversations with families (20).

Limited research has focused solely on PCPs and their unique barriers to initiating and conducting conversations about childhood obesity, making the development of specific recommendations difficult. Previous studies have largely focused on PCP’s perceptions and practices regarding the management of childhood obesity and identified communication skills and confidence to be key barriers (22–26). There is a clear need to characterize how and when PCPs are approaching childhood obesity discussions with families. The current qualitative study engaged PCPs in individual, semi-structured interviews to understand their preferences and behaviours regarding weight-related conversations: (i) when discussions are initiated; (ii) factors that promote or discourage initiation and (iii) how PCPs approach and facilitate conversations. Results of the current study will inform how PCPs initiate and navigate sensitive discussions with children and their families during busy, time-constrained appointments.

Objectives

To describe PCPs behaviours regarding weight-related conversations with paediatric patients (0–18 years of age) and their families.

Methods

Study design and population

Recruitment occurred via e-mails to lists of current and past University of Minnesota-affiliated physicians, and word-of-mouth, including discussion of the study in clinical settings and snowball recruitment. Eligible participants were licensed PCPs currently: (i) practising at least part time in an ambulatory setting; (ii) taking care of children and adolescents within their patient panel and (iii) trained in either family medicine or paediatrics. Physicians were excluded from participation if they were unlicensed, not active in an outpatient setting, not seeing patients under 18 years of age, or who were non-fluent in written and spoken English. Physicians with speciality training in paediatric obesity were also excluded, because the aim of the study was to understand how non-speciality PCPs approached conversations about diet and weight. Recruitment e-mails indicated the study goal was to learn more about how PCPs approach conversations about weight and diet with parents of paediatric patients. Sample extensiveness was determined to be sufficient after the recruitment of new participants offered few additional insights and theoretical saturation was reached.

Data collection

Researchers were trained in standardized interview protocols and conducted semi-structured interviews with PCPs using questions designed to (i) understand how PCPs approach and discuss childhood overweight/obesity during a standard primary care visit; and (ii) explore the factors that promote and discourage PCPs from engaging families in weight-related conversations. The study investigator (K.A.L.) ensured consistency between interviewers by providing detailed training to the research team and ensured consistency across interviews by reviewing transcripts (e.g. checking for adherence to the interview guide) as they were completed. Broad, open-ended questions along with permissive prompts were used to facilitate each semi-structured interview (Supplementary Materials 1). Prior to conducting interviews, the semi-structured interview guide was pilot tested with several family medicine residents to ensure that the questions were clear, generated in-depth discussion and were acceptable to participants; feedback from pilot testing was used to modify the wording, content and order of interview questions.

From May 2018 to July 2018, a total of 20 semi-structured interviews were conducted by each of the research team members, which consisted of one faculty researcher (KAL; n = 4 interviews) and three family medicine residents (n = 11, 3, 3 interviews respectively). Interviews were audio-recorded and lasted approximately 30 min. Interviews were conducted in-person, at various locations (e.g. private office, clinic conference room) or over the telephone. The University of Minnesota’s Institutional Review Board Human Subjects Committee reviewed all study protocols and determined that this project is not human subject research.

Data analysis

Interviews were transcribed verbatim and coded using an inductive thematic analysis approach using NVivo 11 software (NVivo 11, QSR International Pty Ltd, Burlington, MA) (27). Two team members (M.J.A.U. and K.A.L.) read through each interview in its entirety to obtain the full story from participants (28). Initial codes, key thoughts and concepts were established by reading through interviews line-by-line, followed by reducing broad categories into sub-categories and, in turn, refining major concepts into overarching themes and subthemes. Transcripts were double coded to improve the trustworthiness of the data and to reduce bias (29). Following the initial coding process, paper authors and research team members (M.J.A.U. and K.A.L.) met in person to discuss questions and discrepancies until 100% agreement was reached.

Results

Twenty physicians participated in the interviews, 19 trained in family medicine and 1 trained in paediatrics. Average years in practice ranged from 1 to 25, with a mean of 9.7, and estimated paediatric panel (proportion of all patients that are paediatric patients) ranged from 9% to 40%, with a mean of 22.5%. The majority of the interviews were conducted in-person, with the remaining conducted over the phone for participants who could not be scheduled in-person. There were no major differences between in-person interviews and phone interviews with regard to interview length or participant responses.

Interviews with PCPs revealed, from their perspective, the most appropriate time to initiate and facilitate weight-related discussions was during well-child visits. Physicians also identified factors they used to determine when to initiate a conversation: parental size, growth charts, and family background. Several factors prevented PCPs from initiating conversations about weight, such as the visit type/purpose, time constraints and if it was their first encounter with the paediatric patient. Lastly, PCPs described their approaches for initiating and facilitating weight-related conversations with paediatric patients and their parents, which included themes of collaboration, empathy, focusing on health and objective rationale.

Initiating conversations

The majority of PCPs (70%) identified well-child visits as the most appropriate time to initiate discussions about weight (Table 1). Physicians were most likely to address concerns about weight during well-child visits, in addition to feeling more comfortable bringing up the topic. The majority (90%) also stated their approach to, and topics of discussion, during weight-related conversations varied based upon the child’s age, primarily directing their attention and educational messages towards parents with toddlers and preschool-aged children (Table 2). Around 6 years of age PCPs indicated that they gradually started to include their paediatric patients into the conversation and by adolescence, PCPs focused their attention and educational messages towards their paediatric patients.

Table 1.

Summary of responses to question set 1: when do primary care physicians have weight-related discussions? (n = 20 primary care physicians, 2018)

Overarching theme	Sub-theme	Illustrative quotes
Type of visit	Well-child visits (n = 14; 70%)	In well-child checks, I certainly feel much more comfortable [bringing up the topic of weight]. It fits within what we’re already talking about, so the context makes it a lot easier there. I think it’s an expected and a really important part in well-child visits. (Interview 5)

Table 2.

Summary of responses to question set 3: what prompts primary care physicians to bring up and discuss weight with their paediatric patients and families? (n = 20 primary care physicians, 2018)

Overarching theme	Sub-theme	Illustrative quotes
Objective considerations	Growth charts—thresholds of concern (n = 10; 50%)	I pay closer attention if it’s greater than the 85th percentile. And certainly, the highest priority ones, and we see plenty of them, are the ones greater than the 99th percentile. (Interview 4)
	Parental size, genetic, constitutional expectations (n = 17; 85%)	Maybe I’m more concerned about a child whose parent is also morbidly obese [and] who’s showing some signs of obesity at a very early age. Maybe I might be more concerned about them as opposed to a child whose parent appears to be a normal BMI, and that might play into the way that I address it, talking about a healthy lifestyle and choices made at home and that sort of thing. (Interview 10)
	Presence of weight-related comorbidities (n = 8; 40%)	If somebody is coming in for something that may be weight-related, then I absolutely address it at that visit. For example, if somebody had a rash that I thought was acanthosis nigricans, possible diabetes or other skin infection related to obesity, somebody coming in for possible asthma or breathing difficulties, or whose BMI is elevated. (Interview 20)
	History of previous weight discussions (n = 3; 15%)	[If] I’ve seen in their past history that it’s been brought up at their last well visit, then I’ll kind of check in to see how they’re doing even in an acute visit. (Interview 4)
	Child’s age—topics of discussion change as children become older (n = 18; 90%)	Certainly, if a child is overweight [and] under the age of one, it’s more so talking about triggers for when they’re eating, volumes of food and then food choices. For a toddler, oftentimes we’re focused more on frequency of eating, choices of—I guess I find—saying it out loud, it sounds as though I kind of sort of am thinking about it in the same way, but for an infant, I guess it’s more so volume—parent decision too, parent choices of what a child is being fed. As time goes on and children are in that later toddler-preschool to early school years, I tend to talk more about a variety of food, the impact of pickiness on food choices, in addition to just the strict volume and frequency of eating. And then as time goes on into the teenage years or—I should say late elementary, middle school, high school, then I’m focused more on the child and talking to the child about choices of eating habits, whereas while I’m involving the parent in that conversation, I feel like I’m a little more child-focused. (Interview 20)
Subjective Considerations	Family background—desire to understand food and weight in the context of culture (n = 9; 45%)	Meal time looks very different depending on what your family is like and what your cultural background is. I have some patients who are immigrants and for whom like food, you know, has been scarce at some point in life and all those experiences change your approach to food. I think it makes me ask more questions because it makes me realize that I shouldn’t be making assumptions that someone thinks about food the same way I do. (Interview 4)
	Parental concerns (n = 5; 25%)	If parents have a concern about weight, then obviously I’m going to talk about it more. (Interview 3)

Objective considerations

When determining how and when to initiate weight-related conversations with their pediatric patients PCPs reported a variety of objective considerations: the majority (85%) indicated a mixture of parental size, genetics and weight-for-age/stature expectations (Table 2). Over half (55%) of respondents referred to and utilized growth charts as an objective tool to broach and facilitate weight discussions. More specifically, PCPs in this sample were most concerned and initiated weight-related discussions with their paediatric patients who were at or above the 80th percentile. Physicians (40%) indicated that the presence of weight-related comorbidities (e.g. acanthosis nigricans, hypertension, hyperlipidaemia) made it easier to introduce weight-related discussions during a patient visit. A few PCPs (15%) also used the history of previous weight discussions a way to revisit the topic.

Subjective considerations

Physicians identified subjective considerations when determining how and when to initiate weight-related conversations with their paediatric patients (Table 2). Some PCPs (25%) reported initiating weight-related discussions secondary to parental concerns raised about their child’s weight. Over half of PCPs (55%) considered their patients’ family background when initiating discussions around weight, and desired to understand the role that food and weight had within their patients’ cultures. For example, PCPs acknowledged the difficulties of not understanding the types of food regularly consumed by their patients, which made it difficult to provide concrete suggestions. However, this did not deter PCPs from initiating conversations about weight, but instead, they sought to understand their patients’ perception of food and meals.

Barriers to initiating conversations

While every PCP (n = 20) in the sample indicated they engaged in discussions about weight with their paediatric patients, multiple logistical factors (e.g. type of visit and time) influenced whether or not they would discuss weight during a particular visit (Table 3). The majority (70%) reported they were less likely to initiate and have weight discussions with their paediatric patients during an acute or non-well-child visit. For example, PCPs were less likely to discuss weight if a child presented with cold symptoms or an ear infection, despite being diagnosed with overweight or obesity. Physicians (70%) also indicated shying away from discussing weight due to time constraints, and were likely to delay discussions about weight for a future visit in order to stay on track with their schedule. Furthermore, due to competing visit priorities, PCPs (50%) found it difficult to allocate time to talk about weight. A few physicians (15%) also reported not discussing weight during the first encounter in order to build rapport with the families.

Table 3.

Summary of responses to question set 2: when do primary care physicians shy away from initiating weight-related discussions? (n = 20 primary care physicians, 2018)

Overarching theme	Sub-theme	Illustrative quotes
Type of visit	Acute or non-well-child visits (n = 14; 70%)	I’m less likely to bring up [their weight] if it’s not related to their complaint. So if you’re an overweight 14-year old in for a cold; how do I bring that cold back to being overweight? I can’t scientifically, at least not from what I know. (Interview 1)
	First encounter (n = 3; 15%)	I probably won’t bring it up if it’s a first encounter and a family I’ve never met before. In residency, I had some experiences where families were very offended about how I brought up weight and that’s kind of made me kind of shy with doing it on the first encounter, so I probably might not be consistent. (Interview 8)
	Time constraints (n = 9; 45%)	[If] they were squeezed in and I’ve got two other people waiting. I’m probably not going to bring it up. I would love to be able to say that I at least mention it and say, ‘Hey, can you come back and we can talk more about it?’ I can’t even tell you how often I do that. So, yes, there are times when I look and I say, oh, man, this kid’s in trouble, this is a problem, and it just doesn’t fit into the visit that time. (Interview 5)
Time	Competing visit priorities (n = 10; 50%)	Generally, there are many factors that come into play. If it’s an emergent issue, then you tend to address it [first], and then preventive issues tend to be further down the road. Preventive issues that are prescribed, like immunization, obviously come up quicker, but preventive issues that are more around general things that there are no very strict guidelines tend to fall back. So from a priority viewpoint, I think it doesn’t rise to the top as much as it should. (Interview 6)

Facilitating conversations

Physicians emphasized the importance of collaboration, empathy, focusing on health and using an objective approach with paediatric patients and their parents during weight-related discussions (Table 4). Many (65%) engaged in weight-related conversations by obtaining patient and parent perspective. More specifically, PCPs sought to understand if their paediatric patients and their parents were concerned about weight. They (45%) also routinely utilized goal setting as a method to navigate through weight-related conversations. Some PCPs (30%) reported that by capitalizing upon their patients’ previous successes, they had an easier time initiating and maintaining an open conversation about weight. With regards to empathy, around a third of physicians (35%) emphasized the importance of demonstrating care and compassion to help families to feel at ease during weight-related conversations and decrease resistance. A quarter (25%) also reported that asking permission to bring up and discuss weight during the visit worked well to broach the conversation.

Table 4.

Summary of responses to question set 4: what approaches work best to initiate weight-related conversations? (n = 20 primary care physicians, 2018)

Overarching theme	Sub-theme	Illustrative quotes
Collaboration	Obtain patient and parent perspective (n= 13; 65%)	[By] engaging the child in the conversation, getting them involved, [and] getting ideas from the kid. Kids are great at coming up with ideas of things that they can do or things that they can change. Oftentimes the kids that are in school, they’ve heard this stuff at school too, and so they’ll be able to say, ‘Oh, I shouldn’t drink Kool-Aid’. And it’s just like with adults. You hear one or two things and say, ‘Yeah, that’s a great one. Why don’t you work on that? Why don’t you work on not drinking Kool-Aid and drinking more water?’ (Interview 5)
	Goal setting (n = 9; 45%)	I’ll try and shift their focus from appearance or a weight number and use my smart goal, ‘So why don’t we set a smart goal around [being] healthy rather than less belly fat? Why don’t we have it be [where] she plays at the gym or outside’. [We] set a behavioural goal so that their goals become focused on something else. (Interview 15)
	Capitalize on previous success (n = 6; 30%)	I try and acknowledge any work that they’ve done to date. That’s big too. If they say, ‘Yeah, we kind of switched to putting dinner with vegetables every night’, and I see that the weight gain has decelerated a little bit, even if it’s still going up, I try and acknowledge that piece and give them credit for what they’re doing already. (Interview 15)
Health-focused approach	Frame discussions around health behaviours and lifestyle (n = 16; 80%)	Focusing on positive things [families] can do as opposed to negative things they can [avoid]. [For example], eating together as a family, focusing on how can you increase your fruits and vegetables, or how can you increase your activity, as opposed to how can you decrease calories. (Interview 2)
	Have conversations with patients and families early (n = 6; 30%)	I’ve actually found that parents are really receptive to when I bring up weight stuff, you know, and I’ll tell them, ‘I wish that my parents helped me out with this when I was younger’. And usually the parents are kind of in the same boat. (Interview 15)
Empathy	Demonstrate care and compassion (n = 7; 35%)	[My] overall answer is to be compassionate and take people where they’re at is helpful for me so that I don’t feel like I need to alter an approach. (Interview 9)
	Ask permission to bring up weight (n = 5; 25%)	I would say, ‘Do I have your permission to talk about strategies of diet and exercise which can help the child become healthier?’ And then if they would say yes, I would continue. If they would say no, I wouldn’t. (Interview 19)
Objectivity	Present and discuss growth charts (n = 16; 80%)	A lot of times with a visual representation, like showing growth charts, that’s commonly what I do, [and] talk about what the growth chart represents, what the average weight for a particular age is, and then compare that to where their child is. (Interview 19)
	Explain your rationale behind health-concern (n = 9; 45%)	If they don’t bring it up, I have to sell the idea first, sell the idea that we are concerned, and this is the reason why we are concerned. (Interview 6)

Many PCPs (80%) were intentional about their choice to avoid weight- and appearance-focused discussions, but instead, framed their discussions around health behaviours and lifestyle choices. For example, they started conversations by asking families to describe their typical day and emphasized the importance of incorporating healthy behaviours throughout the day. Nearly a third (30%) preferred to have weight-related conversations early: during and throughout the toddler and preschool age range.

Lastly, many PCPs (80%) utilized an objective approach by presenting and discussing growth charts, including a mixture of overall trends and indicating areas of concerns. Almost half (45%) focused on maintaining objectivity during weight-related conversations by explaining the rationale behind their concerns. For example, PCPs would support their concerns about the child’s weight by explaining the risk factors and comorbidities associated with overweight and obesity.

Discussion

The current research aimed to use qualitative interviews with physicians to understand how and when they initiate childhood obesity discussions with families. Overall, findings indicate that PCPs typically initiated, and were more comfortable with, weight-related discussions during annual well-child visits. Physicians rarely initiated weight-related conversations during an acute visit or the first encounter with a patient; these provider preferences were attributed to competing visit priorities (e.g. an acute illness or injury), time constraints (e.g. too many other things to discuss during the short visit), and lack of established rapport (e.g. first time meeting families). Familial factors, such as parent(s) size, influenced when PCPs brought up the topic of weight, and objective measures, such as growth charts, were often utilized to start the discussion. Physicians considered their conversations about weight to be most successful when they included components of collaboration, empathy, health-focused language and objective measures.

Current recommendations encourage PCPs to play a key role in paediatric patients’ weight management with counselling that begins early in life and occurs often thereafter (9,14,19–21). The present study found that PCPs perceived well-child visits to be the most appropriate time to discuss weight and they avoided bringing up weight during other visit types. Well-child visits are regarded as the ideal time for weight-related discussions to occur due to their consistent frequency and prevention-focused nature and given time constraints and competing priorities during other visit types, well-child visits may be the only time PCPs can feasibly bring up weight (9,19,21,30). Moreover, PCPs and parents consider well-child visits to be the appropriate time for both prevention-focused conversations and discussing concerns regarding children’s weight (18,20,31). While the ideal context when weight discussions should occur remains unclear, the focus on anticipatory guidance during well-child visits aligns with the need for physicians to be engaged in primary prevention of childhood obesity (10,13). Evaluating the integration of anticipatory guidance around healthy eating, physical activity and sedentary behaviour, in well-child visits may provide the necessary evidence to support consistent implementation by PCPs.

As PCPs identified in the present study, well-child visits are not immune to the clinic-related barriers of competing visit priorities and time constraints (32). Families face barriers to attending well-child visits and are estimated to miss between one-third to one-half, a proportion that is greater among under-resourced families (33). If PCPs reserve weight-related conversations for well-child visits, a population of children will be missed: families who miss well-child visits regularly, those who are uninsured or publicly insured, families who switch providers, or families who only seek help when acute issues arise. These barriers have been consistently observed in the primary care setting (17,19). Moreover, the present study’s findings reinforce the need to help PCPs understand that tabling weight-related discussions until well-child visits may lead them to potentially miss a whole population of children. Given the many underlying causes that result in missed appointments, or a lack of follow-up, solutions need to be multifaceted (33,34). Specifically, additional research is needed to understand ways to improve access to care, relationship building efforts, and non-well-child visit approaches.

While barriers exist, there is still a need for PCPs to facilitate weight management conversations in ways that are collaborative with the patient and their families (35,36). As PCPs in the present study reported, a collaborative approach fosters a positive relationship with patients and families and, in turn, better understand their individual preferences and needs (18,20,31,35,36). Moreover, in order to effectively collaborate in weight management physicians need to communicate appropriately (18–20,37). A recent systematic review suggests that weight neutral terms (e.g. ‘weight’ versus ‘obese’) are preferred by patients and families, but ultimately PCPs should determine individual preferences when initiating weight-related discussions (37). The present study revealed a majority of PCPs were intentional about avoiding weight talk and instead focused on behaviour talk. Specifically, PCPs brought up a child’s weight with respect to growth charts and proceeded to talk about health behaviour changes. While a health-focused approach to weight management may be preferred by PCPs, patients and parents, the effect on outcomes is still not fully understood (38,39). Additional research is needed to determine if PCPs should focus on health behaviours, and not weight loss, in order to achieve the desired outcome of decreasing childhood obesity rates.

The present study has several limitations, including a sample of self-selected participants, which could have resulted in PCPs with more experience, or interest in childhood obesity, more likely to participate. The initial population the sample was recruited from included past, or current, affiliates of the University of Minnesota, a predominately urban institution.

Therefore, participants’ perspectives may be more representative of urban primary care practices, and not generalizable to suburban or rural settings. Only non-speciality physicians trained in either family medicine or paediatrics were included in the study, limiting the ability to generalize these findings to PCPs with different levels of training, clinicians trained in other disciplines or specialists. The inclusion of only non-speciality PCPs did however provide the benefit of a variety of perspectives, experiences and methods regarding weight management conversations. Lastly, due to the nature of qualitative research, the findings are self-reported behaviours, and may not fully represent the actual practices within our study sample. Given the evidence gap that exists regarding PCPs and childhood obesity treatment and prevention, this study has identified opportunities for future interventions within the well-child visit setting.

Conclusion

The present study explored the timing and context in which PCPs working in the ambulatory care setting had weight-related discussions with their paediatric patients. The well-child visit was PCPs’ preferred setting for having conversations about weight, though time constraints and competing priorities often prevented PCPs from initiating these conversations. Considering a large proportion of well-child visits are missed, especially among under-resourced families, alternative opportunities to have discussions about healthy lifestyle behaviours should be explored. Moreover, while the efficacy of PCP-delivered weight conversations is unknown, the integral role PCPs play in paediatric health warrants further research: understanding the impact of consistent PCP weight counselling and how existing guidelines can be incorporated into paediatric primary care.

Declarations

Funding: This research was supported by grant funding from the Minnesota Association for Family Physicians (PI: Guo and Pavek). Further, Dr Loth’s time was supported by a grant number K23-HD090324-01A1 from the National Institute of Child Health and Human Development (PI: Katie Loth).

Ethical approval: The University of Minnesota’s Institutional Review Board Human Subjects Committee reviewed all study protocols and determined that this project is not human subject research.

Conflict of interest: The authors have no conflicts of interest to declare.

Data availability

The data described in the present manuscript is not available for external usage.