1. 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

2. Acknowledgements Colleagues Families Funders Others

3. Objectives To discuss recommended stages of obesity treatment To define EBMC treatment and its features To review rationale for Evidence-Based Multicomponent (EBMC) Treatment

4. 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

5. StageLocationProvidersFeatures OnePCP officePCPCollaborative goal-setting Visits every 2-3 months TwoPCP office+PCP, with help from RD and/or behavioral and or PA specialist Stage 1+ Monthly visits Self-monitoring ThreeUsually 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 FourPediatric tertiary careMultidisciplinary care team State 3+ Low calorie diet and/or medication and/or surgery Spear BA et al, Pediatrics 2007;120:S254-S288 Expert Committee Recommendations

6. 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

7. Treatment goals Spear BA et al, Pediatrics 2007;120:S254-S288 NICHQ Childhood Obesity Action Network, 2007 *patients with weight loss>2 lbs/wk should be monitored for causes of excessive weight loss BMI 85-94%ile No Risks BMI 85-94%ile With Risks BMI 95-98%ileBMI>=99%ile Age 2-5 years Maintain weight velocity Decrease weight velocity or weight maintenance Weight maintenance Gradual weight loss of up to 1 pound a month if BMI is very high (>21 or 22 kg/m2) Age 6-11 years Maintain weight 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 Maintain weight velocity. After linear growth is complete, maintain weight Decrease weight velocity or weight maintenance Weight loss not to exceed an average of 2 pounds per week*

8. Stages and ages BMI 85-94%ile No Risks BMI 85-94%ile With Risks BMI 95-98%ileBMI>=99%ile Age 2-5 years Prevention Counseling Initial: Stage 1 Highest: Stage 2 Initial: Stage 1 Highest: Stage 3 Initial: Stage 1 Highest: Stage 3 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

9. What is EBMC treatment? Evidence-based Multi (>1) component—behavior change, nutrition, physical activity

10. StageLocationProvidersFeatures OnePCP officePCPCollaborative goal-setting Visits every 2-3 months TwoPCP office+PCP, with help from RD and/or behavioral and or PA specialist Stage 1+ Monthly visits Self-monitoring ThreeUsually 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 FourPediatric tertiary careMultidisciplinary 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?

11. What is EBMC treatment? Focus areaTopicsProviders 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

12. What is EBMC treatment? Focus areaTopicsProviders 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

13. 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

14. 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

15. 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

16. 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 (23 rd 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

17. Adult diseases in childhood Lancet 11.21.14

18. Why EBMC Treatment? Background and Rationale Personal/family costsExamples Medical complicationsCardiovascular, 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 self- esteem and quality of life Academic potentialMore absent days, poorer academic performance, less postsecondary education completion (females) Earning potentialDecreased (females) Marriage ratesDecreased (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

19. Why EBMC Treatment? Background and Rationale Societal costsExamples 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 readinessTop reason for rejecting recruits Academic potentialMore absent days (for employees also), poorer academic performance, less postsecondary education completion (females) Earning potentialDecreased (females) Marder and Chang, Thomson Medstat Research Brief, 2005; Trasande & Chatterjee, 2009; Mission Readiness, 2010

20. 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

21. 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

22. 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

23. 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

24. Potential Savings for Missouri Robert Wood Johnson Foundation, 2012

25. 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

26. 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

27. Thank you!