Clinical Interventions and Policies for
Prevention & Management of
Childhood Obesity
Elsie M. Taveras, MD, MPH
Assistant Professor of Population Medicine and of
Pediatrics, Obesity Prevention Program, Harvard Medical
School and Harvard Pilgrim
g
Health Care Institute;;
Division of General Pediatrics, Children’s Hospital Boston
Academy Health Annual Meeting
J
June
29,
29 2010
Ove v ew
Overview
• Prevalence of the childhood obesity epidemic
– Early life risk factors
– Racial/ethnic disparities
• The roles of the health care system and pediatric
primary care in obesity prevention and management
• Comparative
p
effectiveness research (CER)
(
) on
childhood obesity prevention and management
– Evidence-informed policies and recommendations
• Accelerating the adoption of childhood obesity CER
evidence
– Role of Health Information Technology
High
g Prevalence of Childhood Obesityy in the US
P
Prevalence
l
off Childhood
Childh d Ob
Obesity
it (BMI ≥ 95th P
Percentile)
til )
Boys Aged 2-11 y
Girls Aged 2-11 y
30
30
2-5 years
25
25
Percen
ntage
6-11
6
11 years
20
20
15
15
10
10
5
5
0
Non Hispanic
Non-Hispanic
White
Non-Hispanic
Non
Hispanic
Black
Ogden et al., 2010
Hispanic
0
Non-Hispanic
Non
Hispanic
White
Non-Hispanic
Non
Hispanic
Black
Hispanic
The U.S. Childhood Obesity Epidemic
US DHHS, 2001; Hedley et al., 2004; Ogden et al., 2006, 2008
…and in Younger Children Too
Prevalence of Obesity in Children Age 2-5 years
16
Perce
entage
14
12
NHANES 20012002
Overall in 2007:
NHANES 20072008
• 10.4% of children
age 2-5 years were
obese
10
8
6
21 2% were
• 21.2%
overweight
4
2
0
Non-Hispanic White
Non-Hispanic Black
Hispanic
Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight
among US children and adolescents, 1999-2004. JAMA. 295:1549-55. 2010.
Prevalence of High Weight for Recumbent Length
Among US Children From Birth to 2 Years of Age
Age,
2007-2008
Ogden, C. L. et al. JAMA 2010;303:242-249.
Copyright restrictions may apply.
…higher
g
prevalence in minority
y children
Prevalence of Severe Obesity, BMI ≥ 35 kg/m2 or
120% off th
the age- and
d sex-specific
ifi 95th percentile
til
Severe Obesity, Girls Age 2-19
Severe Obesity, Boys Age 2-19
10
9
8
White
10
Black
White
9
Hispanics
Black
8
Hispanics
7
6.0
66
6.6
6
5
3.9
4
2.8
3
1
1.3
1.8
%
%
6
2
6.2
7
3.7
5
33
3.3
4
2.1
3
2.3
2.4
1.6
2
0.9
1
0
0.5
3.0
1.9
01
0.1
0
1976-1980
1988-1994
1999-2006
1976-1980
Wang, Gortmaker, Taveras, IJPO, 2010, in press.
1988-1994
1999-2006
Childhood obesity is of consequence…
Ebbeling CB, et al. Lancet. 2002;360:473-482.
Evidence-Based Targets of Behavioral
C
Counseling
li – Prenatal
P
t l to
t Early
E l Childhood
Childh d
• Gestational weight gain (Oken,
(Oken
Taveras et al. 2006)
• Maternal smoking during
pregnancy (Oken, Taveras et al. 2006)
• Rapid infant weight gain
et al. 2009)
(Taveras
• Breastfeeding promotion (Taveras
et al. 2005)
• Sleep duration and quality
(Taveras et al. 2008)
• Television viewing (Taveras et al.
2007) & TV sets in bedrooms
• Improved responsiveness to
infant hunger and satiety cues
(Hodges and Fisher, 2008)
• Parental feeding practices,
eating in the absence of
hunger (Taveras,
(Taveras 2006
2006, Fisher and Birch
Birch,
1998 & 2009)
• Portion sizes ((Fisher et al. 2008))
• Fast food intake (Taveras et al. 2006)
• Sugar-sweetened beverages
• Physical activity participation
• Racial/ethnic
differences exist in
almost all known, early
life risk factors for
childhood obesity
Taveras, et al. Pediatrics; 2010
Summary
• The childhood obesity epidemic spares no age
group, is of consequence, and disproportionately
affects racial/ethnic minority children
• Prevention must start early
– S
Search
h ffor modifiable
difi bl d
determinants
t
i
t att early
l stages
t
off h
human
development
• Prenatal
• Infancy
• Early childhood
– Examine earlyy origins
g
of racial/ethnic differences in risk factors
• Need for preventive interventions based on the
b t available
best
il bl evidence
id
Where do we start?
…and how does health care fit in?
Mezzo-level: Role of the Health Care System
y
• Support patient selfself
management
• Provide clinician training
on evidence-informed
practices for decision
pp
support
• Track clinician
performance on obesityrelated
l t d dimensions
di
i
off care
• Use effective clinical
information systems to
track patient progress
Chronic Care Model, Wagner et al.
• Provide adequate
reimbursement for obesityrelated services
High
g Five for Kids!
Improving Primary Care to Prevent
Childhood Obesity
Obesit
Joint project of DACP, Harvard School of Public Health,
Dana-Farber Cancer Institute
Funded by NIH (PI: Gillman)
High Five for Kids
S d Design
Study
i
•
Cluster RCT in 10 pediatric primary care
practices
–
–
•
Children age 2-6.9 years old at elevated risk
–
–
•
5 iintervention
t
ti sites
it
5 usual care
BMI >95th %ile or
85th-95th %ile if at least one parent overweight
12-month intensive intervention
–
Followed by 12
12-month
month maintenance
maintenance, follow-up
follow up
Motivational Interviewing
First Steps for Mommy & Me
Main
i Intervention
i Components
C
1 Pediatricians’ endorsement of mother-infant
1.
mother infant
behavior change using brief focused negotiation
2. Individualized coaching using motivational
interviewingg byy a studyy health educator
3. Matching parent counseling and educational
materials to child’s developmental stage
4 Focus
4.
F
on evidence-based
id
b d behaviors
b h i
5 Group meetings to reinforce content and promote
5.
peer support and social networking
Micro-level: Role of Pediatric Primaryy Care
• The primary care setting offers unique opportunities to
intervene for children at risk for obesity and its
complications.
complications
• Regular visits during childhood allow both detection of
elevated BMI levels and offer opportunities for
prevention and treatment.
• The continuity of the pediatrician/family relationship,
embodied
b di d in
i the
h concept off the
h “medical
“ di l home,”
h
” has
h
been associated with increased parental satisfaction,
particularly
i l l on measures off patient-doctor
i
d
communication.
Role of Pediatric Primary Care
• Institute of Medicine recommends
that child health professionals
routinely:
– Monitor and track BMI
g and
– Offer evidence-based counseling
guidance to improve nutrition, increase
physical activity, and decrease sedentary
b h i
behaviors
Preventing Childhood Obesity: Health in the Balance. Institute of Medicine
Committee on Prevention of Obesity in Children and Adolescents, 2005
Comparative Effectiveness Research
(CER)
• CER compares the
th risks
i k andd benefits
b fit off different
diff
t
interventions and strategies for preventing, diagnosing,
treating, and monitoring health conditions under real
world conditions.
• Dissemination of this evidence can help achieve
improved patient care by allowing individuals,
clinicians,, and policymakers
p
y
to make informed
decisions.
topic in part because of
• Obesity is a high priority CER topic,
the high prevalence among children, its associated comorbidities, and the need for testing of available
prevention
i andd treatment strategies.
i
United States Preventive Services Task
F
Force
(USPSTF)
• In February
b
2010, the
h USPSTF updated
d d their
h i
evidence-based recommendations on screening
and management of obesity in children.
• New recommendations:
d i
– sufficient evidence to recommend that clinicians
screen children ≥ 6 years of age for obesity using
BMI, and
– offer them comprehensive, intensive behavioral
interventions to promote improvement in weight
status.
t t
Systematic
y
Review for USPSTF
• Whitlock,
Whitlock et al.
al Pediatrics,
Pediatrics 2010
– Reviewed 15 good-quality weight management interventions
among children 4 to 18 years of age
– No published studies targeted children < 4 years
– Comprehensive, behavioral interventions of medium-high
intensity were the most behavioral approach for management
– Two medications (orlistat and sibutramine) combined with
behavioral interventions resulted in small or moderate BMI
reduction
d i in
i obese
b
adolescents
d l
on active
i medication
di i
– “Available research supports at least short-term benefits of
comprehensive
h i mediumdi
to high-intensity
hi h i
i behavioral
b h i l
interventions in obese children and adolescents.”
Evidence-Informed Recommendations on
Childh d Ob
Childhood
Obesity
it Management
M
t
1 Expert Committee Recommendations on the
1.
Assessment, Prevention, and Treatment of Child and
g and Obesity.
y
Adolescent Overweight
2. National Committee for Quality Assurance (NCQA)
measures on improving quality in childhood obesity
care.
3 White House Task Force Report on Childhood
3.
Obesity
• Recommendations from the American Academy of
Pediatrics
4 Coming Soon – Institute Of Medicine Report on
4.
Obesity Prevention Policies for Young Children
Expert Committee Recommendations
• In 2005,
2005 the AMA
AMA, HRSA
HRSA, and the CDC
CDC, convened an
expert committee to develop recommendations on the
assessment, prevention, and treatment of childhood
overweight
i ht andd obesity.
b it Pediatrics,
P di i December,
D
b 2007
• For all children 22-17
17 years of age, the recommendations
include:
– Assessment of BMI and specific
p
nutrition and physical
p y
activityy
counseling.
– Methods to screen obese children for current
medical co-morbidities.
co morbidities
– Propose 4 stages of care; the first is brief
counselingg that can be delivered in pediatric
p
primary care, and subsequent stages for
structured weight management.
National Committee for Quality
Assurance (NCQA) HEDIS Measures
• IIn 2009
2009, the
h NCQA released
l
d Health
H l h Plan
Pl andd Employer
E l
Data
D
and Information Set [HEDIS] measures related to childhood
obesity.
y
• The new measures assess how consistently physicians perform
BMI percentile assessments and document nutrition and
physical activity counseling among children.
• HEDIS is a tool used by more than 90% of U.S. health plans to
measure performance on important dimensions of care.
• The new HEDIS measures are expected to foster benchmarking and quality improvement in the area of childhood
obesity assessment and management.
White House Task Force
Report on Childhood Obesity
American Academy of Pediatrics
• AAP pledged in February 2010 to engage in a range of
efforts to achieve two primary goals:
– Calculate BMI for every child at every well-child visit
beginning at age 2, and provide information to parents about
how to help their child achieve a healthy weight.
weight
– Provide “prescriptions” for healthy active living, including
good nutrition and physical activity, at every well-child visit,
along with information for families about the impact of
healthy eating habits and regular physical activity on overall
health.
– www.aap.org/obesity/whitehouse
/ b it / hit h
Institute of Medicine Report
• IOM Committee on Childhood Obesity
Prevention Policies for Young
g Children
statement of task:
– Review factors related to overweight and obesity
in infants, toddlers, and preschool children (birth-5
years) and make recommendations on early
childhood obesity prevention policies.
• Final report in 2011
Accelerating the adoption of childhood
obesity
b it CER evidence
id
by
b clinicians
li i i
• Role
R l off Health
H l h Information
I f
i Technology
T h l
(HIT)
– Use of HIT, such as electronic medical records (EMRs), offers potential
to accelerate the adoption
p
of childhood obesity
y CER evidence.
– Innovative strategies that take advantage of this new technology will be
used to assess and improve quality of care
• In pediatric outpatient settings, EMR-based decision support has
already been shown to improve prescribing patterns, increase
immunization rates,
rates improve delivery of preventive asthma care,
care
and improve documentation of obesity counseling.
• More research needed on design features that may enhance
pediatrician perception of usability and efficiency
Accelerating the adoption of childhood
obesity
b it CER evidence
id
by
b parents
t
• HIT strategies
i may be
b especially
i ll effective
ff i if
augmented by outreach and support to patients and
families.
families
• A variety of patient-outreach
patient outreach strategies could be
effective in improving quality of care, but remain
g
understudied including:
– Direct-to-patient or parent communications e.g. mailings.
• In a school-based setting, DTP communications about children’s BMI
screening was
screening,
as an informative,
informati e motivational
moti ational tool for parents and
resulted in improvement in family diet and activity.
– Patient web-based portals to enhance physician-parent
communication.
Improving the Quality of Pediatric
Obesity Care through the use of
H lth Information
Health
I f
ti Technology
T h l
Elsie M.
M Taveras,
Ta eras MD,
MD MPH
Obesity Prevention Program, Harvard Medical School and
Harvard
d Pilgrim
il i Health
l h Care
C
American Diabetes Association Grant
Study Design
•
Conduct a cluster RCT in 14 pediatric
ppractices to examine the extent to which
direct-to-parent communications and
decision alerts to clinicians can increase BMI
screening, BP monitoring, obesity diagnosis,
provision
i i off counseling
li among all
ll children
hild
2-17 years of age
Overarching framework for improving
quality of pediatric obesity care:
The Chronic Care Model
HIT
interventions
Direct-toParent
communications?
Conclusions
Whatt are Promising
Wh
P
i i Clinical
Cli i l Strategies
St t i
for
o Childhood
C d ood Obes
Obesity
y Management?
a age e ?
1. Focus on evidence-informed targets &
recommendations
2. Start intervening early – early life risk factors and
racial/ethnic disparities call for an earlier focus
•
“Racial and ethnic differences in obesity may be partly
explained by differences in risk factors during the prenatal
pperiod and early
y life.” – White House,, 2010
3. Multi-level changes likely to be most effective for
sustainable changes in the health care system, e.g.
chronic care model
Whatt are Promising
Wh
P
i i Clinical
Cli i l Strategies
St t i
for
o Childhood
C d ood Obes
Obesity
y Management?
a age e ?
4. Use of behavior change approaches
grounded in theory, e.g. stages of change,
motivational interviewing
5. Health information technology (HIT) offers
potential
i l for
f accelerating
l i the
h adoption
d i off
childhood obesityy CER evidence