This document summarizes a panel discussion on tackling childhood obesity. The panelists were experts from major medical institutions across the US. They discussed trends showing rising rates of childhood obesity and the health risks that increase with severity of obesity. Treatment approaches discussed included lifestyle interventions, medications, and weight loss surgery. Barriers to care mentioned were lack of education and resources, as well as the need to address bias and stigma. The role of healthcare systems in population health approaches through primary care, advocacy, and supporting specialized obesity programs was also covered.
Tackling the Complex Challenges of Childhood Obesity
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
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
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
20.
21.
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.
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.
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.