The Latest Treatment
Advances in Childhood
Obesity
Denise E. Wilfley, Ph.D.
Scott Rudolph University Professor of Psychiatry,
Medicine, Pediatrics and Psychology
Washington University in St. Louis
April 21, 2015
Overview
 Highlight the impact of obesity on youth
 Discuss importance of early intervention
 Define the gold standard treatment for children with
obesity
 Propose ideas for how to implement treatment in
community settings
Childhood Obesity in Missouri
• 28% of children in Missouri (more
than 400,000) are overweight or
obese
Obesity Among Low-Income
Children Ages 2-4
• 12.9% of low-income 2-4 year olds
are obese
• Up to 40% of middle school
students in parts of MO—such as
Branson—are overweight or
obese†
National Center for Chronic Disease Prevention and Health Promotion, 2012; Pediatric Nutrition Surveillance System
†Altman et al., in process 2015
The Impact of Obesity and
Stigma on Children
Quality of life rated as low
as young cancer patients
on chemotherapy
Schwimmer et al., JAMA 2003; Williams et al., JAMA 2005
OBESITY IS FOUND TO GAIN ITS
HOLD IN EARLIEST YEARS
“For many obese adults, the die was cast by
the time they were 5 years old.”
70-80% will track obesity into adulthood
“Efforts must start much earlier and focus
more on the children at greatest risk.”
Early Identification and
Intervention is Crucial
 Prevents harmful effects
 Harnesses parental support
 Fosters healthy habits
 Small weight losses can make a big impact
 Age at the start of treatment has a strong impact on treatment
outcome
‒
‒
Treatment is more efficacious at a younger age
Adolescents have more difficulty losing clinically-significant amounts of
weight
Danielsson et al., Arch Pediatr Adolesc Med, 2012; Danielsson et al., Obes Facts, 2012;
Reinehr et al., Am J Clin Nutr, 2010; Reinehr et al., Obesity, 2009; Sabin et al., J Clin Eval Clin Prac, 2007
Providing Resources to Parents
• A grandmother, Diane, called into
KMOX—a St. Louis based radio
station—to find resources for her
granddaughter—who was told she
was obese by her pediatrician.
– Mother is distraught and does not
know where to turn or how to help.
– Access to effective care for children
with obesity is scarce. Pediatricians
could provide resources and serve as
gatekeepers to effective care.
Discussing Child Weight with Parents
• Explain growth charts
• Inform parent of potential health consequences
• Avoid “blame” language
• Use non-stigmatizing language that will motivate
‒ Recent data suggests perceived negative judgment from provider leads to
patient mistrust
• Emphasize lifestyle change, not number on
scale
• Discuss change in a family-context
• Keep the child in the room to facilitate
conversation between parent and child
Puhl et al., Pediatrics, 2011;
Wilfley, et al, Pediatric Clin North Am, 2011; Eneli et al., Clin Pediatrics, 2007; Gudzune, et al., Patient Education and Counseling, 2014
The Energy-Balance Equation:
It’s Not Enough
Energy Intake (Calories)
Running for 3.5 hours
Energy Output (Physical Activity)
Multiple Meta-Analyses Document
Significance of Lifestyle Interventions
Adding a family component stressing parental
A recent systematic review suggests even further that
involvement to behavioral lifestyle interventions
family based interventions including individual family
increases their effectiveness and parents should be
sessions achieve greater magnitude weight loss than
targeted along with children to achieve the greatest
group sessions alone for children with obesity.
reduction in child overweight
Young et al., Clin Psychol Rev; Altman et al. JCCAP, 2014;
Hayes et al., Curr Cardio Rep 2015; Wilfley et al., Health Psych, 2007; Sung-Chan, et al. Obes Rev, 2013; Ho et al., JAMA Pediatrics, 2013
Family-based Behavioral Intervention
 First line of treatment for children and adolescents
 Targets reduction in energy intake and increase in energy expenditure
in both youth and caregivers
 Recognizes that knowledge alone is not sufficient
 Focuses on successive changes using family support
 Core strategies include: self-monitoring, reinforcement, stimulus
control, goal setting, contingency management
 Shown to impact: weight status, psychosocial health, and health-
related parameters (e.g., blood pressure, cholesterol, insulin sensitivity)
 This treatment has shown to have long-sustained effects that improve
weight maintenance
Jelalian et al., J Pediatr, 2010; Kalarchian et al., Pediatrics, 2009;
Epstein et al., Childhood Obesity, 2014; McGovern et al., J Clin Endocrinol Metab, 2008; Altman et al., JCCAP, 2014; Ho et al., Pediatrics, 2013
The Ripple Effect
• FBT can impact not only the child
involved, but the participating
parent and even other siblings
within the household
• Providing treatment for one child
who is overweight/obese in the
family has the potential to impact
others inside and outside the
family (effect will vary based on
sex, age)
• FBT more cost-effective for weight
loss
Epstein et al., Childhood Obesity, 2014; Epstein et al., Obes Res, 2001; Golan et al., Am J Clin Nutr, 1998; Golan et al., Int J Obes Relat Metab Disord, 1998;
Wrotniak et al., Obes Res, 2005; Golan et al., 2006, 2009; Gorin et al., 2008.
Engineer the Environment
to Support Health
Parent and Peer Support Are Key
Call for Early Intervention
• Jazmyne and her mother enrolled in the TODAY trial for
management of Jazmyne’s Type 2 Diabetes :
“At 14, she started feeling really bad …
headaches, nauseated, fatigue […],” her mother
said. “When she went for her checkup before
school, the doctor was alarmed.”
We could prevent future medical costs by
providing targeted intervention in infancy,
Post-treatment: Jazmyne’s headaches got better
childhood,
andTogether,
adolescence.
and her
mood swings improved.
daughter and mother made significant lifestyle
changes.
Diagnosis of type 2 diabetes often brings emotional isolation, lifetime of medication,
hypertension, nephropathy, dyslipidemia, chronic inflammation, nonalcoholic fatty
liver disease
The St. Louis American, January 22, 2010; TODAY Study Group Diabetes Care, 2013; Ebbeling et al., Lancet 2002
Future Directions—The Medical Home
• Consists of a variety of specialists
housed within primary care practices to
provide coordinated care for the
patients
• Individuals prefer to first see their
primary care physician
‒ A gatekeeper for specialist
recommendations
‒ Medical home model can help improve
coordination of primary care services
• Demonstration project with Missouri
Department of Mental Health (DMH)
and the Missouri Coalition for
Community Behavioral Health Care
American Academy of Pediatrics. The Medical Home. Peds, 2004; Grumbach K, Selby JV et al., JAMA,1999
Call to Action
“Ensure that every child and family engages in healthy eating and weight
management practices.”
• Advocate for insurance coverage for treatment
‒ Add your voice to a cooperative effort for reimbursement
• Establishment of a certification system for training individuals to
deliver evidence-based care
• Explore and recommend local options for initiating and sustaining
healthy habits
• Integrate intervention across multiple levels of care
‒ Collaborative partnerships: “It takes a village…”
Wilfley et al., Pediatr Clin N Am, 2011
Work Together to Optimize Health for
Children, Families, and Communities