A Pragmatic Family Centered Approach to Childhood Obesity Treatment - PowerPoint PPT Presentation

A Pragmatic Family Centered Approach to Childhood Obesity Treatment Denise Wilfley (Angela Lima) Scott Rudolph University Professor of Psychiatry, Medicine, Pediatrics, and Psychological & Brain Sciences Washington University September 19, 2019 @WashU_CHWW

Denise Wilfley/Angela Lima Disclosures Rela latio ionship ip Company ny(ies es) Speakers Bureau Advisory Committee Board Membership Consultancy Sunovion, Weight Watchers Review Panel Honorarium Ownership Interests 2

Prevalence of Obesity in Children and Adolescents in the US by Racial/Ethnic Groups (2015 - 2016) 3

Childhood Obesity: Health Risks Now and Later 4

US Preventive Services Task Force Recommendations RECOMMENDATION: The USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status. (Grade B) . Recommended Interventions Height and weight, from which BMI Provide or refer patients to comprehensive is calculated, are routinely measured behavioral interventions (≥26 contact hours) over a during health maintenance visits. period of up to 12 months to improve weight status. UPSTF, 2010, JAMA; USPSTF, 2017, JAMA 5

Lack of Access to Care • Despite national recommendations (USPSTF), most children do not receive adequate care for obesity • Most health insurance coverage excludes coverage of services for weight and/or obesity treatment in children • Many successful programs have to rely on national research grant funding for support 6

AAP/AHRQ Improving Access and Systems of Care Conference: Overview and Consensus Treatment Barriers 1. Family model is critical 1. Lack of insurance coverage 2. Interventions need to be comprehensive & behavioral 2. Cost of treatment 3. ≥25 hours of contact with flexible 3. Lack of provider training scheduling 4. Comprehensive & Consistent Staff Facilitators Training 1. Stakeholder support for Reimbursement innovation 1. Tide is changing to provide coverage 2. Attitudes, beliefs, and knowledge for weight management to children of the intervention and families 2. Accountable Care Organizations (ACOs), Commercial & ERISA plans, and Medicaid are potential payers 7

Engineer the Environment to Support Health 8

Benefits of Family-Based Behavioral Treatment • Demonstrated long-term effectiveness for youth with obesity (first study published in 1980) • Concurrent treatment for parent with obesity • More cost effective than separate treatment of parent and child • Can be individualized and produces positive psychosocial benefits • Can be implemented with ages 2-18 years and in diverse settings like primary care • Family-based interventions can treat obesity and comorbidities in multiple family members, and prevent obesity in high-risk youth 9

Expanding the Reach of Family-Based Treatment NHLBI-funded Trial (UO1HL131552) • First large scale trial of FBT as compared to usual care in primary care settings • Over 450 families will participate from Buffalo NY, Columbus Ohio, Rochester NY & St. Louis MO • Evaluation of generalization of effects in family members & delayed discounting as a moderator PCORI-funded Trial (PCS-2017C2-7542) • Comparing American Medical Association enhanced standard of care (eSOC) vs. eSOC + FBT and treatment moderators (i.e., race, sex) • Over 1200 families will participate from Louisiana, Missouri & New York • Inclusion of multiple stakeholders (e.g., families, providers, payers) and process evaluations to assess RE-AIM domains 10

A Reimbursement Pathway and Preparing the Workforce in Missouri • Proposed MO HealthNet (Missouri Medicaid) obesity treatment benefit anticipated to be active in 2020. Reimbursement matches the USPSTF recommendations . • Pilot trainings to increase capacity for childhood obesity treatment among medical, behavioral health and registered dietician providers in Missouri • State-wide healthcare advisory group (e.g., academic centers, DHSS, MO Primary Care Association, pediatrics, nutrition and dietetics, psychology, telehealth CDC Webinar https://www.chronicdisease.org/page/EBPWMWebinars?&hhsearchterms=%22pediatric+and+weight+and+management%22 Proposed MO Medicaid Rules https://www.sos.mo.gov/CMSImages/AdRules/moreg/2018/v43n17Sept4/v43n17a.pdf

Conclusions • Obesity is a complex disease requiring a multi-sector approach • Early intervention of pediatric obesity is critical • Family-Based Treatment is a robust, evidence-based intervention and an expert committee convened by the AMA recommends a staged approach to childhood obesity treatment • Our work aims to equip families, providers, and payers with evidence on which clinical intervention is right for a family to help both children and parents lose weight in a healthy and sustainable manner 12

Relevant Citations • PCORI Project: Comparing Two Ways to Treat Childhood Obesity • AHRQ Conference • CSC Report: Childhood Obesity Priority Actions • CDC Webinar: Evidence-Based Pediatric Weight Management Programs • Proposed Missouri Medicaid Rules • American Psychological Association Guidelines for Obesity 13

Relevant Citations 1. Imperatore, G., Boyle, J. P., Thompson, T. J., Case, D., Dabelea, D., Hamman, R. F., Lawrence, J. M., Liese, A. D., Liu, L. L., Mayer-Davis, E. J., Rodriguez, B. L., Standiford, D., & , . (2012). Projections of Type 1 and Type 2 Diabetes Burden in the U.S. Population Aged <20 Years Through 2050. Diabetes Care, 35(12), 2515-2520. 2. Eisenberg M. E., Neumark-Sztainer D., Story M. (2003). Associations of weight-based teasing and emotional well-being among adolescents. Arch. Pediatr. Adolesc. Med. 157 733–738. 10.1001/archpedi.157.8.733 3. Hayden-Wade HA, Stein RI, Ghaderi A, Saelens BE, Zabinski MF, Wilfley DE. Prevalence, characteristics, and correlates of teasing experiences among overweight children vs. non-overweight peers. Obes Res . 2005;13(8):1381-1392. 4. Storch EA, Milsom VA, Debraganza N, Lewin AB, Geffken GR, Silverstein JH. Peer victimization, psychosocial adjustment, and physical activity in overweight and at-risk-for-overweight youth. J Pediatr Psychol . 2007;32(1):80-89. 5. Trasande L, Samprit C. The impact of obesity on health service utilization and costs in childhood. Obesity (Silver Spring) 2009;17:1749-1754 6. Visscher, P.M., Brown, M.A., McCarthy, M.I., and Yang, J.(2012). Five years of GWAS discovery. Am. J. Hum. Genet. 90, 7–24. 7. Zaitlen N, Kraft P, Patterson N, Pasaniuc B, Bhatia G, et al. (2013) Using Extended Genealogy to Estimate Components of Heritability for 23 Quantitative and Dichotomous Traits. PLOS Genetics 9(5): e1003520. 8. Glass T.A., McAtee M.J. Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Soc. Sci. Med. 2006;62:1650–1671. 9. Best J. R., Theim K. R., Gredysa D. M., Stein R. I., Welch R. R., Saelens B. E., et al. . (2012). Behavioral economic predictors of overweight children’s weight loss. J. Consult. Clin. Psychol. 80, 1086–1096. 10.1037/a0029827, PMID 14

Relevant Citations 10. Epstein LH, Raja S, Daniel TO, et al. The built environment moderates effects of family-based childhood obesity treatment over 2 years. Annals of behavioral medicine. 2012;44(2):248–258. 11. Theim K.R., Sinton M.M., Goldschmidt A.B., Van Buren D.J., Doyle A.C., Saelens B.E., Stein R.I., Epstein L.H., Wilfley D.E. Adherence to Behavioral Targets and Treatment Attendance during a Pediatric Weight Control Trial. Obesity. 2013;21:394–397. doi: 10.1002/oby.20281. 12. Goldschmidt AB, Wilfley DE, Paluch RA, Roemmich JN, Epstein LH. Indicated Prevention of Adult Obesity: How Much Weight Change Is Necessary for Normalization of Weight Status in Children? JAMA Pediatr. 2013;167(1):21–26. doi:10.1001/jamapediatrics.2013.416 13. Wilfley DE, Saelens BE, Stein RI, et al. Dose, content, and mediators of family-based treatment for childhood obesity: A multi-site randomized controlled trial. JAMA Pediatr. 2017; 14. US Preventive Services Task Force. Screening for Obesity in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(23):2417–2426. doi:10.1001/jama.2017.6803 15. Wilfley DE, Staiano AE, Altman M, Lindros J, Lima A, Hassink SG, Dietz WH, Cook S; Improving Access and Systems of Care for Evidence- Based Childhood Obesity Treatment Conference Workgroup. Improving access and systems of care for evidence-based childhood obesity treatment: conference key findings and next steps. Obesity (Silver Spring) . 2017; 25 (1):16–29 16. Gurka MJ, Filipp SL, DeBoer MD. Geographical variation in the prevalence of obesity, metabolic syndrome, and diabetes among US adults. Nutr Diabetes. 2018;8(1):14. doi:10.1038/s41387-018-0024-2 15