Evidence-based Childhood Obesity Treatment Services: Applying Recommendations from the AAP/AHRQ Obesity Treatment & Reimbursement Conference

Webinar 1 of 2

January 20, 2017

Acknowledgements

The content of this webinar was developed from a July 2015 small conference grant R13HS02281601: “Evidence-based childhood obesity

treatment: Improving access and systems of care” supported by the Agency for Healthcare Research and Quality with matching funds from the American Academy of Pediatrics Institute for Healthy Childhood Weight.

The full summary of the conference is available:

Obesity 2017; 25(1): 16–29. doi:10.1002/oby.21712

Thank you to our supporters!

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Housekeeping

Q & A During the Webinar

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Sandra G. Hassink, MD, FAAPPast-President, American Academy of PediatricsDirector, Institute for Healthy Childhood Weight, American Academy of Pediatrics

Denise E. Wilfley, PhDScott Rudolph University Professor of Psychiatry, Medicine, Pediatrics, and Psychological & Brain Sciences at Washington University in St. Louis

Amanda E. Staiano, PhDAssistant ProfessorDirector, Pediatric Obesity & Health Behavior LaboratoryPennington Biomedical Research Center

Meet the Faculty

Disclosure Statement

Affiliation / Financial Interest Organization

Denise Wilfley, PhD, Consultant Shire Pharmaceuticals

Denise Wilfley, PhD, Consultant Sunovion Pharmaceuticals

Disclosures

Sandra Hassink declares no conflicts of interest.

Amanda Staiano declares no conflicts of interest.

Polling Question

Today’s Agenda

• The Patient Perspective – Sandra G. Hassink, M.D.

• Background and Significance – Denise Wilfley, Ph.D.

• Conference Consensus – Amanda Staiano, Ph.D.

• Question & Answer

• Examine the US Preventive Services Task Force recommendations for childhood obesity treatment

• Including the current DRAFT USPSTF recommendations (anticipated release in 2017)

• Identify consensus for behavioral treatment

• Review and discuss a model for effective childhood obesity treatment: family-based behavioral therapy

• Identify essential team members for the treatment of childhood obesity

• Discuss the format, setting, and training needs for the clinical management of obesity

Objectives

The Patient Perspective

AHRQ/AAP Conference Proceedings

Age 7• 168 lbs• Told she was just going through a growth spurt by pediatrician• Mother felt blamed and concerned about daughter’s weight since she and her

husband also struggle with their weight

Age 12

• 398 lbs• Suffered unbearable stigmatization at school• Maria and her mother completed programs together that were geared either

toward adults or children, except for one which included the entire family but was not of sufficient duration

Age 14• 443 lbs; BMI 63.6• Gastric bypass surgery was her only option after spending countless dollars out-

of-pocket on ineffective, insufficient, or non-evidence based programs

Maria’s story could have been much different. If she had access to an evidence-based treatment and was reimbursed for this care, she may have been prevented from severe obesity tracking into adolescence.

Maria’s Story

Maria’s Growth Chart

Childhood Obesity is a Disease Putting One At Risk for 30+ Co-morbidities

AHRQ/AAP Conference Overview

AHRQ Conference Overview

Pre-conference43 Multi-sector stakeholders convene virtually

ConferenceJuly 8-9, 2015 in-person meeting

Post-conferenceSynthesis with work group and on-going dissemination

Survey

Webinar

Briefing Book

Pre-Conference Survey of Stakeholders

Survey on the Implementation of the USPSTF Recommendations for Childhood Obesity Treatment

BarriersFacilitators

Survey on the Implementation of the USPSTF Recommendations for Childhood Obesity Treatment

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

Wilfley et al., Obesity 2017;25(1):16–29.

Background & Significance

Recommended InterventionsProvide or refer patients to comprehensive moderate- to high-intensity programs (>25 contact hours) that include dietary, physical activity, and behavioral counseling components.

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

RECOMMENDATION: The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to intensive counseling and behavioral interventions to promote improvements in weight status (grade B).

USPSTF, 2010, Pediatrics.

U.S. Preventive Services Task Force Recommendations

Adapted from Figure 3, Whitlock et al., 2010, Pediatrics.

The Systematic Review for USPSTF

Mounting Evidence

Support for Higher Dose

• 2012—Ho et al. (38 studies)• Summarized the positive effects of comprehensive interventions on cardiometabolic

outcomes as well as on weight outcomes in children • Showed that weight loss was greater when the duration of treatment was longer than

6 monthsHo et al., 2012 Effectiveness of lifestyle interventions in child obesity: systematic review with meta-analysis. Pediatrics.

• 2014—Janicke et al. (20 studies)• Showed that comprehensive, family interventions have positive effects on child weight• Looked at moderators:

• Dose (duration, number of sessions, time in treatment) was positively related to effect size

• Individual and in-person comprehensive family interventions were associated with larger effect sizes

Janicke et al., 2014. Systematic review and meta-analysis of comprehensive behavioral family lifestyle interventions addressing pediatric obesity. J Pediatr Psych

Support for Higher Dose

• 2016—Mitchell et al. (18 studies)

• Showed that pediatric overweight/obesity interventions in primary care settings can be effective for BMI reduction

• Parents were targeted as change agents for the child’s BMI reduction in all studies

• All studies incorporated behavioral components (e.g., specifying behaviors to change, reinforcing positive behaviors, setting goals, changing the environment, monitoring behaviors, promoting self-management skills)

• Looked at moderators:

• Dose (number of treatment contacts, duration of treatment, and number of visits with a pediatrician) was a significant moderator of treatment effect

• Larger effect sizes were associated with more treatment contacts, longer treatment duration, and greater number of treatment sessions with a pediatrician

Mitchell TB, Amaro CM, Steele RG. Pediatric Weight Management Interventions in Primary Care Settings: A Meta-Analysis. Health Psychol, 2016.

Recommendations in ProgressNovember 2016 - DRAFT

Higher intensity (>26 contact hours), multi-component behavioral interventions are effective

Components across interventions included:• sessions targeting both the parent and child (separately,

together, or both); • offered individual, family, and group sessions; • encouraged the use of behavioral skills and• included supervised physical activity sessions.

Recommendations in ProgressNovember 2016 - DRAFT

Behavioral interventions with > 52 contact hours demonstrated greater weight loss

and some improvements in cardiometabolic measures.

Children’s Weight Change (zBMI, BMI, kg, %ile) inBehavioral Weight Loss Intervention Trials

Draft Evidence Review: Obesity in Children and Adolescents: Screening. U.S. Preventive Services Task Force. November 2016.https://www.uspreventiveservicestaskforce.org/Page/Document/draft-evidence-review156/obesity-in-children-and-adolescents-screening1

.

.

.

.

52+ hrsWeigel, 2008Savoye, 2007Savoye, 2014Reinehr, 2006Reinehr, 2009Reinehr, 2010Subtotal (I-squared = 43.4%, p = 0.116)

26-51 hrsVos, 2011*Kalarchian, 2009Kalavainen, 2007*Stark, 2011Croker, 2012DeBar, 2012*Sacher, 2010Nemet, 2005*Stark, 2014Subtotal (I-squared = 24.0%, p = 0.230)

6-25 hrsBryant, 2011Golley, 2007Hofsteenge, 2014Gerards, 2015Nowicka, 2008Boudreau, 2013Norman, 2015Subtotal (I-squared = 37.4%, p = 0.143)

0-5 hrsTaylor, 2015Kong, 2013Stettler, 2014*Saelens, 2002*Broccoli, 2016Sherwood, 2015Taveras, 2011Looney, 2014Resnicow, 2015Wake, 2013Van Grieken, 2013Taveras, 2015McCallum, 2007Wake, 2009Subtotal (I-squared = 0.0%, p = 0.913)

Study

1148278787867

454444383837363330

2424171716118

54444333332111

thru 12mcontact hrsEst

7-158-1610-166-1410-168-16

8-178-126-92-58-1212-178-126-162-5

8-166-911-184-812-199-1211-13

4-8NR8-1212-164-72-42-64-102-83-1056-125-95-10

RangeAge

1212612126

241266652.2536

12563.512612

249124361262412121233

DurationTx

1212612126

1212121261261212

121261212612

129127126126241224121512

monthsFollowup,

000000

NA066073.7596

0708.5000

NA003900000120129

endedsince txMonths

zBMIBMIzBMIzBMIzBMIzBMI

zBMIBMIzBMIzBMIzBMIzBMIzBMIBMIzBMI

zBMIzBMIzBMIzBMIzBMIzBMIzBMI

zBMIWeightzBMIzBMIzBMIzBMIBMIzBMIBMI %ilezBMIBMIzBMIzBMIBMI

Outcome

-1.15 (-1.68, -0.63)-1.05 (-1.37, -0.72)-0.72 (-1.25, -0.19)-0.83 (-1.19, -0.47)-1.27 (-1.47, -1.07)-1.50 (-2.05, -0.96)-1.10 (-1.30, -0.89)

-0.25 (-0.73, 0.23)-0.23 (-0.52, 0.05)-0.42 (-0.89, 0.05)-1.68 (-2.85, -0.52)-0.06 (-0.58, 0.45)-0.18 (-0.48, 0.12)-0.49 (-0.94, -0.05)-0.45 (-1.07, 0.18)-0.97 (-1.84, -0.10)-0.34 (-0.52, -0.16)

0.23 (-0.24, 0.70)-0.26 (-0.76, 0.24)-0.28 (-0.68, 0.12)0.49 (0.00, 0.98)-0.31 (-0.79, 0.16)0.17 (-0.66, 1.00)0.00 (-0.38, 0.38)-0.02 (-0.25, 0.21)

-0.23 (-0.53, 0.06)-0.19 (-1.08, 0.69)-0.34 (-0.95, 0.27)-0.56 (-1.22, 0.10)-0.30 (-0.51, -0.10)-0.02 (-0.55, 0.51)-0.13 (-0.47, 0.21)-0.16 (-1.18, 0.85)-0.21 (-0.49, 0.07)-0.23 (-0.61, 0.16)-0.04 (-0.27, 0.18)-0.16 (-0.52, 0.21)-0.03 (-0.36, 0.29)-0.04 (-0.29, 0.21)-0.17 (-0.25, -0.08)

from BL (95% CI)SMD in Change

-.34 (.48)-1.7 (3.1)-.05 (.13)-.3 (.35)-.22 (.35)-.26 (.22)

-.4 (1.29).5 (3)-.3 (.15)-.37 (.41)-.11 (.16)-.15 (.41)-.3 (.51)-1.6 (4.3)-.59 (.75)

.03 (.24)-.24 (.43)-.12 (.46).05 (.26)-.06 (.46)-.03 (.14)-.1 (.36)

-.19 (.52)1.7 (4)-.06 (.5)-.05 (.22)-.12 (.38)-.02 (.37).3 (1.4)-.16 (.48)-4.9 (15.2)-.2 (.5)1.4 (1.5)-.09 (.33)0 (.61).6 (2.6)

IG, Mean (SD)Change in

.26 (.57)1.6 (3.2).04 (.12)0 (.41).15 (.17).05 (.19)

-.1 (1.12)1.1 (2.2)-.2 (.3).4 (.49)-.1 (.16)-.08 (.36)-.01 (.65).6 (5.5)-.03 (.36)

-.03 (.27)-.13 (.4).02 (.53)-.08 (.27).09 (.53)-.05 (.08)-.1 (.44)

-.08 (.43)2.5 (4.3).1 (.41).06 (.17)-.01 (.35)-.01 (.54).5 (1.4)-.07 (.61)-1.8 (13.8)-.1 (.36)1.4 (1.7)-.04 (.32).02 (.55).7 (2.2)

CG, Mean (SD)Change in

661745821147466

67192701658173824023

706297678823106

1815170373715544515312105507335146242

N

-1.15 (-1.68, -0.63)-1.05 (-1.37, -0.72)-0.72 (-1.25, -0.19)-0.83 (-1.19, -0.47)-1.27 (-1.47, -1.07)-1.50 (-2.05, -0.96)-1.10 (-1.30, -0.89)

-0.25 (-0.73, 0.23)-0.23 (-0.52, 0.05)-0.42 (-0.89, 0.05)-1.68 (-2.85, -0.52)-0.06 (-0.58, 0.45)-0.18 (-0.48, 0.12)-0.49 (-0.94, -0.05)-0.45 (-1.07, 0.18)-0.97 (-1.84, -0.10)-0.34 (-0.52, -0.16)

0.23 (-0.24, 0.70)-0.26 (-0.76, 0.24)-0.28 (-0.68, 0.12)0.49 (0.00, 0.98)-0.31 (-0.79, 0.16)0.17 (-0.66, 1.00)0.00 (-0.38, 0.38)-0.02 (-0.25, 0.21)

-0.23 (-0.53, 0.06)-0.19 (-1.08, 0.69)-0.34 (-0.95, 0.27)-0.56 (-1.22, 0.10)-0.30 (-0.51, -0.10)-0.02 (-0.55, 0.51)-0.13 (-0.47, 0.21)-0.16 (-1.18, 0.85)-0.21 (-0.49, 0.07)-0.23 (-0.61, 0.16)-0.04 (-0.27, 0.18)-0.16 (-0.52, 0.21)-0.03 (-0.36, 0.29)-0.04 (-0.29, 0.21)-0.17 (-0.25, -0.08)

from BL (95% CI)SMD in Change

-.34 (.48)-1.7 (3.1)-.05 (.13)-.3 (.35)-.22 (.35)-.26 (.22)

-.4 (1.29).5 (3)-.3 (.15)-.37 (.41)-.11 (.16)-.15 (.41)-.3 (.51)-1.6 (4.3)-.59 (.75)

.03 (.24)-.24 (.43)-.12 (.46).05 (.26)-.06 (.46)-.03 (.14)-.1 (.36)

-.19 (.52)1.7 (4)-.06 (.5)-.05 (.22)-.12 (.38)-.02 (.37).3 (1.4)-.16 (.48)-4.9 (15.2)-.2 (.5)1.4 (1.5)-.09 (.33)0 (.61).6 (2.6)

IG, Mean (SD)Change in

Favors IG Favors CG

0-2.5 0 1

*Study-reported repeated measures or adjusted analysis demonstrated a statistically significant effect

BOYS

Age 90th 95th 97th

8-9 y.o. 5.38 -0.09 -4.72

9-10 y.o. 6.59 -0.35 -6.35

10-11 y.o. 6.06 -2.23 -9.44

11-12 y.o. 7.08 -2.69 -11.13

12-13 y.o. 8.60 -2.54 -12.10

GIRLS

Age 90th 95th 97th

8-9 y.o. 7.10 1.04 -4.01

9-10 y.o. 7.41 -0.11 -6.39

10-11 y.o. 7.87 -1.15 -8.66

11-12 y.o. 7.28 -3.37 -12.24

12-13 y.o. 5.84 -6.42 -16.64

Goldschmidt, Wilfley, Paluch, Roemmich, Epstein, 2013, JAMA Peds.

Necessary Weight Change for Normalization of Weight Status in Children

Change in BMI z Score

Stronger Effects with Higher Treatment “Dose”

Wilfley et al., 2007, JAMA; Wilfley et al., in prep, Dose, content, and mediators of family-based treatment for childhood obesity: A multi-site randomized controlled trial

Reductions in Percent Overweight

Wilfley et al., in prep, Dose, content, and mediators of family-based treatment for childhood obesity: A multi-site randomized controlled trial

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

SFM high SFM low Health Ed

*

SFM+ High SFM+ Low Control

**

Abbreviations: % OW = Percent overweight. SFM+ = Enhanced social facilitation maintenance.*p=.035; **p<.001

Proportion of Children Achieving a Reduction of %OW ≥ 9 units

Stronger Effects with Higher Treatment “Dose”

Wilfley et al., in prep, Dose, content, and mediators of family-based treatment for childhood obesity: A multi-site randomized controlled trial

Months

-12 0 12 24 36 48 60 72 84 96 108 120 132

Chan

ge in

%ag

e ov

erwe

ight

-25

-20

-15

-10

-5

0

5

10

15

20

25

Parent plus childChild aloneNon-specific control

Epstein et al., 1994, Health Psychology.

Stronger Effects with Treating the Parent & Child

Bridging the Gap Between Evidence and Clinical Practice

Conference Consensus

1. Family treatment model is critical

2. Interventions need to be comprehensive and behavioral

3. Treatment should consist of >25 hours of contact with flexibility to adjust intensity of contact based on individual family needs

4. Comprehensive and consistent training is needed for staff teams delivering obesity treatment

Key Consensus Recommendations

Wilfley et al., Obesity 2017;25(1):16–29.

• First line of treatment for children and adolescents

• Targets reduction in energy intake and increase in energy expenditure in both youth and caregivers

• Core strategies: self-monitoring, reinforcement for goal achievement, and stimulus control

Epstein et al., 1990, JAMA; Epstein et al., 2014, Childhood Obesity; Epstein et al., 2007, Health Psychology; Best et al., 2015, Health Psychology; Jelalian et al., 2010, Pediatrics; Gunnarsdottir et al., 2014, Laeknabladid.

Consensus 1:Family Treatment Model

• Demonstrated short- and long-term effectiveness for youth with obesity

• Impacts weight, psychosocial health, physical health (e.g., blood pressure, cholesterol, insulin sensitivity), and energy-balance behaviors

• Provides concurrent treatment for parents with obesity and can generalize to other family members

• More cost effective than separate treatment of obesity in the parent and child

Epstein et al., 1990, JAMA; Epstein et al., 2014, Childhood Obesity; Epstein et al., 2007, Health Psychology; Best et al., 2015, Health Psychology; Jelalian et al., 2010, Pediatrics; Gunnarsdottir et al., 2014, Laeknabladid.

Benefits of Family-based Behavioral Weight Loss

Team Member Suggested Types of ProvidersPediatrician or primary care

providerPhysicianNurse PractitionerPhysician Assistant

Behavioral interventionist

Behavioral/mental health specialist (e.g. psychologist, social worker, master’s level counselor)

Registered dietitianExercise professionalHealth coaches/educators

Subspecialist Medical Subspecialist Mental Health SpecialistExercise Physiologist Registered Dietitian

Care Coordinator InterventionistNavigatorCase workerRegistered nurse

Consensus 2:Building a Comprehensive Team

Wilfley et al., Obesity 2017;25(1):16–29.

Setting:

• Primary care medical home

• Tertiary care center

• Community setting (medical neighborhood)

Format:

• Individual family or mixed-format approaches

Consensus 3:Intensity ˃25 hours of contact with flexibility to adjust based on individual family needs

Wilfley et al., Obesity 2017;25(1):16–29.

• Primary Indicator: Stabilize/reduce relative weight

• Secondary, Patient-Centered Indicators:

• Psychosocial (e.g., quality of life, body image)

• Biomedical outcomes (e.g., progression of medical comorbidities)

• Patient engagement (e.g., satisfaction)

• Behavior Change (e.g., dietary and physical activity goal attainment)

• Parent Change (e.g., weight, psychosocial, biomedical)

• Evaluate, collect and share outcomes with patients

Consensus 3:Intensity ˃25 hours of contact with flexibility to adjust based on individual family needs

• Training specialized based on role

• Cultural and developmental competencies

• Standardized training, certification, and monitoring system

• Ongoing consultation and coaching from experts

Consensus 4:Comprehensive and Consistent Training

For Future Consideration

• Training needs to be scaled up and widely available

• Regions will function according to priority and capacity

• Political landscape is ever-changing

• Reimbursement pathways are just beginning

• Join us on February 16 @ 12 noon CT for Webinar 2

Questions