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The Latest Treatment Advances in Childhood Obesity Denise E. Wilfley, Ph.D. Scott Rudolph University Professor of Psychiatry, Medicine, Pediatrics and Psychology Washington University in St. Louis April 21, 2015

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Overview Highlight the impact of obesity on youth Discuss importance of early intervention Define the gold standard treatment for children with obesity Propose ideas for how to implement treatment in community settings

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Childhood Obesity in Missouri Obesity Among Low-Income Children Ages 2-4 National Center for Chronic Disease Prevention and Health Promotion, 2012; Pediatric Nutrition Surveillance System Altman et al., in process 2015 28% of children in Missouri (more than 400,000) are overweight or obese 12.9% of low-income 2-4 year olds are obese Up to 40% of middle school students in parts of MOsuch as Bransonare overweight or obese

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The Impact of Obesity and Stigma on Children Quality of life rated as low as young cancer patients on chemotherapy Schwimmer et al., JAMA 2003; Williams et al., JAMA 2005

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OBESITY IS FOUND TO GAIN ITS HOLD IN EARLIEST YEARS For many obese adults, the die was cast by the time they were 5 years old. 70-80% will track obesity into adulthood Efforts must start much earlier and focus more on the children at greatest risk.

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Early Identification and Intervention is Crucial Prevents harmful effects Harnesses parental support Fosters healthy habits Small weight losses can make a big impact Age at the start of treatment has a strong impact on treatment outcome Treatment is more efficacious at a younger age Adolescents have more difficulty losing clinically-significant amounts of weight Danielsson et al., Arch Pediatr Adolesc Med, 2012; Danielsson et al., Obes Facts, 2012; Reinehr et al., Am J Clin Nutr, 2010; Reinehr et al., Obesity, 2009; Sabin et al., J Clin Eval Clin Prac, 2007

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A grandmother, Diane, called into KMOXa St. Louis based radio stationto find resources for her granddaughterwho was told she was obese by her pediatrician. Mother is distraught and does not know where to turn or how to help. Access to effective care for children with obesity is scarce. Pediatricians could provide resources and serve as gatekeepers to effective care. Providing Resources to Parents

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Discussing Child Weight with Parents Explain growth charts Inform parent of potential health consequences Avoid blame language Use non-stigmatizing language that will motivate Recent data suggests perceived negative judgment from provider leads to patient mistrust Emphasize lifestyle change, not number on scale Discuss change in a family-context Keep the child in the room to facilitate conversation between parent and child Puhl et al., Pediatrics, 2011; Wilfley, et al, Pediatric Clin North Am, 2011; Eneli et al., Clin Pediatrics, 2007; Gudzune, et al., Patient Education and Counseling, 2014

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The Energy-Balance Equation: Its Not Enough Running for 3.5 hours Energy Intake (Calories) Energy Output (Physical Activity)

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Multiple Meta-Analyses Document Significance of Lifestyle Interventions Young et al., Clin Psychol Rev; Altman et al. JCCAP, 2014; Hayes et al., Curr Cardio Rep 2015; Wilfley et al., Health Psych, 2007; Sung-Chan, et al. Obes Rev, 2013; Ho et al., JAMA Pediatrics, 2013 Adding a family component stressing parental involvement to behavioral lifestyle interventions increases their effectiveness and parents should be targeted along with children to achieve the greatest reduction in child overweight A recent systematic review suggests even further that family based interventions including individual family sessions achieve greater magnitude weight loss than group sessions alone for children with obesity.

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Family-based Behavioral Intervention First line of treatment for children and adolescents Targets reduction in energy intake and increase in energy expenditure in both youth and caregivers Recognizes that knowledge alone is not sufficient Focuses on successive changes using family support Core strategies include: self-monitoring, reinforcement, stimulus control, goal setting, contingency management Shown to impact: weight status, psychosocial health, and health- related parameters (e.g., blood pressure, cholesterol, insulin sensitivity) This treatment has shown to have long-sustained effects that improve weight maintenance Jelalian et al., J Pediatr, 2010; Kalarchian et al., Pediatrics, 2009; Epstein et al., Childhood Obesity, 2014; McGovern et al., J Clin Endocrinol Metab, 2008; Altman et al., JCCAP, 2014; Ho et al., Pediatrics, 2013

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The Ripple Effect FBT can impact not only the child involved, but the participating parent and even other siblings within the household Providing treatment for one child who is overweight/obese in the family has the potential to impact others inside and outside the family (effect will vary based on sex, age) FBT more cost-effective for weight loss Epstein et al., Childhood Obesity, 2014; Epstein et al., Obes Res, 2001; Golan et al., Am J Clin Nutr, 1998; Golan et al., Int J Obes Relat Metab Disord, 1998; Wrotniak et al., Obes Res, 2005; Golan et al., 2006, 2009; Gorin et al., 2008.

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Engineer the Environment to Support Health

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Parent and Peer Support Are Key

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Jazmyne and her mother enrolled in the TODAY trial for management of Jazmynes Type 2 Diabetes : The St. Louis American, January 22, 2010; TODAY Study Group Diabetes Care, 2013; Ebbeling et al., Lancet 2002 At 14, she started feeling really bad headaches, nauseated, fatigue [], her mother said. When she went for her checkup before school, the doctor was alarmed. Post-treatment: Jazmynes headaches got better and her mood swings improved. Together, daughter and mother made significant lifestyle changes. We could prevent future medical costs by providing targeted intervention in infancy, childhood, and adolescence. Call for Early Intervention Diagnosis of type 2 diabetes often brings emotional isolation, lifetime of medication, hypertension, nephropathy, dyslipidemia, chronic inflammation, nonalcoholic fatty liver disease

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Future DirectionsThe Medical Home Consists of a variety of specialists housed within primary care practices to provide coordinated care for the patients Individuals prefer to first see their primary care physician A gatekeeper for specialist recommendations Medical home model can help improve coordination of primary care services Demonstration project with Missouri Department of Mental Health (DMH) and the Missouri Coalition for Community Behavioral Health Care American Academy of Pediatrics. The Medical Home. Peds, 2004; Grumbach K, Selby JV et al., JAMA,1999

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Call to Action Ensure that every child and family engages in healthy eating and weight management practices. Advocate for insurance coverage for treatment Add your voice to a cooperative effort for reimbursement Establishment of a certification system for training individuals to deliver evidence-based care Explore and recommend local options for initiating and sustaining healthy habits Integrate intervention across multiple levels of care Collaborative partnerships: It takes a village Wilfley et al., Pediatr Clin N Am, 2011

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Work Together to Optimize Health for Children, Families, and Communities