A Population Health Imperative: Tackling Childhood Obesity (All slides)
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Speaker presentation from U.S. News Healthcare of Tomorrow leadership summit, Nov. 17-19, 2019 in Washington, DC. Find out more about this forum at www.usnewshot.com.
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A Population Health Imperative: Tackling Childhood Obesity (All slides)
- 1. Dallas, Texas A Population Imperative: Tackling Childhood Obesity U.S. News & World Report “Healthcare of Tomorrow” summit November 18, 2019 Washington, DC
- 2. Dallas, Texas Panel Sarah E Barlow, MD, MPH (moderator) Professor of Pediatrics, UT Southwestern Medical Center, Children’s Health, Dallas TX Fatima Cody Stanford, MD, MPH, MPA Assistant Professor of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA Claudia Fox, MD, MPH Associate Professor of Pediatrics, University of Minnesota Medical School, Masonic Children’s Hospital, Minneapolis, MN Evan Nadler, MD Associate Professor of Surgery and Pediatrics, The George Washington University School of Medicine and Health Sciences, Children’s National Health System, Washington, DC Ihuoma Eneli, MD, MS Professor of Pediatrics, Ohio State University, Nationwide Children’s Hospital, Columbus, OH 2Privileged and Confidential
- 3. Dallas, Texas Childhood obesity prevalence increase 1976-2016 NHANES data Graphic from The State of Obesity RWJ 2018
- 4. Dallas, Texas U.S. Childhood Obesity Epidemic Obesity prevalence 2-19 years NHANES 2015-2016 Ogden 2017. NCHS data brief no 219. Hyattsville, MD Graphic from The State of Obesity RWJ 2018
- 5. Dallas, Texas The pediatric BMI charts are not big enough… Gulati AK Pediatrics 2012 Overweight Obesity Class 2 Obesity (>5%) Class 3 Obesity (~2%) Skinner Pediatrics 2016
- 6. Dallas, Texas Absolute numbers Total Population* Severe obesity (est 5%) 5-13 yo 36,000,000 1,800,000 14-17 yo 17,000,000 850,000 * 2010 US census data
- 7. Dallas, Texas Health risks increase with degree of obesity (8579 children ages 3 to 19 years from NHANES 1999-2012) Prevalenceofriskfactor Skinner 2015. New Engl J Med;373:1307
- 8. Dallas, Texas High healthcare costs now and in the future About half the costs are covered by public insurance Graphic from The State of Obesity RWJ 2018 Kim Value Health 2016 Finkelstein Health Affairs 2009 8Privileged and Confidential
- 9. Complexity of Obesity in Children and Adolescents FATIMA CODY STANFORD, MD, MPH, MPA, FAAP, FACP, FAHA, FTOS OBESITY MEDICINE & NUTRITION, MGH WEIGHT CENTER AMERICAN BOARD OF OBESITY MEDICINE DIPLOMATE
- 12. All Calories are NOT created EQUAL
- 13. Obesity: A Multi-factorial Disorder Genetics Environment Development Behavior
- 15. Central Nervous System regulates weight
- 16. Contributors/ Influencers to Obesity Biological/ Medical Food & Beverage Behavior/ Environment Maternal/ Developmental Social Psychological Economic Environmental Pressures on Physical Activity
- 17. Stage Treatment Strategy Location Stage 1 Prevention Plus Primary Care Office Stage 2 Structured Weight Management • Family Visits with Health Professional Trained in Weight Management •Monthly Visits- Individual or Group Primary Care Office with Support (RD involvement with advanced training ) Stage 3 Comprehensive, Multidisciplinary Intervention •Multidisciplinary Team with Childhood Obesity Experience •Weekly Visits- 8-12 weeks Pediatric Weight Management Center (MD, RD, behavioral counselor, and exercise specialist) Stage 4 Tertiary Care Intervention •Medications •Very Low Calorie Diets (VLCD) •Weight Loss Surgery Tertiary Care Center (MD, RD, behavioral counselor, and exercise specialist) A Staged Approach to Obesity Treatment
- 18. 67 pediatric weight management programs Children’s Hospital Association survey, 2013 18Privileged and Confidential Patients receiving services: 31% with class 1 obesity 58% with severe obesity Payor mixStaffing
- 19. Pharmacological Management of Children and Adolescents with Obesity Claudia Fox, MD, MPH Associate Professor of Pediatrics Diplomate, American Board of Obesity Medicine Co-Director, Center for Pediatric Obesity Medicine University of Minnesota
- 22. What if… • She’s 10 years old. • She weighs 210 lbs. • She has high blood pressure. • She has weight related liver disease. • She can’t fit in the desk at school. • She sits alone at lunch. • (eating her home packed turkey sandwich, carrots, and apple slices) • She’s your daughter.
- 27. FDA-Approved Anti-Obesity Medications Children • Orlistat (≥12 y.o.) Adults • Orlistat • Phentermine • Lorcaserin • Naltrexone+bupropion • Liraglutide • Phentermine+topiramate
- 28. FDA-Approved Anti-Obesity Medications Children • Orlistat (≥12 y.o.) Adults • Orlistat • Phentermine • Lorcaserin • Naltrexone+bupropion • Liraglutide • Phentermine+topiramate
- 29. FDA-Approved Anti-Obesity Medications Children • Orlistat (≥12 y.o.) Semaglutide Adults • Orlistat • Phentermine • Lorcaserin • Naltrexone+bupropion • Liraglutide • Phentermine+topiramate
- 30. Take home points • Obesity is a chronic disease with biological underpinnings • Intensity of obesity treatment must match severity of the disease • Medications can be effective for reducing obesity and obesity-related health problems • Few medications are FDA-approved • Research in this area is brisk
- 31. Surgical Weight Management For Children and Adolescents with Obesity Evan P. Nadler, MD Co-Director, Children's National Obesity Program Director, Children's National Adolescent Weight Loss Surgery Program enadler@childrensnational.org +1-202-476-5669
- 32. Background • Children and adolescents with severe obesity face a lifetime of associated morbidity, mortality, and reduced quality of life.
- 33. • Diet and Behavioral Modification • Pharmacotherapy • Child and Adolescent Weight-Loss Surgery Programs Solutions?
- 34. Bariatric Surgery at Children’s National Child/Family Community Pediatricians IDEAL Surgery Psychology
- 35. Demographics Total Case Number 349 (343 LSG, 2 LAGB, 4 re- LSG) Age at Surgery 17.0 ± 2.4 (range 4.5-25) Gender ~75% Female Race/Ethnicity ~58% AA: 18% H: 18% C: 6% other Length of Stay >95% 1 or 2 days Comorbidity: Obstructive sleep apnea Hypertension Polycystic Ovarian Disease Depression Diabetes NAFLD Musculoskeletal pain Percentage of Population ~60 ~20 ~15 ~15 ~15 ~10 ~10
- 36. Bariatric Surgery in Adolescents • Mean decrease in BMI of 12-15 kg/m2. • Significant improvement in hypertension, dyslipidemia, and type 2 diabetes • Improved neural/executive functioning • Improvement in psychosocial outcomes 1. Inge TH, Courcoulas AP, Jenkins TM, et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. N Engl J Med. 2016;374(2):113-123. 2. Pearce AL, Mackey E, Cherry JBC, et al. Effect of Adolescent Bariatric Surgery on the Brain and Cognition: A Pilot Study. Obesity (Silver Spring). 2017;25(11):1852-1860.
- 37. Barriers to Care • Education of PCPs and Patients – AAP Policy Statement – Driving force behind health inequity in the US. • Resources – Divisions of Obesity Medicine • Hospital Buy-in – USNWR rankings to include care for patients with obesity
- 38. Conclusions • Bariatric surgery is the treatment with the most success for child and adolescent severe obesity. • Surgery is not an “easy way out” but a valuable treatment for a serious illness. • There are ongoing significant barriers to care.
- 40. Leadership for Childhood Obesity: Healthcare & Population Health Ihuoma Eneli MD, MS, FAAP Professor of Pediatrics, The Ohio State University, College of Medicine Director, Center for Healthy Weight and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
- 41. What is population health for childhood obesity? Addressing ALL children 5.9% All children 74 million children Treatment Weight Loss Surgery Primary prevention ~1,200 Children MedicalTreatment/lifestyle Primary prevention ~22 million Children Primary prevention ~52 million Children
- 42. Improve care by addressing bias and stigma http://www.uconnruddcenter.org/
- 43. • Advocacy • Michigan’s law, known as the Elliot Larson’s Civil Rights Act • Anti –bullying- three state laws (Maine, New Hampshire, and NewYork)-Weight • Employer Health • Educate workforce- for employee health and for patient care • Use of People- First language. • Obesity is a condition- Children with obesity, not obese child • Empower the patients • Weave into existing initiatives Hospital-wide initiatives on bias and stigma http://www.uconnruddcenter.org American Academy of Pediatrics. www.aap.org
- 44. Primary Care:What is impact? High Return on Investment (ROI)- Broad Reach, Limited resources Ref Taveras et al. JAMA Pediatr. 2017 Aug 7; 171(8): e171325.
- 45. Population Health & Primary Care: What can we do? 1. Part of the hospital’s strategic plan & CHNA- Most important! 2. Support obesity programs • Provide targeted training for all health care providers • Support allied staff (multidisciplinary team) • Financial support 3. Provide resources • Patient incentives • Appropriate equipment & facilities 4. Build and support tertiary care programs Linkages to primary care and community, expertise High Return on Investment (ROI)- Broad Reach, Limited resources
- 46. What is population health? Defined by Kindig and Stoddart (2003) as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.
- 47. Population Health vs. Management • Disagreement in Definition • existing patients • general populations of neighborhoods surrounding the hospital • more expansive geographies. • Population Health- • “engaging in primary prevention and prevention programs in the community, with kids who hopefully never touch our hospital,” • Population management • Accountable Care Organizations • Care coordination/navigation • School clinics Skinner D et al. BMC Health Serv Res. 2018 Jun 26;18(1):494.
- 48. Population Health & Obesity
Editor's Notes
- Figure 1 (a) Homeostatic regulation; messengers from the digestive tract (ghrelin, PYY, CCK, leptin), from the pancreas (insulin) and from adipose tissue (leptin) directly converge upon the arcuate nucleus in the hypothalamus or they send messages via the intermediate of afferent neurons of the vagus nerve (which carry receptors for PYY, CKK, leptin and ghrelin). Collectively they provide a symbolic representation of the feeding status of the organism. These messages are then translated into either a food-seeking (orexic) or a fasting (anorexic) behaviour. We ignore the role of the spinal nerves in these webpages. (b) Anatomic location of the arcuate nucleus and the nucleus of the solitary tract (nucleus tractus solitarius or NTS). Images adapted from: Cellular warriors at the battle of the bulge. Science 2003;299:846-849
- Stage 2: Registered dietitian or physician/nurse practitioner with additional training, including assessment techniques, motivational interviewing/behavioral counseling (may need to provide specific information with environmental change and reward examples), parenting skills and managing family conflict, food planning (including energy density and macronutrient knowledge), physical activity counseling, and resources/referrals. Stage 3: Multidisciplinary team with expertise in childhood obesity, including behavioral counselor (eg, social worker, psychologist, trained nurse practitioner, or other mental health care provider), registered dietitian, and exercise specialist. Alternative could be dietitian and behavioral counselor based in primary care office, along with outside, structured, physical activity program (eg, team sports, YMCA, or Boys and Girls Club program). For areas without services, consider innovative programs (eg, telemedicine). Stage 4:
- Here discuss some of the process of how kids get referred and how they work with the team to evaluate if surgery is an appropriate treatment and move through the process.
- Because treatment and intervention development research is by its very nature preliminary and “developmental,” the methods used are often exploratory, qualitative, or a combination of qualitative and quantitative approaches. rising incidence among minority populations - particularly concerning when considered with the large body of evidence demonstrating significant health disparities based on race/ethnicity among both youth and adults with T1D, specifically for African-Americans Given lower research participation rates in minority communities, important to take steps to ensure program is accessible and content is relevant Developing culturally competent behavioral interventions that are flexible, accessible, and relevant to diverse individuals and families requires a rich understanding of both the chronic condition and the target population. Thus, while many of these factors, such as longstanding systemic bias, family structure, and environmental stressors, may not be directly addressed by a behavioral intervention, they help us to understand the social patterning of type 1 diabetes outcomes and are important considerations in the assessment of the intervention strategies that have been used to address this patterning.
- Because treatment and intervention development research is by its very nature preliminary and “developmental,” the methods used are often exploratory, qualitative, or a combination of qualitative and quantitative approaches. rising incidence among minority populations - particularly concerning when considered with the large body of evidence demonstrating significant health disparities based on race/ethnicity among both youth and adults with T1D, specifically for African-Americans Given lower research participation rates in minority communities, important to take steps to ensure program is accessible and content is relevant Developing culturally competent behavioral interventions that are flexible, accessible, and relevant to diverse individuals and families requires a rich understanding of both the chronic condition and the target population. Thus, while many of these factors, such as longstanding systemic bias, family structure, and environmental stressors, may not be directly addressed by a behavioral intervention, they help us to understand the social patterning of type 1 diabetes outcomes and are important considerations in the assessment of the intervention strategies that have been used to address this patterning.
- The Internal Revenue Service (IRS) mandate that all nonprofit hospitals conduct Community Health Needs Assessments (CHNAs) provides an opportunity address determinants of health and prevention.