Leveraging Public Health Infrastructure to Confront Childhood Obesityaltarum.org/sites/default/files/uploaded-publication-files/Altarum... · prevention and treatment, and are often

AltArum InstItute PolIcy roundtAbleco-sPonsored by the nAtIonAl InItIAtIve for chIldren’s heAlthcAre QuAlIty (nIchQ)

Leveraging Public Health Infrastructure to Confront Childhood Obesitywith

Philip R. Nader, MDUniversity of California, San DiegoProfessor of Pediatrics, Emeritus

Charles J. Homer, MD, MPHPresident and CEO, National Initiative for Children’s Healthcare Quality

William H. Dietz, MD, PhDDirector, Division of Nutrition, Physical Activity, and ObesityCenters for Disease Control and Prevention

Washington, DCMay 13, 2009

roundtAble rePort

Leveraging Public Health Infrastructure to Confront Childhood Obesity

Table of Contents

I. Roundtable Purpose and Overview

II. Summary of Roundtable Presentations

III. Policy Implications of Roundtable Presentations

IV. Questions and Answers

V. Appendices

Appendix A: Altarum Institute Appendix B: National Initiative for Children’s Healthcare Quality (NICHQ) Appendix C: Roundtable Attendee List Appendix D: Speaker Biographies

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Altarum Institute Policy Roundtable: Leveraging Public Health Infrastructure to Confront Childhood

Altarum Policy Roundtable

Leveraging Public Health Infrastructure to Confront Childhood Obesity

I. ROUNDTABLE PURPOSE AND OVERVIEW

The epidemic of childhood obesity is recognized as one of the leading public health threats of the 21st century. This epidemic is likely to shorten and diminish the quality of life of millions of Americans while creating unsustainable burdens on an already overburdened health and health care system. The Office of the Surgeon General estimates that the medical costs of obesity and overweight was about $117 billion in 2000.i

Overweight children are at increased risk of becoming overweight adults, and will be at risk for the health problems that accompany overweight and obesity, including heart disease and other metabolic disorders. Overweight children face immediate health risks such as higher rates of asthma, Type 2 diabetes, hypertension, and orthopedic complications. As adults, they are at risk for conditions such as heart disease, stroke, cancer, and renal disease. In fact, researchers warn that if current trends in obesity continue, the nation will be at risk for a decline in average life expectancy. For the first time in American history, the children of today may live lives that are on average shorter and less healthy than their parents.ii

The epidemic is not simply the result of poor decisions and unhealthy behaviors by individuals; it is a symptom of a number of broken systems and increasingly unhealthy societal norms. Clinical systems are ill-equipped to manage or prevent childhood obesity. School systems are faced with reduced time for physical education classes and recesses, even as the evidence points to the need for significant physical activity for children; schools also grapple with school feeding programs that do not necessarily serve healthy, nutritious foods, and the presence of vending and soda machines. Communities face challenges in reducing obesity, with barriers ranging from the lack of safe recreational facilities to an inadequate source of fresh fruits and vegetables. Government and corporate practices often promote unhealthy behavior. Disparities in health-promoting resources at the community level make it difficult for children and families who are most at risk to make healthy choices. The need for systems change in each of these sectors presents strategic opportunities for the development of model interventions.

The ongoing debate over health care reform must include systematic approaches to preventing childhood overweight and obesity; unaddressed, this problem will continue to drive rising health care costs and widening health care disparities. One central component of change should be to develop an infrastructure that is capable of assessing and analyzing the thousands of programs underway nationwide. At present, researchers cannot always know if, at the local level, these programs are driving change and affecting the rates of childhood obesity. Few community-based

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programs collect local level data which can be used to formulate smart policies surrounding prevention and treatment, and are often lacking data to guide funding sources as they invest in new programs.

Central to accomplishing obesity prevention policy program assessment and evaluation will be the development of a surveillance strategy to track pre- and post-intervention factors for overweight and obesity. Experts suggest that measures of body mass index (BMI), which is calculated based on weight and height, be used for such surveillance. Leading efforts have followed Arkansas’ model of collecting height and weight data from students in the school setting. But other models are now emerging. Pediatricians and other health care providers, who routinely measure children’s height and weight, could theoretically report these data to public health authorities for research and evaluation purposes. In Michigan and San Diego County, efforts are underway to capture clinically-supplied data in robust immunization registries. By leveraging their existing infrastructure for data collection and reporting, states and communities can collect and analyze data about childhood obesity and overweight, and trends in preventing or reducing its incidence and prevalence.

To better understand how BMI surveillance might be used in tracking the effectiveness of obesity prevention programs, Altarum Institute and the National Initiative for Children’s Healthcare Quality cosponsored a roundtable on Capitol Hill on May 13, 2009. Roundtable presentations focused on two groups that have used BMI surveillance and screening not only to track trends, but also to inform and improve clinical practice and to educate parents. Altarum Institute Fellow Matt Longjohn, MD, MPH, introduced the program, which featured three nationally recognized childhood obesity prevention experts, including:

• Philip R. Nader, MD, University of California, San Diego, Professor of Pediatrics, Emeritus

• Charles J. Homer, MD, MPH, President and CEO, National Initiative for Children’s Healthcare Quality

• William H. Dietz, MD, PhD, Director, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention

II. SUMMARY OF ROUNDTABLE PRESENTATIONS

Dr. Matt Longjohn introduced the program by describing efforts underway in Michigan, and noting that absent accurate surveillance data, there is no clear cut way and efficient way to determine whether or not any of the tens of thousands of local programs working to prevent childhood obesity are actually succeeding. Without such local level data and analyses, smart policies cannot be developed, nor can foundations make sound programmatic investments. This data gap must be addressed and, in fact, models are emerging that warrant policymakers’ attention. Dr. Longjohn described an emerging BMI surveillance program that is being developed in Michigan. With support from Michigan’s Governor and the National Governor’s Association, the Michigan Department of Community Health has created Healthy Kids, Healthy Michigan. Through the Healthy Kids, Healthy Michigan Coalition (HKHM), approximately 110 organizations are working to create and implement a multi-faceted 5-year state-level policy

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agenda. One of the identified policy priorities is the establishment of a BMI surveillance system. A task force of health-provider groups is reaching out to an array of stakeholders, including providers, insurers, health plans, professional societies, disease organizations, nonprofits, and academic institutions to develop a novel approach to BMI surveillance. They are building obesity monitoring capacities to the Michigan Care Improvement Registry (MCIR), a centralized repository of immunization records which is used to ensure that vaccinations are administered accurately and on schedule.

MCIR contains a vast amount of data and is widely used: it has more than 35,000 registered users and receives 13,000 user log-ins daily. In 2007, 2,334 provider sites submitted data; roughly 95% of all providers in the state. The MCIR includes 4.7 million records on Michigan residents and more than 57 million shot records. The system is commonly used for HEDIS reporting and is HIPAA compliant.

The Healthy Kids, Healthy Michigan program built upon this existing infrastructure by revising the registry to include entries for height and weight, from which the system calculates and plots BMI percentile. MCIR then produces a BMI report along with a summary of clinical guidance and recommended billing codes. The clinician then counsels the parent and refers them for additional resources for preventing overweight and obesity. State, local and community groups are able to use the data as well for surveillance, planning, evaluation, and advocacy. The total cost for implementing this change in data collection is expected to be approximately $25,000. A parallel effort is getting underway to amend the regulations governing the MCIR to require data entry by providers. Once these regulation changes are made, the system can become fully operational.

The MCIR-BMI logic model (see below) reflects the short- and long-term outcomes/impacts of the program for providers, for children and families, for health plans and insurers, and for state and local government.

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Dr. Longjohn introduced Philip Nader, MD, professor emeritus from the University of California, San Diego, who prefaced his presentation by noting that his experiences and insights are driven by research and based within a context of 30 years of experience. His presentation focused on the public-private collaborative example from the San Diego County Childhood Obesity Initiative. Dr. Nader noted the significant policy implications of fighting childhood overweight and obesity, and called for intergovernmental efforts to address the epidemic. All elements of civil society are affected by childhood overweight and obesity—and all elements can play a part in reducing the prevalence. Dr. Nader noted that media, businesses, government agencies (including local government agencies, particularly parks and recreation, zoning, and so on) can all have an effect on childhood obesity. He further stated that prevention efforts must be more focused: The money spent on obesity prevention, he said, is nothing compared to what is needed, especially compared to the government and private sector funds spent to promote an “unhealthy path.” Dr. Nader pointed out the great imbalance between expenditures for preventive and curative medicine that characterizes the current health care system. Prevention of childhood obesity, because of its long-term implications, cannot be lost in the current debates over reducing the costs of health care. The current system “pays lip service to prevention” while, in reality, not embracing public health and multi-sector policy activities (i.e., coordinated data collection and surveillance) that are necessary to reduce childhood overweight and obesity. Dr. Nader suggested that by focusing much earlier in children’s lives—in early childhood—primary prevention may become feasible and effective. Children and families must live in neighborhoods and communities that support healthy lifestyles, not in those that make it more difficult to make healthy choices.

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The childhood obesity epidemic is the result of multi-factorial and multi-level factors; consequently, any public policy reform efforts must reward and encourage multi-sector efforts. Such policies could, for instance, offer incentives to providers who do better at prevention efforts, rewarding them, for example, for partnering with other sectors of the community.

A 2006 study of 1000 children reported in Pediatrics (Identifying Risk for Obesity in Early Childhood). Pediatrics, 2006, Sept; 118(3):e594-601) found that children whose BMI exceeded the 85th percentile even once during their preschool years had a five-fold increase in the odds of being overweight or obese by age 12. No one under the 50th percentile during preschool or school years was overweight or obese by age 12. And the risk of overweight/obesity gradually increased as BMI levels increased over the 50th percentile.

Dr. Nader suggested that this study has significant implications for exploring policies that set a framework for early childhood interventions to prevent overweight/obesity. He said that, in essence, “kids may no longer outgrow their baby fat.” Although most programs now target school-aged children and older, programs that target early childhood may be equally as important, and may be likely to reach children and parents/caregivers at a point at which healthy nutrition and activity behaviors and habits can be formed. To this end, researchers must track BMI beginning with early childhood in order to begin to formulate policies that create an environment that supports healthy nutrition and activity for young children.

Even more important, Dr. Nader suggested, would be to “connect the dots” and go further upstream with obesity prevention efforts by focusing on optimal maternal gestational weight gain. A study published in Obstetrics and Gynecologyiii reports that maternal gestational weight gain is an independent predictor of offspring’s adolescent weight status. The Institute of Medicine will soon release new guidelines for maternal weight gain during pregnancy. Such guidelines may help to drive policy that helps to coordinate obesity prevention messages to bridge prenatal to pediatric care and beyond. Again, BMI surveillance would offer an essential tool for monitoring weight gain, allowing ob/gyns, pediatricians, and other child health providers to educate parents about the importance of childhood obesity prevention, and their role in fostering healthy and active lifestyles.

Dr. Nader pointed to the significant problems created by fast food advertising that targets young children.iv One study, describing the effects of branding on children’s taste preferences, found that four-year old children preferred carrots wrapped in a McDonald’s wrapper to identical carrots that were not wrapped in the branded paper. The policy implications of limiting or restricting fast food and junk food media and marketing to young children could be profound, and could include strategies such as fast food taxes, or zoning for locations to prohibit or limit proximity to schools and the numbers of such establishments near schools.

Dr. Nader went on to describe the response of one large urban community, San Diego County, to its childhood obesity epidemic. The San Diego County Childhood Obesity Initiative, launched in

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2006, began as the result of a meeting hosted by University of California San Diego Pediatrics department on childhood obesity; that meeting was attended by federal, state, and local officials’ legislative aides, and inspired one legislative aide to seek funding to develop a coordinated response to the obesity epidemic. San Diego County, with 3 million residents, boasts a diverse population that includes immigrants, active duty military and veterans and their dependents, and Native Americans. The County provided $60,000 in seed money to conduct needs assessment, key informant interviews, and issued, in January 2006, a Call to Action, which outlined a childhood obesity action plan with activities focused on seven domain areas:

• County and city governments • Health care systems and providers • Schools and before- and after-school providers • Childcare and preschool providers • Community-based, faith-based, and youth organizations • Media outlets and marketing industry • Businesses

The county contracts with CHIP – the Community Health Improvement Partnership- to be the fiscal agent and manager of the Initiative. CHIP reflects both public and private health care provider and consumer interests. The San Diego County Childhood Obesity Initiative is governed by a leadership council of key stakeholders from both the public and private sectors. It has several paid staff, but utilizes hundreds of volunteer hours from professionals and community residents in many different fields.

Knowing the importance of BMI surveillance for purposes of program planning and evaluation, the Initiative launched a pilot study to track BMI for children entering school based on paper school entry forms, which record children’s height and weight. Health care providers reported measures on a school health form. However, the return rate was low and there were problems with legibility and missing data. A paper-based format was not the most effective approach for conducting such wide-scale surveillance. Instead, the Initiative asked that San Diego County add a height and weight field to its immunization registry, the San Diego Regional Immunization Registry (SDIR), part of the much larger California Immunization Registry (CAIR).

Like the Michigan Immunization Registry, SDIR contains a large volume of data on a significant portion of the population: It contains 154,562 immunization records of children under the age of 6, which represents about 56% of the population in that age range. Approximately 253 sites participate in the registry, including private and public health care providers, private and public schools, childcare programs, Head Start, WIC, and various county programs, such as foster care, Medicaid, and juvenile services.

For the CAIR/SDIR project, researchers hope to conduct BMI surveillance targeting children between the ages of 0 to 5, using provider-determined BMI information. The program will track

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geographic trends, which can then be used for program planning and to benchmark outcomes. Participating providers will benefit from an educational component of the project, which includes real-time feedback regarding growth and BMI charts, links to current practice guidelines, and links to a variety of community resources. The project is currently working with Community Health Clinics (safety net clinics) to populate the SDIR height/weight database, and is collaborating with HMOs and PPOs to participate in the SDIR surveillance and immunization systems. The project is gathering baseline data on provider needs, practice behaviors, and comfort and satisfaction with using the BMI feature of the immunization registry. Ultimately, the program seeks to “close the loop” for providers by offering them real-time information and guidance to educate patients about obesity prevention and to connect them with community resources that support healthy and active lifestyles.

Dr. Charles Homer, MD, MPH, CEO of the National Initiative for Children’s Healthcare Quality, Inc. (NICHQ), a cosponsor of the roundtable, gave a presentation entitled, How primary care can help tackle the epidemic of childhood obesity—and what policy can do to help. NICHQ works to improve children’s health by improving the systems responsible for children’s health care delivery. Dr. Homer prefaced his remarks by noting that health care should improve health; he quoted the Institute of Medicine report, Crossing the Quality Chasm, which stated:

The purpose of the health care system is to reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States.

According to Dr. Homer, primary care is the “front line for public health,” especially for endeavors aimed at preventing and reducing childhood obesity. Throughout infancy and preschool, almost all children are seen for routine childhood immunizations, and once every year or two through elementary school. Families look to physicians as a trusted source of advice on individual behavior and for expertise on community policies.

Any policy to enhance the health care response to obesity should serve to strengthen primary care in general while also addressing obesity-specific capabilities, according to Dr. Homer. The “medical home” is a term currently being used by policy makers for high performing primary care. Dr. Homer defined a medical home as “a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” To further widespread adoption of this model of primary care, he suggested that policy changes be made, including payment reforms and mechanisms to promote adoption and meaningful use of health information technology, including electronic health records and practice-based registries. Such registries enable practices to identify who is at risk of a condition such as obesity, who has that condition, and what interventions are being delivered. Providers will need to be educated on best practices for implementing the medical home, including how to engage consumers in improving practice performance.

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Barriers to improving primary care practice around obesity prevention specifically include physician skepticism about the evidence that any clinical strategies are effective with children and families in preventing obesity. Dr. Homer noted the increasing strength of the evidence that supports the use of BMI screening as well as specific counseling techniques. Such techniques are different than what physicians learn in their current training. The lack of skills in this area constitute another barrier that requires attention. In addition, although community resources – such as safe parks and places for physical activity – are often insufficient, even when they are present, physicians are often unaware of their availability and how to link families with such services. Finally, as with the structure of primary care payment overall, the payment incentives related to obesity counseling are not aligned with the work a doctor needs to do in order to encourage behavior change.

A 1999 JAMA studyv found that among obese adults who received weight-loss advice and instruction from a physician, 80% actually tried to lose weight, while only 58% of those who did not receive advice, tried to lose weight, suggesting that physician guidance has more impact than most physicians realize.

As noted above, recommendations for health professional activities have evolved from consensus statements to increasingly evidence-based guidance. These recommendations consistently advise physicians to screen for BMI as well as use effective counseling techniques. The following slide categorizes the source of evidence or recommendations and the recommendations given.

In a 2007 article in the journal Health Affairs, Dr. Homer and Dr. Lisa Simpson made several recommendations for how health policy can be used to affect change in health systems roles. His overarching recommendation was:

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Healthcare professionals should commit to halting the epidemic of childhood obesity and partner with government, industry, communities, schools, and families to mobilize the resources needed for success. This includes resources at the federal, state, and local levels and in the private sector.

Within the context of this recommendation, Dr. Homer outlined four goals:

Goal 1: Foster the adoption and use of best-available evidence and clinical and preventive recommendations

Goal 2: Model and support healthy living at all levels

Goal 3: Increase the availability of evidence, measures and data on effective healthcare approaches to address childhood obesity

Goal 4: Enhance healthcare professionals’ advocacy and role in the policy process

There is some indication that policy changes are underway. In fact, a new HEDIS measure requires weight assessment and counseling for nutrition and physical activity for children and adolescents between the ages of 2 and 17. Evidence of this measurement must be included in the medical record, with documentation of BMI percentile, as well as counseling for nutrition and physical activity. HEDIS, the Healthcare Effectiveness Data and Information Set, sponsored by the National Committee on Quality Assurance (NCQA) is used by more than 90 percent of health plans nationwide to measure performance on a range of health measures that reflect quality of performance. HEDIS measures, Dr. Homer noted, can be an effective way to “push for best practices.” That practice today is far from “best”: a 2006 NCQA report found that only 1.5% of the charts examined documented BMI.

The chart below reflects the extent to which improvement is needed in attaining HEDIS goals for BMI measurement and nutrition and activity counseling.

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Dr. Homer then noted the importance of local and regional multi-sector initiatives to address childhood obesity that include health professionals and the health care delivery system as participants. To illustrate this approach, Dr. Homer described The Maine Youth Overweight Collaborative (MYOC), a program sponsored jointly by the Maine Harvard Prevention Research Center, the Maine Chapter of the American Academy of Pediatrics, and the Maine Center for Public Health. The Collaborative brings together experts, primary care practices, and community partners to improve management of childhood obesity and to decrease it through prevention. According to the MYOC website, it aims to create “better-informed and activated patients along with better prepared practice teams.” The program focuses on practice team success in promoting patient self-management and goal setting and on addressing behavioral change. Through such programs, practices often improve their ability to capture BMI data that can contribute to state-based registries. In addition, these programs enable health professionals to see the importance of reaching outside their clinical practice setting to promote positive community-wide change.

One component of the program is the toolkit, Keep Me Healthy, which is available online and includes an array of materials for physicians to use, including clinical decision making tools, educational materials for families, support for office visits, and so on; much of the material has been translated into other languages, including Spanish, Khmer, and Somali.

Dr. Homer pointed to three significant policy opportunities in 2009 that will influence how health care can address childhood obesity. The first involves the Child Health Insurance Program Reauthorization Act (CHIPRA). This legislation requires the federal government to develop a core measurement set for Medicaid and CHIP. Dr. Homer expressed his belief that this measurement set should include indicators both of the medical home and of specific obesity

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prevention performance measures. The CHIPRA legislation also included funding for obesity reduction demonstration projects to advance screening and measurement within communities.

The second opportunity is the American Recovery and Reinvestment Act, more commonly known as the stimulus bill. This law specifies that substantial funds ($2 billion) be made available to promote adoption of health information technology and additional resources ($500 million) be allocated for prevention. Dr. Homer again expressed his recommendation that the health information technology funds not simply promote adoption of electronic health records, but enable the adoption of both practice-based and population-based registry systems that can track and measure this critical aspect of children’s health.

The third major policy opportunity is health reform. Dr. Homer noted his hope that health reform issues address child health needs, which are frequently not addressed in health reform debates. In particular, he advocated for the creation of quality improvement resources at the federal and state level devoted to improving children’s health and health care. In terms of the medical home, changes must be made in the payment structure. Health information technology must include registries; these registries should serve to link personal and public health information and, ideally, should span between health care and non-health care settings (e.g., schools) in ways that enable true community-wide strategies to address the childhood obesity epidemic. Finally, consumers and families must become engaged in the issue of improving the health care system for children.

William H. Dietz, MD, PhD, Director of the Division of Nutrition, Physical Activity, and Obesity for the Centers for Disease Control and Prevention gave the final presentation in which he described the role of the CDC in conducting surveillance. He echoed what other speakers had said, noting that without BMI measures and surveillance, the field cannot understand the nature of the epidemic, nor can it assess or evaluate community programs to combat the epidemic. Dr. Dietz described the role of government in preventing childhood obesity: surveillance, documentation of disease burden, evidence-based targets and strategies, identification of promising practices, and state and community programs.

To date, three existing national surveillance systems track information about children. These surveillance systems serve several functions, offering insight and direction for program planning and evaluation; pointing to directions for health interventions; and monitoring progress toward Healthy People 2010 goals.

• The Pediatric Nutrition Surveillance System (PedNSS) tracks the nutritional status of some 8 million 0- to 5-year old low-income children using county-based data

• The Youth Risk Behavior Survey (YRBS) measures priority health-risk behaviors and the prevalence of obesity among adolescents

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• National Health and Nutrition Examination Survey (NHANES) surveys approximately 5000 adults and children annually; the survey is unique because a portion of it includes actual physical examinations

Such national surveillance is important because it can be used to demonstrate successes and challenges in combating the obesity epidemic. In fact, these surveys indicated that between 1999 to 2006, there was no significant increase in the prevalence of obesity among boys and girls, regardless of demographic factors. However, Dr. Dietz emphasized that such a plateau does not reflect a reversal in the trend, and the children who are currently categorized as overweight and obese are likely to suffer from the adult health consequences of this disease.

As a model for how one state used BMI surveillance to understand better the demographics of its childhood obesity problem and to drive change, Dr. Dietz described a program based in Arkansas. There, schools conduct universal BMI surveillance. Using those data, the state was able to determine which areas of the state had high prevalence of obesity and which had less acute problems. The following image illustrates the nature of the epidemic by Arkansas school districts. Based on this information, the state is able to direct funding and programs to communities in which overweight is a significant problem, affecting more than 40 percent of the children in the district.

Monroe County, NY, also characterized its obesity/overweight problem by towns, finding that some towns were more likely to be faced with childhood obesity than were others. The illustration below reflects trends in several cities in the Rochester, NY, area. These data were

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gathered from physician offices; health care foundation funding has been used to infuse money into obesity prevention and control. Although the results were telling, they also reflect an intense level of effort required to enlist pediatric practices to participate.

Such community-wide endeavors are difficult for most state and local governments to implement. At a May 6, 2009, IOM Workshop on Community Perspectives on Obesity Prevention in Children, participants pointed to surveillance needs and barriers. These included a high, unmet need for monitoring and evaluation; challenges in actually measuring, including the desire to obtain BMI but being unable to do so; and the expense of obtaining such information.

Dr. Dietz suggested that one way to enable communities to undertake such surveillance is to align programs more closely with the medical system, specifically using the chronic care model as a way to organize coherent services for obesity. He noted that to address a problem that affects 30 percent of all children, we must change the treatment paradigm. The chronic care model, with its focus on self-disease management in partnership with health care providers, offers a model for such an approach. The chronic care model (described by Wagner and others at www.improvingchroniccare.org) calls upon the community and health systems to support patients in self-management, while also improving the delivery system design, supporting decision making, and enhancing clinical information systems. This process can lead to “informed, activated patients” and a “prepared, proactive practice team.” BMI measures could be an “entry point” to the chronic care system, which would then build capacity for patient and family self-management.

At the same time, Dr. Dietz added, environmental and social issues that bear upon the child, family, school, and community, must also be addressed: access to supermarkets and fresh fruits and vegetables, for instance, presents a major barrier to healthy nutrition for many children. The lack of safe play areas and facilities prohibits many children from engaging in essential physical activity. BMI surveillance measures may offer one strategy for bridging social issues and policy with health care and medicine.

Dr. Dietz described a California-based program in which a provider system is joining with the community to focus on obesity prevention: Kaiser-Permanente’s HEAL-CHI (Healthy Eating, Active Living-Community Health Initiative), a demonstration program in five communities in the state. HEAL-CHI offers financial support, health sector leadership, and work with local collaboratives. Among the program’s initiatives has been opening a farmer’s market in communities served by Kaiser-Permanente to make it easier for members to purchase fresh fruits and vegetables.

Blue Cross Blue Shield of Massachusetts has also launched a program aiming to bridge ecological approaches to obesity prevention with the health care system; communities, schools, media, family, and health care organizations are involved in a variety of activities. For instance,

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http://www.improvingchroniccare.org/

targeted toolkits for families, teachers, and clinicians have been developed; local media have launched campaigns and contests; and peer leader training is underway.

Dr. Dietz noted that surveillance and policy and environmental changes ultimately led to a significant reduction in smoking, which peaked in the early 1960s, and then began to decline with the release of the First Surgeon General’s Report on Tobacco. Other major smoking and health events played into the decrease, including the broadcast advertising ban, Fairness Doctrine messages on TV and radio, doubling of the federal cigarette tax, a second Surgeon General’s report, and the master settlement agreement. Similarly, ending the obesity epidemic will require widespread efforts by many partners, including changes in public policies, regulations, and practices. Dr. Dietz noted that the health care reform debate must include a focus on systematic childhood obesity prevention; this system-wide approach must include BMI screening and surveillance as an essential tool for evaluating prevention and management efforts. In short, he said, “We don’t know the dose needed at the community level because we don’t have the data.”

III. POLICY IMPLICATIONS OF ROUNDTABLE PRESENTATIONS

Health and health care policy and practices must be revised if they are to effectively address childhood obesity and overweight. Local-level public health surveillance data will be essential tools for researchers and policymakers as they track trends in the epidemic and the effectiveness of changing policies and practices

Body mass index (BMI), a measure based on a person’s height and weight, is the established ‘gold standard’ in monitoring obesity trends because BMI data are collected via simple and low cost methods; BMI data are strongly correlated with future health risks; and height and weight data are measured at virtually every infant and child health care visit. By tracking BMI, researchers can develop very concrete and practical information about the incidence and prevalence of childhood overweight and obesity, ascertain demographic/socioeconomic trends, and monitor and evaluate prevention, management, and reduction programs. Federal and state government can play a significant role in encouraging the development of BMI surveillance systems, in part by leveraging the existing infrastructure. For instance, statewide immunization registries, often supported by federal agencies and grants, offer a compelling mechanism to which BMI can be added as a measure. Federal policy and programs can be focused on fostering such changes by requiring standards for data collection and reporting, by requiring federal grant programs to support state information systems that are making these changes, etc.

Additional research is essential to understanding and fostering best practices in building these systems and research grants could also be made available through the National Institutes of Health and other federal agencies

More prevention-oriented programs and policies need to focus on the early prevention of childhood obesity. These efforts need to be tailored to reach pregnant women, the parents of infants and children ages 0- to 5, and preschool children themselves. Because elevated BMI in

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early childhood is correlated with higher risk for future weight and health problems, and because maternal gestational weight gain can also be a predictor of a child’s obesity risk, BMI surveillance efforts should be built to capture data on young children and expectant mothers.

Any health care reform effort should focus on primary care as a “front line” for efforts to prevent and reduce overweight and obesity. Primary care physicians and pediatricians are a trusted source of advice, professionals to whom individuals turn for advice and counsel and to whom communities turn for expert guidance. Strengthening primary care within the context of health care reform is an essential step to improving the quality of children’s health care. Such initiatives should focus on developing strategies and financing mechanisms that support medical homes, that better align funding mechanisms with practice, and that improve health information technology, including electronic health records. BMI surveillance efforts can and should be integrated into primary care strengthening policies.

The model of chronic care management could inform the obesity prevention field with ways to work with individuals and communities to bring disease self-management strategies to children and families while engaging the entire community, including clinicians, in that process. By focusing on the environment and the medical system, the chronic care model would enable the prevention and reduction field to promote family/patient self-management. Environmental factors would include family, schools, worksites and communities; medical systems would include information systems development, decision support, delivery system support, and self-management support. Again, BMI surveillance systems will be instrumental in evaluating the effectiveness of this approach.

Another policy reform might be to include additional HEDIS measures, similar to one recently added to it which requires weight assessment and nutritional counseling for children ages 2 to 17, to the National Committee for Quality Assurance measures of health plans’ effectiveness. HEDIS is widely used to gauge health care quality, and could be leveraged not only for improved BMI surveillance, but also to include other measures that reflect progress in the clinical management of childhood obesity.

Similarly, the CHIPRA core measurement set for Medicaid and SCHIP might also be augmented to include medical home and obesity measures.

Lastly, stimulus funding earmarked to study childhood obesity should be specifically focused to include assessments of financial structures and mechanisms that encourage best practices for prevention and reduction, for the development of information technologies that would be useful in monitoring and managing childhood obesity, and to link public health and individual health.

IV. Questions and Answers

Question

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I have a couple of questions related to the survey. One is that, at the national level, is there an effort to create a longitudinal layout of the data, so we can really detect patterns of growth, much like Dr. Nader showed us? Because I think part of the trouble with physicians is not knowing which of those children, what their growth projected …My second question is related to the health care and health management issue. Have there been efforts to really have the family in housing of the data, considering that they are the link between the clinical system and the community in the form of patient medical records, or access to a particular electronic record, where it can be tracked that way?

Dr. Dietz

With respect to the national data, the only data of those three data sets that I showed you that can be linked are the PedNSS data, the Pediatric Nutrition Surveillance System. The Youth Risk Behavior (YRBS) and the National Health and Nutrition Examination Survey (NHANES) are anonymized, although there is the capacity for follow-up, but not to do the kind of study that you’re describing. I think that’s more likely to become available in more focal data sets, which lack the strength of the national data sets in that they’re not representative.

I’m not particularly enamored of longitudinal data at the national level, because I think what it does is allows us to frame hypothesis that then need to be translated into interventions, and I think that we can shortcut that now by investing in interventions and looking at the outcome. It doesn’t get at what you’re describing, but it’s where I think the emphasis of national funding goes, and I’ll defer to my colleagues for a closer look…

Dr. Nader

I was just going to comment that if you want to wait 25 or 30 years, they’re starting a national children’s study. Our kids might be able to answer your questions. I agree with Bill. The other thing I would kind of like to draw out is where we’re starting with this effort, and how medicalized we want to make it. I think that the data, certainly coming down the pike, I think that this [overweight and obesity problem] starts very early, and most of our efforts are in the wrong place right now. It’s always good to try to intervene in the cycle. I think, also, I’m a little concerned about medicalizing it from the point-of-view of how the doctor gets involved and now the mother feels guilty, the kid’s on the spot, and the doctor is uncomfortable even raising the question, because he or she doesn’t want to drive patients away.

I think, somehow, with this connection with public health, we need to get it more on health, and, as you say, the goal of health care is to make people healthy. I guess one path is to put better stents in, so people don’t die from coronary artery disease, which is probably the reason why coronary artery disease is maybe getting a little better, and it may be smoking also. But I think, if we can figure out a clever way to engage families in having a life that is basically healthy, and how this is going to improve your child’s health in the future, rather than your baby is in the 97% percentile, because what’s mom going to do with that? She wants to feed the baby. We have to get a little more in depth about what’s actually happening. Is the WIC mom breastfeeding, and also giving milk? I know that happens, and juice, thank goodness, they changed the WIC guidelines recently. There’s a new WIC package. They’re getting rid of all the sugary fructose drinks and fruit drinks. So, I think we have to be a little more clever about where we’re starting from.

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Dr. Homer

Let me go through Phil’s last comment, and then go back to your second question. I believe it is harmful to over-medicalize this, but I think the solution is not to say physicians have had an important role. I personally believe, and this is part of the training in technical support, is part of what needs to happen is a retraining, or a training in appropriate counseling methods and techniques. And that, to the extent that physicians are taught about counseling on this topic in medical school, what we’re taught is generally wrong, and it’s along the lines of what you said. As opposed to identifying family goals and providing topics on that healthy lifestyle, we have what they can do to help achieve their goals, and a variety of things that are not … and not making you feel bad for families who have a disease. So I do think that that’s a very important…

Your second question was an intriguing one. It was about the use of what I think most people in the room would know as personal health records, so rather than the electronic health record owned by a doctor’s office or a hospital or a health system, what about having the family or the individual own their own health information and having access to it? I know there are a number of research programs that have been talking about this and using this to track BMI and give appropriate feedback with messages to families. And I would be intrigued to maybe learn, together with you, what some of those are. I know most of the PHRs that are out there, personal health records, right now tend to be more populated by administrative data, a lot of concerns about quality and the data, and probably less valuable to the kinds of very personal specific information of tracking things over time. But I do think that’s a very clever, creative way. I think it’s great.

Question

This question is for Dr. Dietz. Given the amount of stimulus funding that was given to CDC for prevention, how much of that is for obesity will be used in light of today’s conversation? I’m asking questions from Congressional staff, just so you know.

Dr. Dietz

The decision about where the stimulus money is going is still not done, and I, unfortunately, can’t comment on that. I would ask Congressional staff to redirect those questions to the Office of the Secretary. I wish I could elaborate on that, but I can’t. I will say that it’s quite clear that obesity is a high priority. Peter Orszag has said repeatedly that health reform and the budget deficit are intimately connected. That if we control medical costs that we can begin to address the deficit, and the most recent data on the funds running out for Medicaid and Medicare specifically emphasize that, so I’m very optimistic that this is going to be addressed.

Question

I saw on the slides, particularly that Dr. Nader did, there was one mention of businesses as one of the seven sectors that you’re approaching. It wasn’t clear to me exactly what that connection was, but, more broadly, I guess to all three of you, do you see a role for employers in terms of BMI screening in the future? If you could elaborate a little bit on what you are thinking about doing.

Dr. Homer

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It has been the last domain to get active, mainly because people really aren’t sure exactly how to engage the business community. Certainly it has come up around health and medical issues, for example, worksite facilitation of breastfeeding for mothers. That was one thing I think to business would be very important. I personally think the businesses play a much more important role, because of their financial investment in health insurance plans, and their ability, I think, to call some shots in terms of what goes in and what are the services, what are the requirements. So I think it’s a great leverage place to actually have businesses involved. Many programs, like the Chicago Program, have a business council. They’re much further along than we are in terms of developing that, but I think it’s very important for health folks to get their act together and have enough dialogue to know what to say, because it has to be tighter for businesses. They have to see what the bottom line is going to be, and I think there has to be a bottom line in terms of health care costs for this problem. I don’t know what the details are in-between.

Dr. Nader

A declaration, I’m a member of the National Business Group on Health Institute on Obesity, so much of what I’m about to reflect, I suspect you already know, but for the benefits of others. Businesses that are members of this Institute of Obesity at the National Business Group on Health are very concerned about childhood obesity, and it surprised me to see that level of concern, which comes from several different sources. Some of the most enlightened employers recognize that this is their future workforce, and that the costs their current employees are generating are only going to be amplified if childhood obesity is not addressed.

Secondly, there is a broad recognition that they can’t focus these interventions on their employee. They’re paying the cost, not only to that employee, but that employee’s spouse and dependent children, and, although the medical cost of obesity in children and adolescents doesn’t come anywhere close to those in adults, there are significant payments. There are significant increases in illness associated with obesity in children and adolescents that pull parents out of work to care for those children and adolescents. I think, and we saw this last week, in terms of cost control at the national level, businesses are going to play a critical role, and are taking, at least the businesses in the institute, are taking the long view of the need to control, not only current costs, but future costs as well. I’ve been very encouraged by that. I think it’s a model that those businesses, which are doing those, are model businesses, and what we need to learn is whether there is a synergistic impact of an investment in the control of childhood obesity within those businesses at the same time that they’re addressing the issues of obesity in their employees and spouses.

Question

I have a question for Dr. Dietz about the immunization registry. Can you tell me the specific states that are funded?

Dr. Dietz

I can’t tell you the specific states that are funded, but like our program, the immunization registries fund 80% of states. I think it’s about 40 states. The challenge there is that the programs are quite variable. Michigan is an exemplary program, but other states really have some difficulty in getting complete reporting, so that’s one challenge. There is a whole branch devoted to this. But one of the major

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challenges is to incentivize providers to do this, and to get states to enforce the regulations that are in place that require those provider data. Matt, you can speak to this better than I, but I understand that there is a program in Western Michigan in which one payer, one managed care plan is incentivizing providers to collect those data and giving them a payment at age two years. Do you want to comment on that?

Dr. Longjohn

There is at least one health system in Michigan providing incentives to their enrolled physicians to conduct BMI screenings. I’m really glad that you, in particular, asked the question, because in the Trust for America’s Health (TFAH) ‘F as in Fat’ reports, you talk about 17 states having BMI surveillance legislation. What we’re finding is that there are a number of states, 24 or so, that have considered statutes, but have actually gone towards regulatory change, or things that might not be picked up in some of those policy reports. My understanding is that there are 50 states that have immunization registries that CDC supports, maybe 80% of them, but how those data are impacted by policy is really important.

If you don’t have a statute, for example, or a regulatory code that says this is how you’re going to collect data, the public health authority can’t be implemented by the state health department to come into compliance with HIPAA and utilize these data systematically. Figuring out, for example, how TFAH could talk about things beyond just statutory change in this area would be really important.

Dr. Nader

If I could just jump in, maybe from a slightly different perspective. From a quality improvement perspective, there is, obviously, regulation and requirements, and that’s all well and good. But, with the investment that we’re doing in the health information infrastructure, the goal should be for a clinician to only need to document things once, so it is somewhat unreasonable to say write it in your medical record, and, by the way, write it separately into your immunization registry or your BMI registry. The goal should be that the clinician documents it, really for the purpose that they’re documenting it, which is clinical care and monitoring of that child to determine what that child needs. And that it seamlessly, interoperably, to use the word others have used today, will feed into those registry systems. I believe that’s the way we should be going, in addition to, or add the regulatory, mandatory environment that you just mentioned.

Question

I’m a Pediatric Resident. I have 21 members in my class this year, and 17 will go into a specialty field, so a big shift is needed in the paradigm on how to do primary care. I have a question for Dr. Nader on the use of the immunization registry. Are physicians able to look at that on a practice basis for them to see how they were performing?

Dr. Nader

Not yet, but that certainly would be part of it. They should be able to get a report, for example, on their clinic just to see how many times they are recording BMI. It can be either real-time, or it can be delayed, but a good point. We’re not there yet.

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Dr. Dietz

In the Michigan example, it’s not just a physician looking up his or her own record of performance, but also using the measurements. Having the plan administrators critically looking at their provider base, and reviewing the surveillance data that are geographically sorted, and also sorted by practice. Say our provider group in Grand Rapids is consistently reporting lower numbers of BMI screenings in clinics. So we need to work with this group of physicians to increase that screening methodology. We think that the business community, especially the insurers and the providers in the business community, have seen some self-motivational measures that change behavior. We want to not just be looking at it through policy, but be creating market forces that help look at that.

Question

I have two questions – one is about data collection, and the other is about productivity. I know you talked pretty broadly in here today about the health of our workforce and productivity. We have recognized that many healthy behaviors are instilled in us when we are young and of school age. And healthier students are likely to be more productive citizens. As it relates to role of schools, I think you talked about it a lot here, I’m curious to know two things. Schools are required to maintain student health records. And in the State of Virginia, all students are required to have a health examination annually. I would imagine you have already tried to leverage BMI data from school health records?

My follow-on question is has any study been done in terms of correlating the weight and height and possibly the BMI data to academic achievement, and what does this mean overall related to the long-term conversation about health of our workforce and productivity?

Dr. Nader

With respect to your first question, if the people that collect the data in schools are employed by the health department, those data can be shared through health networks. If they belong to the schools, there is a pretty firm barrier between the public health department and the schools with respect to sharing those data.

Dr. Dietz

It’s the equivalent of HIPAA, but in the education system it’s called FERPA, and that’s a pretty impenetrable law. They struggled with that in Arkansas a lot.

With respect to your second question, there have been some data that have cut both ways. Older data suggested that obese kids did better in school, perhaps because they were more socially isolated, and therefore, studying more. More recent data suggests that that may not be the case, and there are some data that have not been replicated that come from a controlled population that was compared to kids who have an inborn error of metabolism that results in obesity, showing that early childhood obesity was associated with a substantial reduction in IQ. Those data have never been replicated. It was the control group for the Prader Willi group, and they’ve linked that with MRI data of the brain showing some opacities. To me, that was really disturbing, because it implied that there were beyond physiologic consequences, that there were actually anatomical and permanent anatomical impairments in brains

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associated with obesity. Others may know more about the cognitive literature on obesity than that, but you’ve just heard everything I know about it.

Dr. Homer

In the thousand kids studied, we’ve been trying to look at some cognitive correlations with obesity. There are so many co-variants, and it’s so difficult to tease out specific affects. There’s too much noise in the system, from a research point-of-view, to tease out, in these longitudinal studies, the effect on cognitive.

Dr. Longjohn

I would also take the prerogative of being at the podium and answer. One thing is that [this epidemic mirrors] the slide that showed the tobacco history. We’re early, relatively, in this epidemic. There are data that show that physical activity and some of the precursors to obesity, the behaviors that are related to obesity, do have academic performance implications. So the more active, the better the academic performance. Obesity is associated with absenteeism and other things that are maybe correlated with academic performance.

Question

The thing that seems to be missing here seems to be executions. There are a number of health care entities that are often accountable, often under contract to various people, to actually operate programs on childhood obesity. I work with a lot of these kinds of entities and they don’t know what works, and the experiments they’ve been doing so far are indicating that what seems to work for one population, doesn’t work for another one. Are any of you aware of any organized effort or process to start to collect data on different program designs that can be analyzed and patched up against this?

Dr. Longjohn

Both Charlie and I can respond to that. I’m not sure whether Phil has an experience here as well. We’ve begun some of these discussions with health plans too, and just for that purpose, to find out what they’ve been doing and what works. One of the biggest deficits is experience in primary care settings, which is where, in my view, a good part of this care has to happen. That’s not to say that there isn’t a desperate need for good tertiary care programs for kids that are severely obese, 97 percentile, or some cut above that, which, to Charlie’s earlier point, is the role of the medical system, and intensive interventions are likely to be necessary for that group.

In my view, one of the more important developments in this arena has been the development of the Childhood Obesity Action Network that Charlie has hosted, and I think provides just that opportunity.

Dr. Homer

Almost five years ago now, we started a Web-based network, where people who were in programs could start to report out what they’re doing and what the results would be. Our vision, or dream, is that this would actually have a consistent set of metrics. People would report consistently on that. We’re still in the process of doing that, but we have about 2,500 individual clinicians who are sharing information about what their programs are, what the program characteristics are, and we have an annual conference meeting of those people to try to further that kind of knowledge. That was very much the idea behind

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what you’re saying, how to share the knowledge that’s out there in the field, so we can learn and improve, while, at the same time, that there was basic science and clinical research available.

Dr. Dietz

I have just one more point on this. I think there is a real opportunity here for health plans to come together around this issue. I understand the proprietary interest that these plans have, but nobody is doing it very well, and it makes little sense to have half a dozen different initiatives all trying the same thing without trying to coordinate and grow from that. And I’m hoping that that convening function may be a role that we can play.

Dr. Longjohn

We have time for one, or maybe two if they’re short questions. I want to note that the audience is broken up into thirds. We’ve heard from Altarum staff, and we’ve heard from experts in the field, but I wonder if there are any Congressional staff members who have questions?

Question

I was wondering if you could expound on some policy initiatives that Congress should think about asking at health care reform time?

Dr. Dietz

Specifically, I mentioned a number of things that I think need to happen in health reform around childhood obesity. One is the promotion of the medical home concept. I think it’s critically important. The second is this health information technology investment and linking the interoperability of that HIT investment to practice and population based trends. I think those are at least two good starts on it.

Dr. Nader

I like the carrot stick thinking in terms of both organized health care and community stuff, so that both get reinforced and/or punished. In other words, it’s a win/win program for both sides to work a lot closer together, and that goes all through actually all of the federal agencies. There is a tremendous need for better communication between federal agencies in this whole topic of childhood obesity, all sectors. Just like in San Diego, we have the multi-sector involved. Somehow, health reform has to reflect that multi-sector approach, because most of the problems are going to be dealt with in a multi-sector fashion.

Dr. Homer

I’ll just add one last point is that these words wellness and prevention are going to be very frequent buzz words that we hear in this conversation nationally, and I hope that every time that they’re mentioned, lawmakers who may have staff in the room, have been encouraged to ask the hard question. How are we going to know whether this is going to be effective ten years from now? Actually, yesterday, I had the chance to site an interaction I had with the GAO, maybe five years ago or so. The GAO, to my understanding actually, because there were no state level BMI data and local level BMI data, were putting some pressure back on the CVC around funding levels and saying how do we know that you’ve been effective. Unless we have systems like this built into legislation, effectiveness in measuring systems built

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in, we will not know whether the investments of political capital, as well as financial capital, ultimately were useful. So, making sure that that tough question is asked about evaluation and what kinds of systems we need in place to conduct those evaluations is really one of the take home messages today.

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V. Appendices

Appendix A: Altarum Institute

Altarum Institute is a nonprofit health systems research and consulting organization serving government and private-sector clients. Altarum provides comprehensive research and tailored consulting services that help clients understand and solve complex systems problems that impact health and health care. Combining the analytical rigor of a research institution with the business agility of a consulting firm, the Institute is uniquely positioned to deliver practical, systems-based solutions to its clients and funders. Altarum’s nonprofit status ensures that the public interest is always preeminent in its work. Services and Offerings Altarum Institute is widely recognized for delivering research and solutions that are technically robust, pragmatic, and carefully aligned with the cultural norms of the populations being served. The Institute’s service offerings are grouped into the following five categories:

- Health Research and Analysis - Health Program Development and Evaluation - Health Care Operations and Finance - Health Promotion and Knowledge Transfer - Clinical Research Support and Pharmacovigilance

Areas of Expertise Altarum applies its service offerings across a wide array of domains in which it has developed deep expertise: • Military and Veterans Health • Behavioral Health • Women, Children, and Adolescents • Community Health • HIV/AIDS • Obesity • Managed Care and the Continuum of Care • Chronic Disease Management • Health Disparities and Intercultural Health • Health Information Technology • Food Assistance and Nutrition Altarum Institute Staff and Values With a history dating back more than 60 years, Altarum Institute offers unparalleled knowledge and practical expertise. Altarum’s more than 350 employees represent the best in health care policy, research, business and clinical process improvement, technical assistance, and program evaluation. The Institute’s staff is diverse in experience and background, but of one mind on its core values, including intellectual excellence, impeccable business ethics, and a commitment to client success.

For more information, please visit www.altarum.org.

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Appendix B: National Initiative for Children’s Healthcare Quality (NICHQ)

Founded in 1999, the National Initiative for Children’s Healthcare Quality (NICHQ) is an action-oriented organization dedicated to achieving a world in which all children receive the healthcare they need.

Led by experienced pediatric healthcare professionals, NICHQ’s mission is to improve children’s health by improving the systems responsible for the delivery of children’s healthcare. Specifically, NICHQ:

• builds sustainable system improvement capabilities; • accelerates adoption of best practices; and • advocates for high quality children’s healthcare.

NICHQ’s current initiatives focus on ensuring that every child receives care in a high-performing medical home, including:

• the prevention and treatment of childhood obesity; • improving care systems for children with special healthcare needs; and • improving perinatal care.

Over the past ten years, through the expertise of clinical and improvement leaders and parents, NICHQ has directly shaped the quality of care for children and youth in the areas of access and efficiency in office practice, asthma, autism, children in foster care, diabetes, attention deficit hyperactivity disorder, cystic fibrosis, hearing loss, epilepsy, obesity, oral health, prevention and spina bifida.

NICHQ provides results in children’s care, enabling practitioners, hospitals, public health systems to deliver better health outcomes for children. NICHQ uses a variety of programs and teaching models including collaborative learning, public events, training and technical assistance and has created practical tools, change packages, measures and resources for practitioners and the community.

For more information, please visit www.nichq.org.

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Appendix C: Roundtable Attendee List

Name Affiliation

Amanda Cash Health Resources and Services Administration

Fritz Chaleff Office of Rep. Bilbray (CA)

Eric Eason Miami Children’s Hospital

Sherri Farias Altarum Institute

Glen Greenlee Altarum Institute

Vanessa Hernandez Office of Rep. Capps (CA)

Rebecca Hines Health Resources and Services Administration

Anjali Jain Children’s National Medical Center

Kathryn Kietzman Office of Sen. Stabenow (MI)

Mark Kielb Altarum Institute

Lesley Kandaras Office of Rep. Sandlin (SD)

Ed Kobrinski Altarum Institute

Ryan Leavitt Office of Sen. Alexander (TN)

Olivia Lindley Altarum Institute

Karah Mantinan Altarum Institute

Megan McHugh First Focus

Jesse Milan Altarum Institute

Jeffrey Moore Altarum Institute

Ruth Morgan Altarum Institute

Mary Mosquera Government Health IT

Cleve Mesidor Office of Rep. McCollum (MN)

Rachelle Mirkin National Initiative for Children’s Healthcare Quality

Willie Neal Office of Sen. Kerry (MA)

Jonathan Orr Altarum Institute

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Scott Pickens Pickens Associates

Daveida Pittman Altarum Institute

Michael Potter Altarum Institute

Robert Riccio Altarum Institute

Kristen Robinson Altarum Institute

Kara Rudolph Altarum Institute

Janice Lynch Schuster Altarum Institute

Amy Sheon Altarum Institute

Leslie Sim The National Academies

Jamie Solak Altarum Institute

Thomas Storch Technical Assistance to Community Builders

Paul Thewissen Royal Netherlands Embassy

Cynthia Tuttle National Business Group on Health

Serena Vinter Trust for America’s Health

Liza Veto Centers for Disease Control and Prevention

Mark Weissman Children’s National Medical Center

Dennis Zaenger Altarum Institute

Beth Zimmerman Altarum Institute

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Appendix D: Speaker Biographies

Philip R. Nader, MD

Dr. Phil Nader, Emeritus Professor of Pediatrics, University of California San Diego (BA Wooster College, MD University of Rochester) is a “Behavioral Pediatrician” who has been engaged in research in health behavior (nutrition and activity) and the

influence of families, schools, and communities on child health since the early 1970’s.He has led and participated in several multi-disciplinary research teams examining both longitudinal descriptive and randomized population-based interventions regarding activity and nutrition. He participated as an Investigator in the NICHD Study of Child Care and Youth Development. He was a Visiting Scholar at the Stanford University Institute for Communication Research, a Fogarty International Fellow, and a UC Investigator on Pacific Rim Indigenous Health. He continues his active community role in San Diego as a Senior Consultant to the San Diego County Obesity Initiative. He has recently published a new book for parents: “You CAN Lose Your Baby Fat. New Rules to Protect Kids from Obesity” http://www.youcanloseyourbabyfat.org

Charles J. Homer, MD, MPH

Dr. Charles Homer co-founded the National Initiative for Children's Healthcare Quality in July 1999 and he currently serves as the organization's President and CEO. A graduate of Yale University, Charlie received his MD from the University of Pennsylvania Medical School, and his MPH (Epidemiology) from the University of North Carolina School of Public Health. Charlie is a pediatrician and serves as an Associate Professor of the Department of Society, Human Development and Health at

the Harvard University School of Public Health, and an Associate Clinical Professor of Pediatrics at Harvard Medical School. He was a member of the third US Preventive Services Task Force from 2000-2002, and served as Chair of the American Academy of Pediatrics Steering Committee on Quality Improvement and Management from 2001-2004. Prior to his position at NICHQ, Charlie was Director of the Clinical Effectiveness Program at Children’s Hospital, Boston, and served as Program Director of the first federally supported fellowship training programs in pediatric primary care and health services research. He currently serves as Vice Chairman of the Board for the Catalyst Institute for Oral Health and on the Board of Directors for the Institute for Pediatric Innovation, both in Boston.

William H. Dietz, MD, PhD

Dr. William H. Dietz is the Director of the Division of Nutrition, Physical Activity, and Obesity at the CDC. Prior to his appointment to the CDC, he was a Professor of Pediatrics at the Tuft′s University School of Medicine, and Director of Clinical

Nutrition at the Floating Hospital of New England Medical Center Hospitals. He received his medical degree from the University of Pennsylvania in 1970 and a Ph.D. in Nutritional Biochemistry from the Massachusetts Institute of Technology. He is a member of the Institute of Medicine, a recipient of the

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http://www.youcanloseyourbabyfat.org/

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Holroyd-Sherry award from the American Academy of Pediatrics for his contributions to the field of children and the media, and the recipient of the 2006 Nutrition Research award from the AAP for outstanding research in pediatric nutrition.

i U.S. Department of Health and Human Services. The Surgeon General’s call to action to prevent and decrease overweight and obesity. [Rockville, MD]: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001. ii Olshansky, SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. New England Journal of Medicine. March 17,2005; 352(11):1138‐1145. iii Oken E, Rifas‐Shiman SL, Field AE, et al. Maternal Gestational weight gain and offspring weight in adolescence. Obstetrics and Gynecology 2008 Nov; 112:5:999‐1006 iv Robinson TN, Borzekowski DLG, Matheson, DM, Kraemer HC. Effects of Fast Food Branding on Young Children’s Taste Preferences. Arch Pediatr Adolesc Med 2007: 161(8):792‐797. v Galuska DA et al, Impact of Weight Loss Advice from a Health Care Provider Among Obese Adults, JAMA 1999

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