PEDIATRICS Vol. 123 Supplement June 2009, pp. S253-S257 (doi:10.1542/peds.2008-2780B)
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SUPPLEMENT ARTICLE |
Responding to the Childhood Obesity Epidemic: From the Provider Visit to Health Care Policy—Steps the Health Care Sector Can Take
National Initiative for Children's Healthcare Quality, Cambridge, Massachusetts
Abbreviations: MYOC—Maine Youth Overweight Collaborative • COAT—Children's Obesity Action Team • NICHQ—National Initiative for Children's Healthcare Quality • COAN—Childhood Obesity Action Network
Pediatricians, along with most of the American public, now well know that childhood obesity is a leading threat to the long-term health of the population, rivaling smoking in its potential impact. What pediatricians and other health professionals who deal with children have not known is what they can do to affect this epidemic and how they can be most effective in doing it.
From the perspective of the clinician in practice, the problem of obesity seems overwhelming. The number of children affected is vast, with healthy lifestyles a concern for all children and overweight or obesity affecting as many as one quarter of children ages 2–19 years. In part because of the limited emphasis on effective counseling methods in traditional medical education, addressing behaviors such as increasing use of car seats or reducing tobacco use is difficult for many clinicians. This has been the case even when the evidence is strong and there is broad societal support for these changes. Behaviors related to diet and physical activity seem even more difficult to influence, not only because they are embedded in family and ethnic culture, but because so many societal and community pressures lean on the side of foods of lower nutritional value (eg, sugar-sweetened beverages, highly processed fast foods) and limited exercise (unsafe neighborhoods, absence of sidewalks). Health professionals may feel that influencing these societal behaviors and policies are outside the scope of their professional role.
Health professionals have also been unsure what to do, because no unequivocal direct scientific evidence links clinician counseling to the prevention of obesity. This has been clearly stated by the US Preventive Services Task Force (USPSTF), which reported in 2005 that there was insufficient evidence to recommend for or against counseling about childhood obesity by clinicians.1
However, although most observers acknowledge the state of evidence when held against the standard of the best possible evidence, the real question is whether there is sufficient evidence to make positive recommendations and to take action. The organizational and community leaders, researchers, and authors of the articles in this supplement have taken the perspective that action is justifiable given the available evidence. These studies and program reports (and this supplement includes both) emerge from a perspective that action is needed now, that such action should be based on inferences from the best evidence that is now available about behavior change in other fields and about the causes of this epidemic, and, finally, that the probability of harm from inaction is greater than the probability of harm from either the actions taken or opportunity costs foresworn.
The general approach to evidence (making decisions on the basis of best available evidence and balancing the likelihood of benefits and harm) is similar to that used by the American Academy of Pediatrics in creating its Bright Futures2 guidelines for preventive care. It is also aligned with the argument advanced by Berwick3 in supporting widespread use of quality improvement to address deficiencies in quality of care. Even the Community Preventive Services Task Force,4 when examining community-based interventions outside of the clinical sphere, uses a broader view of acceptable evidence than does the clinically oriented USPSTF. This broader view of evidence was also adopted by the Expert Committee on Childhood Obesity.5
In its 2005 report on childhood obesity, the Institute of Medicine wrote, "pediatricians, family physicians, nurses, and other clinicians should engage in the prevention of childhood obesity. Health-care professionals should routinely track BMI, offer relevant evidence-based counseling and guidance, serve as role models, and provide leadership in their communities for obesity prevention efforts.6" Three years later, Robert Wood Johnson Foundation chief executive Risa Lavizzo-Mourey wrote, "[p]hysician action begins in the examination room. Measuring patient BMI at every well-child visit is essential, along with evidence-based prevention assessment, and treatment strategies...however, physician action must extend beyond the examination room.7" These experts have advocated that clinicians engage in a set of activities starting at the clinical encounter, moving to "leading by example" by serving as role models for healthy lifestyles, and, ultimately, influencing community practice and policy and, potentially, broader societal policies through advocacy informed by policy research (Fig 1).
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We have assembled in this supplement articles that illustrate this recommended spectrum of activities and efforts to change clinical care and to change local communities. Several of the articles (Polacsek et al,8 Oetzel et al,9 Rogers and Motyka,10 and Pomietto et al11) are program reports that describe the programs and include some level of formative evaluation—experience in implementation, perception of "clients," and largely self-reported changes in clinician behaviors. Appropriate for this type of report, these articles provide information on context and illustrative data rather than abstract, independently assessed trial data. These programs rely heavily on quality-improvement methods as their strategy for altering clinical practice and system performance; we have provided a glossary (see Appendix) to assist the reader in understanding the approaches presented. Other articles use more traditional descriptive and analytic study methods to assess the extent to which health care settings provide healthy food choices, the health payment environment related to obesity services, and the levels of disparities in obesity rates according to state, all of which can inform future program and policy interventions.
More specifically, Polacsek et al8 focus squarely on how to effectively prevent and manage obesity in the practice setting. They describe this setting as ripe with largely untested opportunities for addressing overweight risk. Through an intervention known as the Maine Youth Overweight Collaborative (MYOC), they sought to evaluate changes to clinical decision support and family management of childhood overweight in 12 sites in Maine during an 18-month period (see the Appendix for an explanation of quality-improvement terms, such as "collaborative," used in these articles). Their efforts included tracking BMI percentiles and counseling patients and their families by using the 5-2-1-0 approach: eat at least 5 fruits and vegetables every day, limit recreational screen time (computer and television) to 2 hours/day, engage in at least 1 hour of physical activity per day, and cut back on sugared drinks in favor of beverages such as water and low-fat milk.
The authors reported large changes in practice once the MYOC was implemented. For example, use of a body mass index (BMI) assessment jumped from 38% to 94%, and use of the 5-2-1-0 behavioral screening tool increased from 0% to 82%. Parents at the intervention sites received more counseling about diet and exercise than those in the control group, and the providers themselves benefited, reporting improvements on several measures of knowledge and effective implementation of the plan. Overall, the intervention improved clinical decision support and family management of risk behaviors, indicating a promising (but not proven) approach to reducing the prevalence of overweight on the basis of a primary care model.
Oetzel et al9 also examined a program to enhance clinical care that used a quality-improvement strategy. The specific clinical sites for this intervention were school-based health centers, which are closer to the community than many practices but are still considered health care deliverers. Participants underwent a less intensive improvement approach than did the practices in the MYOC, receiving only one 2-day training and limited follow-up reinforcement in quality-improvement approaches and several elements specific to obesity: motivational interviewing techniques, measurement of BMI, establishing weight-category diagnosis, assessing readiness to change health behaviors, and assessment of ability to take in 4 messages that are key to weight management. As occurred with the MYOC, the New Mexico intervention achieved substantial changes in clinical practice, with only modest attrition after conclusion of the intervention. The study offers evidence that such training leads to better implementation of prevention and treatment guidelines for pediatric overweight and obesity.
Following the framework of extending from clinical to community change, Rogers et al10 applied the 5-2-1-0 approach in the schools, testing the schools' ability to deliver healthy messages and assessing the penetration of those messages. They provided 9 participating schools in southern Maine with a resource kit containing strategies to promote the 5-2-1-0 goals. They also provided technical assistance and worked with other local organizations, including doctor's offices, to help disseminate the message within the community. The project was well received by teachers, students, and parents, with some respondents even describing the 5-2-1-0 message as a "common language" for the various participants to use when discussing desirable behaviors. However, teachers conceded that although they found the project worthwhile, they struggled to find time to implement it, emphasizing that attention to implementation of changes in school settings requires the same focus on systems as implementing change in clinical settings.
Recognizing the importance of policy change as a key strategy in reversing the obesity epidemic, Bethell et al12 provide the type of data that can inform advocacy and policy at a state level. Exploring more deeply the well-known disparities in rates and severity of obesity between more and less advantaged populations, these authors highlight that the degree of disparity varies greatly from state to state and cannot be predicted by either the overall rate of obesity or the degree of economic and social disadvantage in that state. State-specific data are needed to inform and craft local solutions. Ultimately, any approach to prevention, management, and treatment must be tailored to address the needs of a given population.
Lawrence et al13 focus on another, too-often-overlooked means of influence by health care: leading by example. The authors specifically examined the food environment of health care facilities and found that it was wanting. Fewer than half of the facilities surveyed were in the process of adopting healthy vending policies similar to the types of school vending standards that are increasingly widespread. Most sites demonstrated an abundance of vending machines stocked with sugared sodas and energy-dense items such as candy and chips. Assuming the families we serve watch what we do as well as listen to what we say, we have a long way to go.
Both Boyle et al14 and Simpson and Cooper15 identify the real and perceived barriers to sustained clinician engagement in the types of changes outlined above and propose pragmatic solutions. Basing their research in those communities in California engaged in the Healthy Eating, Active Communities program, Boyle et al focus on physician perceptions of what is needed to improve outcomes and support clinician engagement in the process. Clinicians recognize the critical role of environmental change (to the point of undervaluing the role of the clinician as an effective motivator of behavior change). They perceive lack of reimbursement to be an obstacle to both clinical and community advocacy roles. They also articulate that the latter function is also impeded by a lack of skills, time, mentorship, and role expectations. Each of these, Boyle et al assert, can be addressed through institutional and public policies.
Similarly, Simpson and Cooper15 scan the national environment related to payment for not only clinical services but also for broader health-sector engagement. They note health plans directly engaged in community change but not necessarily focused on the clinician's role. They also highlight the pragmatic, and perhaps short-term, approach taken by plans of focusing their expenditures on initiatives with a shorter-term return (adult obesity) rather than a longer-term one. With their qualitative research, Simpson and Cooper also question the true importance of the lack of clear reimbursement for obesity-related services in that those plans that have established mechanisms for such coding have found few clinicians taking advantage of it. They conclude by noting policy and program interventions (eg, linking reimbursement to participation in a registry to assess intervention effectiveness) that could break through the current sterile debates between insurers and providers.
For the most comprehensive program detailed in this issue, Pomietto et al11 describe how Seattle's Children's Hospital and Regional Medical Center's Obesity Action Team (COAT) partnered with Steps to Health King County to develop a multifaceted quality-improvement program that addresses pediatric obesity.
The COAT began as a yearlong "learning collaborative" with local clinics; 4 years later, it became a statewide program adopted by the Washington State Department of Health. As did the practices participating in the MYOC, clinics participating in the collaborative worked within the chronic-care model as an organizing framework for practice-based systems and for interaction with the community. They used the model for improvement as their strategy for implementing system change. By partnering with the King County Steps to Health program (a separately funded Centers for Disease Control and Prevention initiative), the COAT was able to build on an extensive network of community partnerships and promote linkages between practices and community agencies. Furthermore, the program provided training in advocacy, with the participating individuals and institutions providing testimony to school boards and local legislative bodies. Because all of the relevant stakeholders (including payers) were involved in the initiative, understanding increased, laying a strong foundation for negotiations about financial incentives. By putting forth a model that sought to integrate the many facets involved in care for childhood overweight and obesity, the authors point the way for other efforts aimed at tackling a problem of such magnitude.
Taken together, these articles indicate that it is possible, right now, for child health professionals and the organizations in which they work to take an active role in addressing this epidemic. They highlight that effective tools for guiding clinical actions exist and that training methods can work in a variety of settings to positively influence clinical practices. Moreover, with appropriate training, support, and, ideally, reimbursement, child health professionals can contribute to community-level advocacy and policy change.
The National Initiative for Children's Healthcare Quality (NICHQ) is an independent nonprofit organization that seeks to improve child health through improving the systems of children's health care. In response to the magnitude of the epidemic and expert assessments that indicate a gap between desired and typical practice, we initiated demonstration programs for pediatric practices as long ago as 2003. In accord with the philosophy outlined above and the experiences reported in the types of studies included in this supplement, we placed the prevention and treatment of childhood obesity as a top item on our agenda for improving children's health care in 2006. We convened national panels of advisors and obtained widespread endorsement from more than 30 prominent health organizations to commit to concerted action to address this epidemic. In 2007 we launched the NICHQ Childhood Obesity Action Network (COAN). With more than 2000 members, the COAN is one of our primary vehicles in a national campaign to mobilize the health care sector's response to the epidemic of childhood obesity; it links clinicians and policy makers together, provides widespread access to tools and materials for clinical and policy change, and promotes innovation through social networking and the opportunity to share data and information about programs and policies (see Fig 2).
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These articles also validate the concept of the NICHQ COAN. Many of these programs came about, or, more precisely, were shaped and influenced, by the informal networking and more formal linkages that came about through the forum for productive interactions that our organization provided. The policy research grew out of appreciative dialogue between front-line clinicians who were eager to make a difference with institutional and government policy makers engaged in the network. Many of the tools developed by these and other programs are readily available through our Web site (www.nichq.org.) so that other practices and organizations seeking to take action will not have to "reinvent the wheel." We anticipate that the network will even stimulate the generation of new information that will inform questions about what works in preventing and treating this condition. We invite you to join our network and, through your participation, join in the health care campaign to reverse this epidemic of childhood obesity.
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APPENDIX: GLOSSARY |
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 TOP APPENDIX: GLOSSARY REFERENCES |
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Breakthrough Series Collaborative:
The Breakthrough Series (created by the Institute for Healthcare Improvement) was designed to help organizations close that gap by creating a structure in which interested organizations can easily learn from each other and from recognized experts in topic areas in which they want to make improvements. It is a short-term (6- to 15-month) learning system that brings together teams from hospitals or clinics to seek improvement in a focused topic area. This is sometimes referred to as a learning collaborative or chronic-disease management initiative.
Chronic-care model:
The chronic-care model (created by Dr Ed Wagner and colleagues at Improving Chronic Illness Care and the McColl Institute) identifies the essential elements of a health care system that encourage high-quality chronic-disease care. These elements are the community, the health system, self-management support, delivery-system design, decision support, and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. This is sometimes referred to as the chronic-disease model, planned-care model, or care model.
Clinical decision support:
One component of the chronic-care model that aims to promote clinical care that is consistent with scientific evidence and patient preferences.
Community collaboratives:
The Healthy Eating, Active Communities (HEAC) program is designed to demonstrate how collaborative approaches can change environmental risk factors. It engages youth, families, community leaders, health professionals, and communities in creating healthy environments to facilitate healthy choices, particularly in low-income communities. Local collaboratives address the program objectives by working to change the environment in each of 5 sectors: schools, after-school programs, neighborhoods, food and beverage marketing and advertising, and health care.
Early adopters:
The early adopter is considered by many as the "individual to check with" before using a new idea. The role of the early adopter is to decrease uncertainty about a new idea by adopting it and then conveying a subjective evaluation of the innovation to near-peers by means of interpersonal networks. Early adopters tend to be social leaders, popular, and educated.
Learning session:
A 1- or 2-day meeting of teams participating in a collaborative. A typical collaborative has 3 learning sessions over the course of the project. The goals of the learning sessions are to learn the best evidence available for care, learn quality-improvement methodology, and interact with other collaborative teams.
Model for improvement:
Developed by Associates in Process Improvement (www.apiweb.org/API_home_page.htm), the model for improvement is a tool for accelerating improvement. The model has 2 parts:
- Three fundamental questions, which can be addressed in any order: (1) What are we trying to accomplish? (2) What changes can we make that will lead to improvement? and (3) How will we know that a change is an improvement?
- The plan-do-study-act cycle for testing and implementing changes in real work settings. The plan-do-study-act cycle guides the test of a change to determine if the change is an improvement.
Promotoras:
Community members who serve as liaisons between their community and health, human, and social service organizations. They work with organizations and institutions (formally and informally as employees or volunteers) to bring information to their communities. As liaisons they often play the roles of advocate, educator, mentor, outreach worker, role model, translator, and more.
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ACKNOWLEDGMENTS |
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This supplement was made possible by grants from the California Endowment, Kaiser Permanente Community Benefits, the Nemours Foundation and the HSC Foundation.
We extend our appreciation to the authors of these articles for their continued efforts to reverse the childhood obesity epidemic and for sharing their knowledge as reflected in these reports. In addition, we thank the more than 2000 members of the NICHQ Childhood Obesity Action Network who, by exchanging their ideas and experiences, are accelerating and improving the health care response to this epidemic. We also thank Nicole Van Borkulo, Allison Cunningham, and Molly Fubel for their efforts in assembling this supplement.
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FOOTNOTES |
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Accepted Feb 18, 2009.
Address correspondence to Charles J. Homer, MD, MPH, National Initiative for Children's Healthcare Quality, 20 University Rd, 7th Floor, Cambridge, MA 02138. E-mail: chomer{at}nichq.org
The author has indicated he has no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPAPPENDIX: GLOSSARYREFERENCES |
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- US Preventive Services Task Force. Screening and Interventions for Overweight in Children and Adolescents: Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ publication 05-0574-A. Available at: www.ahrq.gov/clinic/uspstf05/choverwt/choverrs.htm. Accessed April 11, 2008
- Hagen JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008
- Berwick DM. The science of improvement.
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[Free Full Text] - Centers for Disease Control and Prevention, Guide to Community Preventive Services. Obesity prevention. Available at: www.thecommunityguide.org/obese. Accessed December 7, 2008
- Barlow SE and the Expert Committee. Expert Committee Recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics. 2007;120
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[Abstract/Free Full Text] - Koplan JP, Liverman CT, Kraak VI. Preventing Childhood Obesity. Washington, DC: Institute of Medicine of the National Academies; 2005
- Lavizzo-Mourey R. Childhood obesity: what it means for physicians.
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[Free Full Text] - Polacsek M, Orr J, Letourneau L, et al. Impact of a primary care intervention on physician practice and patient and family behavior: Keep ME Healthy—the Maine Youth Overweight Collaborative. Pediatrics. 2009;123 (6 suppl). Available at: www.pediatrics.org/cgi/content/full/123/6/S5/S258
- Oetzel KB, Scott AA, Mcgrath JW. School-based health centers and obesity prevention: changing practice through quality improvement. Pediatrics. 2009;123 (6 suppl). Available at: www.pediatrics.org/cgi/content/full/123/6/S5/S267
- Rogers VW, Motyka E. 5-2-1-0 goes to school: a pilot project testing the feasibility of schools adopting and delivering healthy messages during the school day. Pediatrics. 2009;123 (6 suppl). Available at: www.pediatrics.org/cgi/content/full/123/6/S5/S272
- Pomietto M, Docter AD, Van Borkulo N, Alfonsi L, Krieger J, Lui LL. Small steps to health: building sustainable partnerships in pediatric obesity care. Pediatrics. 2009;123 (6 suppl). Available at: www.pediatrics.org/cgi/content/full/123/6/S5/S308
- Bethell C, Read D, Goodman E, Johnson J, Besl J, Cooper J, Simpson LA. Consistently inconsistent: a snapshot of across- and within-state disparities in the prevalence of childhood overweight and obesity. Pediatrics. 2009;123 (6 suppl). Available at: www.pediatrics.org/cgi/content/full/123/6/S5/S277
- Lawrence S, Boyle M, Craypo L, Samuels S. The food and beverage vending environment in health care facilities participating in the Healthy Eating Active Communities program. Pediatrics. 2009;123 (6 suppl). Available at: www.pediatrics.org/cgi/content/full/123/6/S5/S287
- Boyle M, Lawrence S, Schwarte L, Samuels S, McCarthy WJ. Health care providers' perceived role in changing environments to promote healthy eating and physical activity: baseline findings from health care providers participating in the Healthy Eating, Active Communities program. Pediatrics. 2009;123 (6 suppl). Available at: www.pediatrics.org/cgi/content/full/123/6/S5/S293
- Simpson LA, Cooper J. Paying for obesity: a changing landscape. Pediatrics. 2009;123 (6 suppl). Available at: www.pediatrics.org/cgi/content/full/123/6/S5/S301
PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics
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