Overview of Evidence-Based
Multicomponent Treatment
Sarah Hampl, MD
Center for Children’s Healthy Lifestyles & Nutrition
Division of General Academic Pediatrics
Children’s Mercy Hospitals and Clinics
April 21, 2015
Acknowledgements
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Colleagues
Families
Funders
Others
Objectives
•To discuss recommended stages of obesity treatment
•To define EBMC treatment and its features
•To review rationale for Evidence-Based Multicomponent
(EBMC) Treatment
Stages of obesity treatment
•2007 Expert Committee Recommendations on Assessment,
Prevention and Treatment of Child and Adolescent Overweight
and Obesity
•Stage 1: Prevention Plus
•Stage 2: Structured Weight Management
•Stage 3: Comprehensive Multidisciplinary Intervention
•Stage 4: Tertiary Care Intervention
Barlow SE et al. Pediatrics 2007; 120:S164-S192
Expert Committee Recommendations
Stage
Location
Providers
Features
One
PCP office
PCP
Collaborative goal-setting
Visits every 2-3 months
Two
PCP office+
PCP, with help from RD
and/or behavioral and or
PA specialist
Stage 1+
Monthly visits
Self-monitoring
Three
Usually pediatric
tertiary care of
university
Multidisciplinary care
team (e.g. behavioral
specialist, RD and exercise
specialist) w/monitoring
by PCP
Stage 2+
Periodic assessment of body
measurements, dietary intake,
physical activity
Individual and/or Group visits
Four
Pediatric tertiary care
Multidisciplinary care
team
State 3+
Low calorie diet and/or medication
and/or surgery
Spear BA et al, Pediatrics 2007;120:S254-S288
Starting and advancing treatment stages
•Treatment intensity depends on
•Age
•Degree of obesity
•Co-morbidities
•Motivation/readiness to change
•Distance to treatment
•Advancing to more intense intervention depends on
•Response to treatment
•Age
•Health risks
•Motivation
Spear BA et al, Pediatrics 2007;120:S254-S288
Treatment goals
Spear BA et al, Pediatrics 2007;120:S254-S288
NICHQ Childhood Obesity Action Network, 2007
Age 2-5
years
BMI 85-94%ile
No Risks
BMI 85-94%ile BMI 95-98%ile
With Risks
Maintain weight
velocity
Decrease weight
velocity or
weight
maintenance
Weight
maintenance
BMI>=99%ile
Gradual weight
loss of up to 1
pound a month if
BMI is very high
(>21 or 22 kg/m2)
Age 6-11 Maintain weight
years
velocity
Decrease weight
velocity or
weight
maintenance
Weight
maintenance or
gradual loss
(1 lb per month)
Weight loss not to
exceed an average
of 2 pounds per
week*
Age 12 –
18 years
Decrease weight
velocity or
weight
maintenance
Weight loss not
to exceed an
average of 2
pounds per
week*
Weight loss not to
exceed an average
of 2 pounds per
week*
Maintain weight
velocity. After
linear growth is
complete,
maintain weight
*patients with weight loss>2 lbs/wk should be monitored for causes of excessive weight loss
Stages and ages
BMI 85-94%ile
No Risks
BMI 85-94%ile
With Risks
BMI 95-98%ile
Age 2-5 Prevention
years
Counseling
Initial: Stage 1
Highest: Stage 2
Initial: Stage 1
Highest: Stage 3
Initial: Stage 1
Ages
6 – 11
years
Prevention
Counseling
Initial: Stage 1
Highest: Stage 2
Initial: Stage 1
Highest: Stage 3
Initial Stage: 1-3
Highest: Stage 3
Ages
12 – 18
years
Prevention
Counseling
Initial: Stage 1
Highest: Stage 3
Initial: Stage 1
Highest: Stage 4
Initial: Stage 1-3
Highest: Stage 4
NICHQ Childhood Obesity Action Network, 2007
BMI>=99%ile
Highest: Stage 3
What is EBMC treatment?
•Evidence-based
•Multi (>1) component—behavior change, nutrition, physical
activity
What is EBMC Treatment?
Stage
Location
Providers
Features
One
PCP office
PCP
Collaborative goal-setting
Visits every 2-3 months
Two
PCP office+
PCP, with help from RD
and/or behavioral and or
PA specialist
Stage 1+
Monthly visits
Self-monitoring
Three
Usually pediatric
tertiary care of
university
Multidisciplinary care
team (e.g. behavioral
specialist, RD and
exercise specialist)
w/monitoring by PCP
Stage 2+
Periodic assessment of body
measurements, dietary intake,
physical activity
Individual and/or Group visits
Four
Pediatric tertiary care
Multidisciplinary care
team
State 3+
Low calorie diet and/or medication
and/or surgery
Spear BA et al, Pediatrics 2007;120:S254-S288
What is EBMC treatment?
Focus area
Topics
Providers
Nutrition/Physical
Activity behavior
changes
1. Fruits and Vegetables
2. Sugar sweetened drinks
3. Eating behaviors
4. Planned negative energy balance
5. Structured behavioral modification
program
6. Involvement of primary caregivers
7.Training to improve home food/activity
environment
Multidisciplinary team with
expertise in childhood
obesity
1. Behavioral counselor,
(SW, psychologist, other
mental health care
provider, trained NP)
2. RD
3. Exercise specialist
Or PCP-based RD and
behavioral counselor with
outside structured activity
program
Consider telemedicine in
areas without service
Spear BA et al, Pediatrics 2007;120:S254-S288
What is EBMC treatment?
Focus area
Topics
Providers
Behavior change
techniques
1.Self-monitoring
2.Stimulus control
3.Eating management
4.Contingency management
5.Cognitive behavioral techniques
Licensed clinical
social worker
Psychologist
Trained nurse
practitioner
Spear BA et al, Pediatrics 2007;120:S254-S288
Where does the PCP fit in to EBMC
treatment?
•“…complexity of obesity also needs changes in health-care
delivery, including the engagement of interdisciplinary treatment
teams”.
•PCP refers to this program and remains involved to monitor
medical issues, maintain alliance with family for support
•PCP office houses other discipline(s) and treatment occurs onsite
or in partnership with other disciplines
Dietz WH et al, Lancet 2015;http://dx.doi.org/10.1016/S0140-6736(14)61748-7
Spear BA et al, Pediatrics 2007;120:S254-S288
What outcomes of EBMC treatment
should be tracked?
•Regularly scheduled evaluations of body measurements such as
BMI, BMI%ile, BMIz-score in addition to weight
•Regular assessments of dietary intake and physical activity
Spear BA et al, Pediatrics 2007;120:S254-S288
Where is EBMC treatment provided and
how long does it last?
•EBMC treatment is typically provided by a multidisciplinary
obesity care team and usually exceeds capacity of PCP office
alone
•These providers are most often found in pediatric tertiary care
institutions and university settings
•Length of treatment was studied by the US Preventive Services
Task Force (USPSTF)
•Comprehensive moderate- to high-intensity interventions were
most effective for children ages 6 and older with obesity and
there was no evidence of harm
•These are 26-75 contact hours in duration, over at least 6 months
Spear BA et al, Pediatrics 2007;120:S254-S288
Whitlock EP et al for USPSTF, Pediatrics 2010;125:e396-e418
Why EBMC Treatment?
Background and Rationale
•One in 3 or >23 million US children are overweight or obese
•Nearly 3 in 10 MO 10-17 year olds are overweight or obese (23rd
highest in US)
•Thirteen percent of MO 2-5 year olds in WIC are obese; even
more are overweight
•Preschoolers with obesity are five times more likely to be
overweight or obese as adults
Ogden et al, 2014; Natl Survey of Children’s Health 2011-12; PedNSS, 2011; Nader PR et al, 2006
Adult diseases in childhood
Lancet 11.21.14
Why EBMC Treatment?
Background and Rationale
Personal/family costs
Examples
Medical complications
Cardiovascular, endocrine, pulmonary,
musculoskeletal, GI, renal and others starting in
childhood and tracking into adulthood, higher
rates of early death (severe obesity)
Psychological
complications
Stigmatization, bullying, depression, low selfesteem and quality of life
Academic potential
More absent days, poorer academic performance,
less postsecondary education completion
(females)
Earning potential
Decreased (females)
Marriage rates
Decreased (females)
Krebs NF et al, 2007; Kitahara C et al, 2014; Dietz WH, 1998; Dreyer & Egan, 2008; Geier AB et al,
2007; Gable S et al, 2012; Gortmaker SL et al, 1993
Why EBMC Treatment?
Background and Rationale
Societal costs
Examples
Increased healthcare
utilization
3X higher healthcare costs (MCD>private
insurers) compared to healthy weight peers,
2-3X more likely to be hospitalized; have
higher outpatient and ED visits,
prescription drug expenditures
Military readiness
Top reason for rejecting recruits
Academic potential
More absent days (for employees also),
poorer academic performance, less
postsecondary education completion
(females)
Earning potential
Decreased (females)
Marder and Chang, Thomson Medstat Research Brief, 2005; Trasande & Chatterjee,
2009; Mission Readiness, 2010
Why EBMC Treatment?
Background and Rationale
•Cost impact of childhood obesity in US is $14 billion/year; in
adults is $168 billion/year
Brookings Institute 2012
Missouri Spending on Obesity
• In 2000, MO spent an estimated $1.6 billion in direct
medical costs for adults alone
• Missouri total healthcare costs related to obesity are
projected to increase to $12 billion annually by 2030
Finkelstein et al., 2004, Obesity Research; Robert Wood Johnson Foundation, 2012
Costs of childhood obesity
•Annually, the average total health expenses for a child treated for
obesity under Medicaid is $6,370 while the average health costs for
all Medicaid insured children is $2,446
•This represents a difference of $3,924 in spending
• Only 18% of children presenting to Children’s Mercy’s Weight
Management Clinic did not have a co-morbidity of their obesity
Marder and Chang, 2005, Thomson Medstat Research Brief
Example of downstream costs associated
with evaluation for co-morbidities
•14 yo boy with a BMI of 46 presents for initial evaluation
•History of snoring, difficulty awakening, poor school
performance, napping after school
•Referral to Sleep Clinic
•Overnight sleep study
•Diagnosis=Obstructive Sleep Apnea
•Treatment recommended=CPAP
•Tonsillectomy and adenoidectomy may also be needed
Potential Savings for Missouri
Robert Wood Johnson Foundation, 2012
Why EBMC Treatment?
Background and Rationale
•Pay now or pay later
•EBMC treatment of at least 26 contact hours is supported by
scientific literature
•EBMC treatment delivered in group format and including parent
and child together is potentially more cost-effective than
individual treatment
USPSTF, 2010; Epstein et al, 2014
Hayes et al, 2015
Summary
• Evidence supports provision of EBMC
treatment in children with obesity
• PCP screens for obesity, co-morbidities, and
manages or refers for co-morbidity care
• PCP refers to EBMC treatment team
• EBMC treatment includes behavior change
around nutrition, physical activity
• PCP and EBMC treatment team collaborate
to monitor child’s progress and health
Thank you!