Overview of Evidence-Based Multicomponent Treatment Sarah Hampl, MD Center for Children’s Healthy...

Overview of Evidence-Based Multicomponent Treatment

Sarah Hampl, MDCenter for Children’s Healthy Lifestyles & Nutrition

Division of General Academic PediatricsChildren’s Mercy Hospitals and Clinics

April 21, 2015

Acknowledgements

• Colleagues

• Families

• Funders

• Others

Objectives

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

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

Stage Location Providers Features

One PCP office PCP Collaborative goal-setting Visits every 2-3 months

Two PCP office+ PCP, with help from RD and/or behavioral and or PA specialist

Stage 1+Monthly visitsSelf-monitoring

Three Usually 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 activityIndividual and/or Group visits

Four Pediatric tertiary care Multidisciplinary 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

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


Treatment goalsSpear 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%ileNo Risks

BMI 85-94%ileWith Risks

BMI 95-98%ile BMI>=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


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




Stages and ages

BMI 85-94%ileNo Risks

BMI 85-94%ileWith Risks

BMI 95-98%ile BMI>=99%ile

Age 2-5 years

Prevention Counseling

Initial: Stage 1Highest: Stage 2



Ages 6 – 11 years




Initial Stage: 1-3Highest: Stage 3

Ages 12 – 18 years




Initial: Stage 1-3Highest: Stage 4

NICHQ Childhood Obesity Action Network, 2007

What is EBMC treatment?

•Evidence-based•Multi (>1) component—behavior change, nutrition, physical activity

Stage Location Providers Features

One PCP office PCP Collaborative goal-setting Visits every 2-3 months

Two PCP office+ PCP, with help from RD and/or behavioral and or PA specialist

Stage 1+Monthly visitsSelf-monitoring

Three Usually 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 activityIndividual and/or Group visits

Four Pediatric tertiary care Multidisciplinary care team

State 3+ Low calorie diet and/or medication and/or surgery


What is EBMC Treatment?


Focus area Topics Providers

Nutrition/Physical Activity behavior changes

1. Fruits and Vegetables2. Sugar sweetened drinks3. Eating behaviors 4. Planned negative energy balance5. Structured behavioral modification program6. Involvement of primary caregivers7.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.RD3.Exercise specialist Or PCP-based RD and behavioral counselor with outside structured activity program

Consider telemedicine in areas without service



Focus area Topics Providers

Behavior change techniques

1.Self-monitoring2.Stimulus control3.Eating management4.Contingency management5.Cognitive behavioral techniques

Licensed clinical social workerPsychologistTrained nurse practitioner


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)61748-7Spear BA et al, Pediatrics 2007;120:S254-S288

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


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

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 (23rd 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

Adult diseases in childhood

Lancet 11.21.14


Personal/family costs Examples

Medical complications Cardiovascular, 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 potential More absent days, poorer academic performance, less postsecondary education completion (females)

Earning potential Decreased (females)

Marriage rates Decreased (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


Societal costs Examples

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 readiness Top reason for rejecting recruits

Academic potential More absent days (for employees also), poorer academic performance, less postsecondary education completion (females)

Earning potential Decreased (females)

Marder and Chang, Thomson Medstat Research Brief, 2005; Trasande & Chatterjee, 2009; Mission Readiness, 2010


•Cost impact of childhood obesity in US is $14 billion/year; in adults is $168 billion/year

Brookings Institute 2012

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

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

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

Potential Savings for Missouri

Robert Wood Johnson Foundation, 2012


•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, 2014Hayes et al, 2015

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

Thank you!

Overview of Evidence-Based Multicomponent Treatment Sarah Hampl, MD Center for Children’s Healthy...

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