Evidence-based Childhood Obesity Treatment Services: Applying Recommendations from the AAP/AHRQ Obesity Treatment & Reimbursement Conference Webinar 1 of 2 January 2, 217
Acknowledgements The content of this webinar was developed from a July 215 small conference grant R13HS228161: Evidence-based childhood obesity treatment: Improving access and systems of care supported by the Agency for Healthcare Research and Quality with matching funds from the American Academy of Pediatrics Institute for Healthy Childhood Weight. The full summary of the conference is available: Obesity 217; 25(1): 16 29. doi:1.12/oby.217
Thank you to our supporters!
Housekeeping Before we begin, please note a few housekeeping details: Please use *6 to mute your phone; if you re using computer speakers, please mute them to avoid feedback. Please do not put yourself on hold, as we will be able to hear your hold music. Today s webinar will be recorded. The link to the recording will be shared ~1 week following today s event. Questions will be answered at the end of the webinar. All questions from the webinar, including those that were not answered due to time constraints, will be available in a summary document that will be posted with the recording.
Q & A During the Webinar Please enter your question in the chat box
Meet the Faculty Sandra G. Hassink, MD, FAAP Past-President, American Academy of Pediatrics Director, Institute for Healthy Childhood Weight, American Academy of Pediatrics Denise E. Wilfley, PhD Scott Rudolph University Professor of Psychiatry, Medicine, Pediatrics, and Psychological & Brain Sciences at Washington University in St. Louis Amanda E. Staiano, PhD Assistant Professor Director, Pediatric Obesity & Health Behavior Laboratory Pennington Biomedical Research Center
Disclosure Statement Disclosures Sandra Hassink declares no conflicts of interest. Amanda Staiano declares no conflicts of interest. Affiliation / Financial Interest Denise Wilfley, PhD, Consultant Denise Wilfley, PhD, Consultant Organization Shire Pharmaceuticals Sunovion Pharmaceuticals
Polling Question
Today s Agenda The Patient Perspective Sandra G. Hassink, M.D. Background and Significance Denise Wilfley, Ph.D. Conference Consensus Amanda Staiano, Ph.D. Question & Answer
Objectives Examine the US Preventive Services Task Force recommendations for childhood obesity treatment Including the current DRAFT USPSTF recommendations (anticipated release in 217) Identify consensus for behavioral treatment Review and discuss a model for effective childhood obesity treatment: family-based behavioral therapy Identify essential team members for the treatment of childhood obesity Discuss the format, setting, and training needs for the clinical management of obesity
The Patient Perspective AHRQ/AAP Conference Proceedings
Maria s Story Age 7 Age Age 14 168 lbs Told she was just going through a growth spurt by pediatrician Mother felt blamed and concerned about daughter s weight since she and her husband also struggle with their weight 398 lbs Suffered unbearable stigmatization at school Maria and her mother completed programs together that were geared either toward adults or children, except for one which included the entire family but was not of sufficient duration 443 lbs; BMI 63.6 Gastric bypass surgery was her only option after spending countless dollars outof-pocket on ineffective, insufficient, or non-evidence based programs Maria s story could have been much different. If she had access to an evidence-based treatment and was reimbursed for this care, she may have been prevented from severe obesity tracking into adolescence.
Maria s Growth Chart
Childhood Obesity is a Disease Putting One At Risk for 3+ Co-morbidities
AHRQ/AAP Conference Overview
AHRQ Conference Overview Pre-conference 43 Multi-sector stakeholders convene virtually Conference July 8-9, 215 in-person meeting Post-conference Synthesis with work group and on-going dissemination Survey Briefing Book Webinar
Pre-Conference Survey of Stakeholders
Survey on the Implementation of the USPSTF Recommendations for Childhood Obesity Treatment Facilitators Barriers
Survey on the Implementation of the USPSTF Recommendations for Childhood Obesity Treatment Barriers 1. Lack of insurance coverage 2. Cost of treatment 3. Lack of provider training Facilitators 1. Stakeholder support for innovation 2. Attitudes, beliefs, and knowledge of the intervention Wilfley et al., Obesity 217;25(1):16 29.
Background & Significance
U.S. Preventive Services Task Force Recommendations RECOMMENDATION: The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to intensive counseling and behavioral interventions to promote improvements in weight status (grade B). Recommended Interventions Provide or refer patients to comprehensive moderate- to highintensity programs (>25 contact hours) that include dietary, physical activity, and behavioral counseling components. Height and weight, from which BMI is calculated, are routinely measured during health maintenance visits. USPSTF, 21, Pediatrics.
The Systematic Review for USPSTF Adapted from Figure 3, Whitlock et al., 21, Pediatrics.
Mounting Evidence
Support for Higher Dose 2 Ho et al. (38 studies) Summarized the positive effects of comprehensive interventions on cardiometabolic outcomes as well as on weight outcomes in children Showed that weight loss was greater when the duration of treatment was longer than 6 months Ho et al., 2 Effectiveness of lifestyle interventions in child obesity: systematic review with meta-analysis. Pediatrics. 214 Janicke et al. (2 studies) Showed that comprehensive, family interventions have positive effects on child weight Looked at moderators: Dose (duration, number of sessions, time in treatment) was positively related to effect size Individual and in-person comprehensive family interventions were associated with larger effect sizes Janicke et al., 214. Systematic review and meta-analysis of comprehensive behavioral family lifestyle interventions addressing pediatric obesity. J Pediatr Psych
Support for Higher Dose 216 Mitchell et al. (18 studies) Showed that pediatric overweight/obesity interventions in primary care settings can be effective for BMI reduction Parents were targeted as change agents for the child s BMI reduction in all studies All studies incorporated behavioral components (e.g., specifying behaviors to change, reinforcing positive behaviors, setting goals, changing the environment, monitoring behaviors, promoting selfmanagement skills) Looked at moderators: Dose (number of treatment contacts, duration of treatment, and number of visits with a pediatrician) was a significant moderator of treatment effect Larger effect sizes were associated with more treatment contacts, longer treatment duration, and greater number of treatment sessions with a pediatrician Mitchell TB, Amaro CM, Steele RG. Pediatric Weight Management Interventions in Primary Care Settings: A Meta-Analysis. Health Psychol, 216.
Recommendations in Progress November 216 - DRAFT Higher intensity (>26 contact hours), multi-component behavioral interventions are effective Components across interventions included: sessions targeting both the parent and child (separately, together, or both); offered individual, family, and group sessions; encouraged the use of behavioral skills and included supervised physical activity sessions.
Recommendations in Progress November 216 - DRAFT Behavioral interventions with > 52 contact hours demonstrated greater weight loss and some improvements in cardiometabolic measures.
Draft Evidence Review: Obesity in Children and Adolescents: Screening. U.S. Preventive Services Task Force. November 216. https://www.uspreventiveservicestaskforce.org/page/document/draft-evidence-review156/obesity-in-children-and-adolescents-screening1 Children s Weight Change (, BMI, kg, %ile) in Behavioral Weight Loss Intervention Trials Study Est contact hrs thru m Age Range Tx Duration Followup, months Months since tx ended Outcome SMD in Change from BL (95% CI) Change in IG, Mean (SD) Change in CG, Mean (SD) N 52+ hrs Weigel, 28 114 7-15 Savoye, 27 82 8-16 Savoye, 214 78 1-16 6 Reinehr, 26 78 6-14 Reinehr, 29 78 1-16 Reinehr, 21 67 8-16 6 Subtotal (I-squared = 43.4%, p =.116). 26-51 hrs Vos, 211* 45 8-17 24 Kalarchian, 29 44 8- Kalavainen, 27* 44 6-9 6 Stark, 211 38 2-5 6 Croker, 2 38 8-6 DeBar, 2* 37-17 5 Sacher, 21 36 8-2.25 Nemet, 25* 33 6-16 3 Stark, 214 3 2-5 6 Subtotal (I-squared = 24.%, p =.23). 6-25 hrs Bryant, 211 24 8-16 Golley, 27 24 6-9 5 Hofsteenge, 214 17 11-18 6 Gerards, 215 17 4-8 3.5 Nowicka, 28 16-19 Boudreau, 213 11 9-6 Norman, 215 8 11-13 Subtotal (I-squared = 37.4%, p =.143). -5 hrs Taylor, 215 5 4-8 Kong, 213 4 NR Stettler, 214* 4 8- Saelens, 22* 4-16 Broccoli, 216 4 4-7 Sherwood, 215 3 2-4 Taveras, 211 3 2-6 Looney, 214 3 4-1 Resnicow, 215 3 2-8 Wake, 213 3 3-1 Van Grieken, 213 2 5 Taveras, 215 1 6- McCallum, 27 1 5-9 Wake, 29 1 5-1 Subtotal (I-squared =.%, p =.913). 24 9 4 3 6 6 24 3 3 6 6 6 6 6 6 9 7 6 6 24 24 15 NA 6 6 7 3.75 9 6 7 8.5 NA 3 9 9 BMI BMI BMI Weight BMI BMI %ile BMI BMI -1.15 (-1.68, -.63) -.34 (.48) -1.5 (-1.37, -.72) -1.7 (3.1) -.72 (-1.25, -.19) -.5 (.13) -.83 (-1.19, -.47) -.3 (.35) -1.27 (-1.47, -1.7) -.22 (.35) -1.5 (-2.5, -.96) -.26 (.22) -1.1 (-1.3, -.89) -.25 (-.73,.23) -.4 (1.29) -.23 (-.52,.5).5 (3) -.42 (-.89,.5) -.3 (.15) -1.68 (-2.85, -.52) -.37 (.41) -.6 (-.58,.45) -.11 (.16) -.18 (-.48,.) -.15 (.41) -.49 (-.94, -.5) -.3 (.51) -.45 (-1.7,.18) -1.6 (4.3) -.97 (-1.84, -.1) -.59 (.75) -.34 (-.52, -.16).23 (-.24,.7).3 (.24) -.26 (-.76,.24) -.24 (.43) -.28 (-.68,.) -. (.46).49 (.,.98).5 (.26) -.31 (-.79,.16) -.6 (.46).17 (-.66, 1.) -.3 (.14). (-.38,.38) -.1 (.36) -.2 (-.25,.21) -.23 (-.53,.6) -.19 (.52) -.19 (-1.8,.69) 1.7 (4) -.34 (-.95,.27) -.6 (.5) -.56 (-1.22,.1) -.5 (.22) -.3 (-.51, -.1) -. (.38) -.2 (-.55,.51) -.2 (.37) -.13 (-.47,.21).3 (1.4) -.16 (-1.18,.85) -.16 (.48) -.21 (-.49,.7) -4.9 (15.2) -.23 (-.61,.16) -.2 (.5) -.4 (-.27,.18) 1.4 (1.5) -.16 (-.52,.21) -.9 (.33) -.3 (-.36,.29) (.61) -.4 (-.29,.21).6 (2.6) -.17 (-.25, -.8).26 (.57) 1.6 (3.2).4 (.) (.41).15 (.17).5 (.19) -.1 (1.) 1.1 (2.2) -.2 (.3).4 (.49) -.1 (.16) -.8 (.36) -.1 (.65).6 (5.5) -.3 (.36) -.3 (.27) -.13 (.4).2 (.53) -.8 (.27).9 (.53) -.5 (.8) -.1 (.44) -.8 (.43) 2.5 (4.3).1 (.41).6 (.17) -.1 (.35) -.1 (.54).5 (1.4) -.7 (.61) -1.8 (13.8) -.1 (.36) 1.4 (1.7) -.4 (.32).2 (.55).7 (2.2) 66 174 58 211 474 66 67 192 7 16 58 173 82 4 23 7 62 97 67 88 23 16 181 51 7 37 371 55 445 15 3 15 57 335 146 242-2.5 1 Favors IG Favors CG *Study-reported repeated measures or adjusted analysis demonstrated a statistically significant effect
Necessary Weight Change for Normalization of Weight Status in Children GIRLS BOYS Age 9th 95th 97th 8-9 y.o. 5.38 -.9-4.72 9-1 y.o. 6.59 -.35-6.35 1-11 y.o. 6.6-2.23-9.44 11- y.o. 7.8-2.69-11.13 Age 9th 95th 97th 8-9 y.o. 7.1 1.4-4.1 9-1 y.o. 7.41 -.11-6.39 1-11 y.o. 7.87-1.15-8.66 11- y.o. 7.28-3.37 -.24-13 y.o. 5.84-6.42-16.64-13 y.o. 8.6-2.54 -.1 Goldschmidt, Wilfley, Paluch, Roemmich, Epstein, 213, JAMA Peds.
Stronger Effects with Higher Treatment Dose Change in BMI z Score Reductions in Percent Overweight Wilfley et al., in prep, Dose, content, and mediators of family-based treatment for childhood obesity: A multi-site randomized controlled trial Wilfley et al., 27, JAMA; Wilfley et al., in prep, Dose, content, and mediators of family-based treatment for childhood obesity: A multi-site randomized controlled trial
Stronger Effects with Higher Treatment Dose Proportion of Children Achieving a Reduction of %OW 9 units 1.9.8.7.6.5.4.3.2.1 * SFM + High SFM + Low Control ** SFM high SFM low Health Ed Abbreviations: % OW = Percent overweight. SFM + = Enhanced social facilitation maintenance. *p=.35; **p<.1 Wilfley et al., in prep, Dose, content, and mediators of family-based treatment for childhood obesity: A multi-site randomized controlled trial
Stronger Effects with Treating the Parent & Child 25 Change in %age overweight 2 15 1 5-5 -1-15 Parent plus child Child alone Non-specific control -2-25 - 24 36 48 6 72 84 96 18 132 Months Epstein et al., 1994, Health Psychology.
Bridging the Gap Between Evidence and Clinical Practice
Conference Consensus
Key Consensus Recommendations 1. Family treatment model is critical 2. Interventions need to be comprehensive and behavioral 3. Treatment should consist of >25 hours of contact with flexibility to adjust intensity of contact based on individual family needs 4. Comprehensive and consistent training is needed for staff teams delivering obesity treatment Wilfley et al., Obesity 217;25(1):16 29.
Consensus 1: Family Treatment Model First line of treatment for children and adolescents Targets reduction in energy intake and increase in energy expenditure in both youth and caregivers Core strategies: self-monitoring, reinforcement for goal achievement, and stimulus control Epstein et al., 199, JAMA; Epstein et al., 214, Childhood Obesity; Epstein et al., 27, Health Psychology; Best et al., 215, Health Psychology; Jelalian et al., 21, Pediatrics; Gunnarsdottir et al., 214, Laeknabladid.
Benefits of Family-based Behavioral Weight Loss Demonstrated short- and long-term effectiveness for youth with obesity Impacts weight, psychosocial health, physical health (e.g., blood pressure, cholesterol, insulin sensitivity), and energy-balance behaviors Provides concurrent treatment for parents with obesity and can generalize to other family members More cost effective than separate treatment of obesity in the parent and child Epstein et al., 199, JAMA; Epstein et al., 214, Childhood Obesity; Epstein et al., 27, Health Psychology; Best et al., 215, Health Psychology; Jelalian et al., 21, Pediatrics; Gunnarsdottir et al., 214, Laeknabladid.
Consensus 2: Building a Comprehensive Team Team Member Pediatrician or primary care provider Behavioral interventionist Subspecialist Care Coordinator Suggested Types of Providers Physician Nurse Practitioner Physician Assistant Behavioral/mental health specialist (e.g. psychologist, social worker, master s level counselor) Registered dietitian Exercise professional Health coaches/educators Medical Subspecialist Mental Health Specialist Exercise Physiologist Registered Dietitian Interventionist Navigator Case worker Registered nurse Wilfley et al., Obesity 217;25(1):16 29.
Consensus 3: Intensity 25 hours of contact with flexibility to adjust based on individual family needs Setting: Primary care medical home Tertiary care center Community setting (medical neighborhood) Format: Individual family or mixed-format approaches Wilfley et al., Obesity 217;25(1):16 29.
Consensus 3: Intensity 25 hours of contact with flexibility to adjust based on individual family needs Primary Indicator: Stabilize/reduce relative weight Secondary, Patient-Centered Indicators: Psychosocial (e.g., quality of life, body image) Biomedical outcomes (e.g., progression of medical comorbidities) Patient engagement (e.g., satisfaction) Behavior Change (e.g., dietary and physical activity goal attainment) Parent Change (e.g., weight, psychosocial, biomedical) Evaluate, collect and share outcomes with patients
Consensus 4: Comprehensive and Consistent Training Training specialized based on role Cultural and developmental competencies Standardized training, certification, and monitoring system Ongoing consultation and coaching from experts
For Future Consideration Training needs to be scaled up and widely available Regions will function according to priority and capacity Political landscape is ever-changing Reimbursement pathways are just beginning Join us on February 16 @ noon CT for Webinar 2
Questions