A Pragmatic Family Centered Approach to Childhood Obesity TreatmentDenise Wilfley (Angela Lima)Scott Rudolph University Professor of Psychiatry, Medicine,

Pediatrics, and Psychological & Brain Sciences

Washington University

September 19, 2019

@WashU_CHWW

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Denise Wilfley/Angela Lima

DisclosuresRelationship Company(ies)

Speakers Bureau

Advisory Committee

Board Membership

Consultancy Sunovion, Weight Watchers

Review Panel

Honorarium

Ownership Interests

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

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Childhood Obesity: Health Risks Now and Later

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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 InterventionsProvide or refer patients to comprehensive behavioral interventions (≥26 contact hours) over a period of up to 12 months to improve weight status.

Height and weight, from which BMI is calculated, are routinely measured during health maintenance visits.

UPSTF, 2010, JAMA; USPSTF, 2017, JAMA

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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

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AAP/AHRQ Improving Access and Systems of Care Conference: Overview and Consensus

Barriers1. Lack of insurance coverage2. Cost of treatment3. Lack of provider training

Facilitators1. Stakeholder support for

innovation 2. Attitudes, beliefs, and knowledge

of the intervention

Treatment1. Family model is critical2. Interventions need to be

comprehensive & behavioral3. ≥25 hours of contact with flexible

scheduling4. Comprehensive & Consistent Staff

TrainingReimbursement

1. Tide is changing to provide coverage for weight management to children and families

2. Accountable Care Organizations (ACOs), Commercial & ERISA plans, and Medicaid are potential payers

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Engineer the Environment to Support Health

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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

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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

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%22Proposed MO Medicaid Rules https://www.sos.mo.gov/CMSImages/AdRules/moreg/2018/v43n17Sept4/v43n17a.pdf

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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

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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

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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

Relevant Citations

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Relevant Citations10. 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

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Relevant Citations19. Quattrin T, Wilfley DE. The Promise and Opportunities for Screening and Treating Childhood Obesity: USPSTF Recommendation

Statement. JAMA Pediatr. 2017 Aug 1;171(8):733-735. doi: 10.1001/jamapediatrics.2017.1604. PubMed PMID: 28632843.20. Quattrin T, Cao Y, Paluch RA, Roemmich JN, Ecker MA, Epstein LH. Cost-effectiveness of Family-Based Obesity Treatment.

Pediatrics. 2017 Sep;140(3). pii: e20162755. doi: 10.1542/peds.2016-2755. PubMed PMID: 28842402; PubMed Central PMCID: PMC5574729.

21. Wilfley DE, Hayes JF, Balantekin KN, Van Buren DJ, Epstein LH. Behavioral interventions for obesity in children and adults: Evidence base, novel approaches, and translation into practice. Am Psychol. 2018 Nov;73(8):981-993. doi: 10.1037/amp0000293. PubMed PMID: 30394777; PubMed Central PMCID: PMC6220709.

22. Epstein LH, Paluch RA, Wrotniak BH, Daniel TO, Kilanowski C, Wilfley D, Finkelstein E. Cost-effectiveness of family-based group treatment for child and parental obesity. Child Obes. 2014 Apr;10(2):114-21. doi: 10.1089/chi.2013.0123. Epub 2014 Mar 21. PubMed PMID: 24655212.

23. Wilfley DE, Stein RI, Saelens BE, Mockus DS, Matt GE, Hayden-Wade HA, Welch RR, Schechtman KB, Thompson PA, Epstein LH. Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial. JAMA. 2007 Oct 10;298(14):1661-73. PubMed PMID: 17925518.

24. Epstein LH, Paluch RA, Roemmich JN, Beecher MD. Family-based obesity treatment, then and now: twenty-five years of pediatric obesity treatment. Health Psychol. 2007 Jul;26(4):381-91. PubMed PMID: 17605557; PubMed Central PMCID: PMC2387251.

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