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Dealing With the Challenges of Childhood Obesity

Posted on Oct 04, 2017

Dr. Hernandez co-authored an editorial that recently was published in the Journal of the American Medical Association.

Childhood obesity is an issue that Americans have been facing for years. About 12.7 million children and adolescents are overweight or obese and children of low-income families are disproportionality affected. Excessive weight can contribute to other conditions historically considered “adult” diseases, such as high blood pressure and Type 2 diabetes.

Recently, you may have heard about new recommendations regarding childhood obesity from the U.S. Preventative Services Task Force (USPSTF). These recommendations state that physicians should regularly screen 6- to 18-year-olds for obesity and refer those with a Body Mass Index in the 95th percentile or higher to a comprehensive behavioral intervention program.

While it is a start to addressing the obesity epidemic, some experts think there are more pieces to the puzzle. An editorial published in the Journal of the American Medical Association (JAMA) offers further thoughts on addressing the issue, but to get the full picture, we sat down with co-author Raquel Hernandez, M.D., M.P.H., director of medical education and medical director for Fit4Allkids at Johns Hopkins All Children’s Hospital and assistant professor of pediatrics for the Johns Hopkins University School of Medicine.

THE USPSTF recommends an intensive, individualized intervention program. What is the value in such a treatment plan?

To be successful in managing individual patients with pediatric obesity, you need an intensive multidisciplinary approach. The value is in recognizing that not one approach is going to work with every child or family and that you have to have nutrition, mental health, a clinical piece, as well as an activity specialist to really make any strides with families.

The new recommendations highlight a minimum of 26 contact hours, suggesting this amount of contact can’t happen in just one or two visits. It has to happen over time and that speaks to how providers need to be in touch with these families, not just within the clinic but by phone, with patient portals for example, as well as other more innovative methods. Otherwise, this amount of treatment time will be difficult to reach with current clinical structures.

Are there challenges faced by health care providers and/or families with this sort of treatment plan?

The biggest challenge from a family perspective is finding the right fit. There are very few pediatric multidisciplinary programs within the country (about 34) and many of them are tiered toward the most severely obese children who are either candidates or being considered for bariatric surgery. That population is at the peak of the pyramid of risk. When it comes to the middle tiers, the existing programs are really not targeting the majority of the population.

From the provider perspective, there are many challenges. For example, finding the right team members. Connecting mental health to all of these programs is a challenge because we know there is a shortage of pediatric mental health providers and most of the issues these kids are encountering are self-perception, low mood, anxiety and depression. It is very difficult to make strides in obesity without addressing those components to the clinical care team.

How does Medicaid funding play into this situation?

Medicaid is actually a huge issue. The current funding that Medicaid offers has only recently started to recognize that obesity screening, including measuring body-mass index (BMI), and proving support for nutritional counseling for children who are obese is reimbursable. The threat of losing Medicaid funding for children only further exacerbates the epidemic because we would have even greater losses in our screening and providing care for at-risk children.

Beyond the doctor’s office, what factors in communities contribute to the occurrence of childhood obesity and how can those factors be addressed?

The factors that impact kids with respect to obesity are the social determinants of health: Everything a child encounters in his or her day-to-day can impact activity, diet and mental health.

A key place with opportunity for change is in schools and child care environments. Having evidence-based approaches in one place to assess and manage, and also provide healthy food and activity options, can make an immediate impact on kids. Past efforts have been toward managing kids who are already obese, though we could turn the conversation more toward prevention and younger age groups.

The other place is within communities and neighborhoods. Right now, the easiest decisions are often the unhealthiest. A plethora of data shows changing the walkability of our neighborhoods and the food environment of our communities offer families more opportunities to make healthy choices. By considering how we can change the food and physical environment of our children, as well as how we can improve the school and child care environment, we can begin to make meaningful changes outside of the clinic setting.

What are we doing at Johns Hopkins All Children’s Hospital to address childhood obesity?

We’re committed to providing programs in both our clinic environment at Johns Hopkins All Children’s and the community.

Our Healthy Steps Clinic is a clinical intervention for any infant through young adult who is having challenges in weight trajectory. Even young infants who are growing or gaining weight more than we want are eligible patients for Healthy Steps. The clinic includes myself and a nutrition specialist, as well as a research arm where we are gathering data around the factors that contribute to weight in all of these ages. In addition, the clinic provides very individualized care. We commit ourselves to setting goals with each family that are relevant to them versus just offering generic diets or generic food supplements. We really want this to work for families so we spend at lot of time getting to know them and what their barriers are.

Within the community we are excited that we’ve been successful in implementing programs within our high schools. We had programs called the Health Squad and Teens Tracking 4 Health (TT4H) within a local high schools and are now collecting and reviewing data to know what was successful that we could replicate in other schools.

We also have our First Steps community program for 7 – 11 year olds and their families where the goal is education, interactivity and physical activity for the family. We provide education on healthy lifestyle choices over a six-week period. We hope in the near future to develop even more age-specific programs for our teens as well as toddlers.

What can community members do to help the make sure the kids in their neighborhoods grow up healthy?

Advocacy has to be multi-tiered through several areas:

  • Caregivers can talk to their local schools, their principals and their PTA about what the school is doing for nutrition and physical activity.
  • Community members, parents and others, can talk to their council members about environmental and neighborhood efforts, like sidewalks and parks.
  • If you happen to be in health care and are aware of the challenges, contacting your congressmen and women can influence funding, such as Medicaid.

Learn more about First Steps, the Healthy Steps Clinic and other obesity prevention efforts by Fit4Allkids at Johns Hopkins All Children’s Hospital. 

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