Improving access and systems of care for evidence-based childhood obesity treatment: Conference key findings and next steps

Abstract

Objective: To improve systems of care to advance implementation of the U.S. Preventive Services Task Force recommendations for childhood obesity treatment (i.e., clinicians offer/refer children with obesity to intensive, multicomponent behavioral interventions of >25 h over 6 to 12 months to improve weight status) and to expand payment for these services.

Methods: In July 2015, 43 cross-sector stakeholders attended a conference supported by the Agency for Healthcare Research and Quality, American Academy of Pediatrics Institute for Healthy Childhood Weight, and The Obesity Society. Plenary sessions presenting scientific evidence and clinical and payment practices were interspersed with breakout sessions to identify consensus recommendations.

Results: Consensus recommendations for childhood obesity treatment included: family-based multicomponent behavioral therapy; integrated care model; and multidisciplinary care team. The use of evidence-based protocols, a well-trained healthcare team, medical oversight, and treatment at or above the minimum dose (e.g., >25 h) are critical components to ensure effective delivery of high-quality care and to achieve clinically meaningful weight loss. Approaches to secure reimbursement for evidence-based obesity treatment within payment models were recommended.

Conclusions: Continued cross-sector collaboration is crucial to ensure a unified approach to increase payment and access for childhood obesity treatment and to scale up training to ensure quality of care.

Figure 1. The patient and parent perspective

At 12 years old, Maria Caprigno* was told she would not live to see her 18^th birthday because of her weight. Maria’s story begins at 4 years old when she was told she had a “growth spurt” and was the size of a 7-year-old in her pediatrician’s office. This was the first notation in her medical record she was designated as “overweight.” Maria remembers feeling proud that day in her doctor’s office; at the time she did not understand “growth spurt” was the pediatrician’s positive spin on saying she was overweight. The figure below summarizes Maria’s childhood weight record graphed onto a BMI growth chart; all heights and weights were recorded at the pediatrician’s office. Maria recalled the advice from her pediatrician and office staff being “nice and well-meaning” but provided no real guidance for weight management. They would tell her to ride a bike, take a walk, and eat healthier, but Maria and her mother did not know how to implement that advice into their daily lives. At 4 years old, Maria and her mother started their pursuit of effective weight loss programs. During the next 7 years, Maria and her mother sought out treatment through four different hospital programs, two commercial programs, and one adult-centered gym, and all had limited results. All of Maria’s treatment was paid for out-of-pocket; none of the programs or interventions were reimbursable. The majority of programs she received were not evidence-based, and none were effective for Maria in maintaining weight loss long-term. Maria and her mother did complete one multicomponent, group- and family-based program for 12 weeks, which she and her mother found to be the most useful for making changes to their eating, exercise, and self-monitoring behaviors; however, they wished the program would have lasted longer. They participated in this program when Maria was 9 years old. As a 12-year-old, Maria suffered unbearable weight-based stigma. She was shamed by her school’s administration. After a difficult encounter with the school nurse, she went home crying and became inspired to find a bariatric surgeon. Within a short period of time, she was in touch with a bariatric surgeon who agreed to meet with her. Over the next two years, Maria continued her journey to leading a healthier life. She was followed closely by a medical center in Boston, MA but was unable to have a surgical intervention there. After insurance denied coverage of her surgical case because she was deemed a high risk, Maria appealed to her insurance company saying she was willing to be a “guinea pig” since the several programs she tried previously were unable to help her achieve successful weight loss. On February 9, 2010, at 14 years old, Maria weighed 443 pounds. Grateful that the insurance company had approved the bariatric surgery, Maria underwent a sleeve gastrectomy. Maria is now 21 years old and is excitedly preparing for graduation from college as a Communications major and hopes to continue as a strong patient advocate for other suffering with obesity and its related stigma. Her bariatric surgery was five years ago, and she has lost more than 140 pounds. Maria’s story illustrated the numerous barriers faced by pediatric patients with obesity in the healthcare system. Whereas effective behavioral interventions for childhood obesity exist, none of these were made available to Maria and her mother, or they did not last long enough create sustainable weight loss. Furthermore, even if they had been offered effective intervention, they would likely have had to pay for it out-of-pocket. Without effective interventions offered or provided when she was first identified with overweight at 4 years old, Maria continued to gain weight rapidly until bariatric surgery became her only option. She also experienced devastating bullying and stigma, which are both common psychosocial consequences in children with obesity. This story illustrates the necessity to provide evidence-based intervention to all children with obesity as early as possible to prevent additional weight gain and associated comorbidities and costs. * Note that the patient and parent gave permission to be identified. Source: Gulati AK, Kaplan DW, Daniels SR. Clinical tracking of severely obese children: A new growth chart. Pediatrics. 2012;130(6):1136–40. PubMed PMID: 23129082.