Health Systems and Childhood Obesity:
Components of a Comprehensive
Response
Lisa Simpson, MB, BCh, MPH, FAAP
Professor & Director
Disclosures
• I have no financial relationships
p to
disclose.
• I will not be discussing investigational
drugs.
Outline
•
•
•
•
The Child Policy Research Center
Role of the health system in childhood obesity
Health system recommendations
Health system innovations
Child Policy Research Center
CPRC develops, translates and
communicates evidence to measurably
g and
improve child health and well-being
the quality of health care for children.
Our partners include community
community, local
local,
state and national policy makers, program
managers and advocates.
advocates We address
the most urgent challenges facing
children and families
families.
Center Themes & Activities
•Themes
Population Child Health




Infant Mortality
Obesity
Injury
Chronic Illness
Health insurance & access
Health system performance
quality
y
&q
Activities
• Research
– Quantitative, qualitative,
large datasets, surveys
– Policy analysis
• Translation/Communication
– Reports
– Policy brief series
– Expanded website
– Workshops,
Workshops audiocalls,
audiocalls
etc..
• Building the field
– Training
T i i
– Hosting rotations
Policy Publications
Outline
• The Child Policy Research Center
• Role of the health system in childhood obesity
The Chronic Care Model Provides a
Framework to Address Obesity
Environment
Health Care System
F il
Family
School
I f
Information
i Systems
S
Family/Patient
Self-Management
g
Worksite
Decision Support
Delivery System Design
Community
Self Management Support
“The normal physician treats the problem;
the good physician treats the person;
the best physician treats the community.”
Chinese proverb
p
*Adapted from the World Health Organization Care Model (http://www.who.int/chronic_conditions/framework/en/) and
Improving Chronic Illness Care (www.icic.org)
Scope of Child Health Policy:
National
• “Traditional” health policy
– Insurance coverage, access, quality, public health
• Welfare policy
• Education policy
– IEP’s, specialized services
• School policies
– School lunches, pouring contracts
• USDA policies
li i
– WIC, food stamps
• Juvenile Justice
• Others?
(1) Research and demonstration funding and priorities needed
to identify effective prevention and treatment approaches;
(2) training and competency of health care professionals in
preventing, identifying, and treating affected children & families;
(3) inclusion of a broad range of community-based
obesity-related
b it
l t d services
i
iin b
benefit
fit coverage;
(4) incentives for providers and health plans to address obesity;
(5) support of innovations, including quality improvement in
clinical
li i l settings,
tti
to
t accelerate
l t the
th mostt effective
ff ti and
d efficient
ffi i t
Strategies to deliver obesity-related services; and
(6) promoting the use of health information technology (including
electronic medical records with decision
decision-support
support systems and
obesity registries).
Barriers to Clinician Uptake
of Evidence
• Reported rates of BMI screening vary widely
– 2% to 60%
• Many (most?) providers still feel unprepared
– Sense of futility
– Unaware
U
off llatest
t t evidence
id
• Referral resources limited
• Payment varies widely
Reported Barriers (2004)
Mail survey of 287 pediatricians and FMDs
53% of FMDs and 43% of peds had BMI 25+
19% aware of national recommendations, only 3%
reported adherence to all.
Poor to fair perceived efficacy
FMD Ped
Personal ability to counsel
41% 23%
Efficacy of obesity counseling
59% 56%
Ambulatory management of childhood obesity.
Kalagotla et al. Obesity Res 2004; 2:275.
Obesity Coverage
• Employers
• Wellness incentives
• IBM
• Health Plans
• Benefit design
• Incentives – patient and provider
• Community benefit programs
• Partnerships - with states, community organizations
• States
• Medicaid and CHIP
• Public employees
• Insurance coverage mandates
Key Findings:
• Significant increase in obesity but not
overweight
g variation in p
prevalence across states
• Growing
• Significant disparities within and across states
• Independent effects of health behavior and
health care quality
g
access to p
parks
• Neighborhood
• State matters
• School outcomes
Bethell et al, Health Affairs, 2010
Bethell et al
• Prevalence:
– N
National
ti
l prevalence
l
off obesity
b it ((>= 95th percentile)
til ) among children
hild
age
10-17 increased significantly from 14.8% in 2003 to 16.4% in 2007
– Accounted for the entire increase in the combined prevalence of
overweight and obesity between 2003 and 2007 (30
(30.6%
6% to 31
31.6%).
6%)
• Growing variation
– 2003: 20.9% (Utah) to 39.5% (Washington, DC)
– 2007: 23.1% (Utah) to 44.4% (Mississippi)
• Disparities
– Significant increases in subgroups between 2003 and 2007 for:
• Publicly insured (39.6% to 43.2%)
• Poor families (39.8% to 44.8%)
• Hispanic vs non
non-Hispanic
Hispanic
Prevalence in the High and Low income groups
by Income Disparity Ratio Quartile, 2003
= low
= high
Average Low
Income
prevalence
Average High
Income
prevalence
Goal 2: Model and Support Healthy Living at all Levels
Strategy 1: Personal Role Models
St t
Strategy
2
2: Organizational
O
i ti
l Role
R l Models
M d l
Personal Role Models
• Several studies show that health professionals
professionals’
health habits affect their practice:
– Counsel more often (nutrition and exercise)
– In one study, pediatricians least likely to counsel
– Low
L
iimportance
t
ffor screening
i and
d counseling
li if
exercise <once/month (OR 3.4), unaware of own (OR
2.0)
2 0)
– Greater perceived difficulty of counseling for
overweight:
• OR 5.69 self
self--identified as thin; OR 3.84 selfself-identified as
overweight
Health System
• 580,000 establishments
– 77%
%p
practitioner offices
– 1% hospitals 35% employee
• 14 million
illi jjobs
b
• $3 million new wage/salary
g
y jjobs between
2006 and 2016
Organizational Role Models
•
•
•
•
Study of children
children’s
s hospitals in US & Canada
29 fast food franchises in 24 hospitals
Vending machines in all but 4 hospitals
What’s in the cafeteria (54% externally operated)?
–
–
–
–
–
–
99% regular soft drinks
92% chocolates / candy
91% potato chips
87% burgers and fries
82% meat pizza
34%
% lowlow-fat
f desserts
• As membership organizations
• As employers
– Influence with employees and dependent
– Influence
I fl
with
ith suppliers
li
– Control over benefit and coverage decisions
– Philanthropic resources
• Not live in glass houses!
Health Policy
Acosta, 2003
What do we need to move policy?
• Recognition that a problem exists
– Evidence, data, stories
We hear a lot about Obesity…
What do we need to move policy?
• Recognition that a problem exists
– Evidence, data, stories
• Strategies which address the problem
– Evidence, information
What do we need to move policy?
• Recognition that a problem exists
– Evidence, data, stories
• Strategies which address the problem
– Evidence, information
• Policy window of opportunity
–
–
–
–
–
–
Timing
Policy champion
Personal connections
Stories
Focusing event
Advocacy
Funded by RWJF
Led by NICHQ in
partnership
t
hi with
ith AAP &
the CMAF
www.nichq.org/advocacy
Q
Questions?