The Journal of Texas Medicine: June 2012 Texas Medicine June 2012

Combating Childhood Obesity With A Multiprong Attack

The Journal – June 2012 

 Tex Med. 2012;108(6):e1.

  By Swapna Reddy, JD, MPH; Marisa Finley, JD, LLM; Sean Alloju; and James Rohack, MD  

Mr Reddy and Ms Finley, Scott & White Center for Healthcare Policy, Temple, Texas; Mr Alloju, Texas Tech University; and Dr. Rohack, The William R. Courney Centennial Endowed Chair in Medical Humanities, director, Scott & White Center for Healthcare Policy, and professor of medicine and humanities, Texas A&M Health Science Center. Send correspondence to Swapna Reddy, JD, MPH, 801 W 5th St #2902, Austin, TX 78703; email: Swapreddy01[at]yahoo[dot]com.   

Abstract 

The issue of childhood obesity in the United States has grown to alarming proportions in recent years as 23 million children are afflicted with this condition. Texas has particularly high rates, from toddlers to teenagers. While various entities are addressing this problem, the issue persists. Instead of traditional approaches, a multiprong strategy that combines the strengths of health care professionals, health plans, and community stakeholders would be more effective. An example of such an approach now being used in Central Texas shows encouraging results. This partnership combines the health expertise of a health care system, the financial support of a health plan, and community knowledge of community-based organizations to help children and families combat obesity and learn to lead healthier lives.   

Introduction 

In the past few decades, the United States has witnessed an alarming escalation in the segment of its population classified as obese. The literal widening of the nation has resulted in almost 40% of adults living with obesity.¹ An offshoot of that trend, and one that has more long-term negative financial impact for the United States, is the rapid increase in obesity rates among the nation's children, of whom 23 million are obese or overweight.² Children with a body mass index (BMI) above the 85th percentile but lower than the 95th are considered overweight, and those with a BMI over the 95th percentile are classified as obese.² In just three decades, rates of childhood obesity have risen from 6.5% in 1980 to 16.9% in 2010.¹ Four percent of children aged from 2 through 5 years, 19.6% of those aged from 6 through 11 years, and 18.1% of those aged from 12 through 19 years are struggling with obesity nationally. Children in Texas have been particularly impacted by obesity as 32.4% of those aged from 10 through 17 years, 16.2% of those aged from 2 through 4 years, and 29.2% of high school students in the state are obese or overweight.³   

The current rates of obesity are particularly concerning because obesity in children results in a significantly higher risk for a wide gamut of related health issues such as high blood pressure, high cholesterol, type 2 diabetes mellitus, sleep apnea, skin conditions, asthma, joint problems, fatty liver disease, gallstones, reflux, menstrual abnormalities, and also social and psychological problems.² All of these, when continued to adulthood, can result in even more troubling health concerns, all of which affect the quality of life, workforce productivity, and thus the production of taxable income to support the government infrastructure at local, state, and federal levels. Ultimately, some health conditions may negatively affect the potential life span of the individual.  

While children across racial and socioeconomic lines have been afflicted with this issue, some disparities seem to exist among racial and ethnic groups. Among male children, Mexican Americans are more likely to have higher BMIs than their non-Hispanic white counterparts at the same age. Similarly, among female children, Mexican American and African American female children are more likely to have higher BMIs than their non-Hispanic white counterparts by age.⁴ Accordingly, certain groups appear to be disproportionately affected, and more must be done to address community-specific issues.  

As the issue of childhood obesity has become more prominent nationally, a wide variety of entities have taken up the fight against the problem. These range from the White House to local schools and churches and many stakeholders in between. While many types of interventions have been proposed and instituted, clearly, no single approach is the solution as rates continue to increase.  

We need to advocate for approaches that can use and combine the strengths of various entities. While the multipronged strategy can be employed by using a variety of stakeholders, such as schools and religious organizations that come into contact with children regularly, some of the most potentially powerful partners in this issue are also those in the health care arena. Traditionally, health care professionals serve as a regular and trusted contact for children and parents, while health plans can determine what services can be accessed and provide powerful financial incentives for families. Finally, community-based organizations have the best understanding of the needs, beliefs, barriers, and motivations for the groups they serve. Combining the strengths and resources of health care professionals and health plans with those of community-based organizations has a high potential for addressing the issue of childhood obesity in a particularly effective manner that to date has been underutilized.   

Health Care Professionals 

 Strengths

 Frequent Interaction: Most children tend to have regular visits with health care professionals throughout their childhood. Most children have these visits for various reasons such as vaccination requirements for schools, frequent and common childhood illnesses and injuries, and recommended wellness checks. Obese children who have access to care may have to visit practitioners more often because of the health issues related to their weight. As a result, health care professionals have regular access and contact with children, and the basis of their relationship is rooted in the context of health.  

In these interactions with children, practitioners are able to screen for and identify risk factors for obesity. The American Medical Association, along with other national organizations like the American Academy of Pediatrics and the American Academy of Family Physicians, recommends a specific workup for children when seen by a health care professional. These recommendations are intended not only to identify the problem but also to include prevention and treatment. Generally, these recommendations include the following:⁵  

Assessment

1. Determine BMI for age 
2. Review medical history 
3. Parental obesity 
4. Review family medical history 
5. Other health problems related to obesity 
6. Review physical activity, diet, and other behaviors  

Prevention-Patient Level

1. Limit: portion sizes, high-calorie foods, artificially sweetened drinks, eating outside of home, screen time more than 2 hours a day 
2. Encourage: breakfast, 9 servings of fruits and vegetables daily, family meals, physical activity, fiber, calcium, balanced diet, breastfeeding   

Treatment

1. More frequent monitoring by physician 
2. Structured weight-management program with specific goals and support for child 
3. Multidisciplinary intervention that includes more frequent visits with different types of practitioners 
4. Medications, low-calorie diets, and/or surgery for severely obese children    

If these recommendations are properly incorporated into visits with practitioners, they can effectively serve as important intervention points in the lives of children who are at risk or already obese. Because practitioners are encouraged not only to identify the health issue but also to suggest tools to prevent and treat the problem, families and practitioners become partners in the solution. If parents with children identified for intervention comply, they should more often visit appropriate practitioners who can provide additional and constant care. This regular presence from a health expert in the family's life can provide them with frequent monitoring and intervention to support a healthier lifestyle.

Trusted Relationship: Health care professionals, especially physicians, are in a unique position as they are generally viewed with trust by parents and their children. Parents tend to rely heavily on the determinations and advice of physicians and take their advice very seriously. This relationship provides a valuable context in which to advise families about the health of their children when they are obese. Also, because the proper assessment of obesity in children not only involves objective factors such as BMI, but also takes into account medical and family history and lifestyle, parents can feel more comfortable that the diagnosis is a didactic determination. Furthermore, practitioners are in a position to detect other possible related health issues and to discuss the severity of an obese child's current health and risks for future health problems from a position of expertise that most parents feel they can trust. If a parent seeks a second opinion, the use of a consistent assessment tool should result in similar conclusions among practitioners, thus furthering a parent's ability to rely on the advice for prevention and treatment.  

Limitations

While health care professionals should have regular contact with children, and their relationships with family are generally those of trust, these models are only effective if children and families comply with all of the recommendations and have access to the care. Even though obesity affects children across society, those in poverty and from certain socioeconomic groups are affected disproportionately. Children on Medicaid are close to 6 times more likely to be treated for obesity than those with private health insurance, and the cost of caring for an obese Medicaid child is $6,700 per year, compared with $3,700 for a privately covered obese child.⁶ In Texas, 43.5% of obese children aged from 10 through 17 years are in families with less than 100% of the federal poverty level.⁶ Accordingly, children from lower socioeconomic backgrounds are disproportionately affected by obesity, which in turn is also disproportionately costly for the larger society.  

Children and families in poverty are less likely to have health insurance, which affects their ability to have regular care from a primary practitioner and limits access to specialists. Poor families also tend to have difficulty enrolling in and retaining coverage. This makes it challenging to have a regular practitioner over time who can monitor the child as he or she may be transitioning back and forth between insured and uninsured status. Additionally, lower income families can experience other barriers such as transportation to care, ability to take time off of work to attend appointments, linguistic issues, limited access to healthier foods, unsafe neighborhoods that restrict ability for physical activity, and cultural issues that the practitioner may not be familiar with or able to address. Because children are dependent on their parents and caregivers, any limited options of the adults automatically make it more difficult for children to prevent or curb their obesity.

Health Plans

Strengths

Can Define Which Services Are Covered: As most Americans cannot afford to pay for all their health care needs out of pocket, they rely on pooling of funds either through employer-sponsored group insurance, individual private, or public health insurance to cover most of the costs of the care they seek. The types of services covered by health insurance companies often determine the care options for enrollees because most cannot afford to pay for services that do not fall under their coverage plan.  

Currently, wide variances exist in what different states cover or mandate to be covered for obesity-related prevention and treatment. Inconsistent policies within single states as to inclusions and exclusions in plan packages are also common.⁷ When health care professionals cannot receive reimbursement for prevention and treatment programs, they have significant less incentive to provide those services, thereby creating a serious barrier for families.⁸  

In the context of obesity, health plans can play a pivotal role in providing enrollee families options for weight-loss tools and management. All too often, insurance coverage is limited for treatment associated with obesity, sometimes even when comorbidities exist.⁹ Health plans can provide coverage for such providers as nutritionists, physicians who specialize in obesity programs, and mental health professionals, as well as for services such as weight-loss programs, weight-loss medication, and bariatric surgery when recommended. In this way, health plans can remove much of the financial hurdle of using expert assistance to address obesity.  

Financial Incentives: In looking at long-term costs, it makes sense for health plans to use prevention-based models that address nutrition, physical activity, and social and psychological indicators that contribute to obesity in children and families. While requiring investment from the health plan on the front end, such a model is far less expensive than covering the health effects of obesity in children or later when they become adults.¹⁰ Health plans make sense financially when they reduce the prevalence of obesity and its related consequences in enrollees before they experience more serious and chronic conditions.  

Health plans can also employ financial incentives to encourage enrollee families afflicted with obesity to address the issue. Offering financial incentives is a potentially powerful motivation for enrollees to address their obesity; this is particularly true for parents of obese children as those incentives can affect the economics of the family. Further, because obesity disproportionately affects children from low-income families, financial incentives could be especially effective tools in motivating parents to become actively involved in seeing that their children lead healthier lives. Health plans can offer incentives that result in cost-sharing reductions such as lowered insurance premiums for measurable weight-loss results. Other potential incentives include vouchers for health club membership, vouchers for farmers markets or for healthy foods at supermarkets, and credits for enrolling in commercial and community weight-loss programs.  

Health plans can also offer incentives for health care professionals to provide obesity-specific prevention and treatment services by adequately reimbursing those services as well as offering payments, materials, or other supports for those who demonstrate high success rates for serving obese children and families.  

Limitations

While health plans can offer powerful financial incentives, they are still limited by the fact that they usually neither have personal relationships with their enrollees nor do they always have community ties or presence. Enrollees and other purchasers of health insurance generally do not have the same trust in their health plans as they do with their physicians.¹¹ Similarly, most health plans simply do not have the community understanding, ties, and trust as community-based organizations.  

Further, incentives such as reducing insurance premiums may be potentially problematic in states that prohibit insurance rate setting based on health status.⁷ Nevertheless, 26 states are silent on rate adjustment criteria, so these incentives remain a viable, though imperfect, strategy in many areas nationally.⁷

Health plans also question if the investment in the health of a patient is financially prudent. As an example, having a plan spend $30,000 for bariatric surgery for a patient who then leaves the plan during the next open enrollment for a less expensive plan that does not cover bariatric surgery does not justify coverage of such expensive interventions. 

While financial motivations can be significant, especially in these lean economic times, they still do not provide the human relationships that can be so essential to fighting obesity, especially in children. Because social and psychological issues often contribute to obesity, those components must be addressed thoroughly on a personal and community-specific level.  

 Community-Based Organizations

Strengths

Knowledge of Community: While health care professionals and health plans have unique advantages with families and children, community-based organizations have the invaluable strength of knowing and understanding the needs, limitations, biases, and constructs of the communities in which they exist.¹² Because the problem of obesity is so inextricably tied to socioeconomic issues and other social and cultural factors, we must truly understand the perspectives and lifestyles of the afflicted children and their families.  

Community-based organizations are typically colocated within the geographical communities they aim to serve and usually comprise community members or those with community experience. These factors garner a high level of trust among community members that is an important step in working with families to change their lifestyles and health habits. Community-based organizations can offer information and advice in a nondidactic manner in cases where communication can be a pitfall for health care professionals to effectively connect with patients, especially those with low health literacy. Additionally, community-based organizations are in a key position to present information in a manner that is directed and culturally sensitive to the group they serve.¹³ Health care professionals or health plans often find this difficult because, due to geographical, economic, or cultural reasons, they do not have the physical or experiential proximity to the target audience.  

Community-based organizations such as community centers, child care centers, parks, places of worship, education centers, Boys and Girls Clubs, local grocers, legal aid offices, child and family advocacy centers, cultural groups, and entertainment venues can be key players in the fight against obesity. Because they are often "of the communities" they serve, they have direct and sometimes firsthand experience with limitations and barriers such as access to affordable healthy foods, safe places to exercise, and foods that are served or available through vending machines in school. Community-based organizations can often also provide the person-to-person contact, outreach, encouragement, and regular monitoring that can be so valuable to those most in need of obesity intervention.  

Connection With Hard-to-Reach Groups: Another key strength of community-based organizations is their ability to connect with hard-to-reach populations, specifically those composed of uninsured, undocumented, or recent immigrants.¹⁴ These groups have less regular contact with health care professionals or health plans. Connecting with these groups may be particularly important for the uninsured as many are low-income, a factor that is disproportionately present in families and children battling obesity. Newer immigrant groups, both documented and undocumented, tend to have less contact outside of their communities. This may be due to language access limitations or hesitance to connect with agencies that may threaten their residency. For these reasons, both the uninsured and immigrant communities often also have less access to health and nutrition education. Organizations within their communities have the best chance of reaching these groups and including them in health and wellness programs.  

Limitations

Though community-based organizations have strong ties and connections within the communities they serve, they have limited resources. Because most operate as nonprofit organizations, they depend primarily on public and private grants and philanthropy to operate. They also usually have limited budgets that may only be getting tighter in these lean financial times. These limited resources often affect the scope of their work and their ability to serve new children and families and to expand services to meet the changing needs of the community. Additionally, many community-based organizations provide various forms of assistance in their area, and obesity prevention may only be one of many vital services provided. When resources are stretched thin among competing interests, funding devoted to obesity-related issues becomes even more limited.  

Because of their limited resources, community-based organizations are also generally not in the position to offer financial incentives to participate in obesity programs. While they may have relationships and partnerships with area vendors to offer discounts on items like local health clubs or supermarkets, they are unlikely to be able to offer the types of incentives that health plans can, which can affect a family's bottom line.  

Furthermore, while many community-based organizations partner with area hospitals or other practitioners to provide and distribute health and nutrition education in their communities, they generally do not have the same health expertise as practitioners, especially those who specialize in children's health and obesity. Thus, they are not always able to necessarily identify risk factors, conduct proper screenings, or identify and address other health issues related to obesity in children. While community-based organizations usually have an advantage in identifying the socioeconomic contributors for a child's obesity, the correct line of messaging to convince the child or family, and the ability to facilitate wellness programs, these organizations are not typically able to fully address the complex health and medical issues for an obese child.  

A Multipronged Approach  

While each of the stakeholders listed offers its own significant advantages in the battle against childhood obesity, each also has limitations that prevent it from being a singular solution. Accordingly, the best strategy is a multipronged approach that combines the strengths from each stakeholder and can also overcome the other's weaknesses. Employing a strategy that combines all three stakeholders can provide expert medical care in the most vulnerable communities with adequately funded intervention and treatment programs.  

Central Texas MEND Partnership

An example of such a strategy is that of the MEND Program (Mind, Exercise, Nutrition, Do It!), a project in conjunction with Scott & White Healthcare and Scott & White Health Plan in Central Texas. This program seeks to combine the medical expertise provided through the Healthcare System with funding provided in part through the Health Plan and community staff and venues provided by the City of Temple Parks and Recreation and local YMCAs. This joint effort is meant to reach children and families at high risk for obesity in the community by focusing on the behaviors that cause obesity.¹⁵  

The MEND program originated in the United Kingdom and focuses on four aspects that affect eating and lifestyle habits: Mind (social learning theory and behavior modification), Exercise (active play for children), Nutrition (customized healthy eating), and Do It (putting what is learned into action). The program in Central Texas started in early 2011. In this Central Texas partnership, the funding partners (including Scott & White Health Plan) provide funding and financial resources to the MEND program, which provides the curriculum, training, and equipment to the delivery partners (City of Temple Parks and Recreation, YMCAs, and Scott & White Healthcare) who connect the community and administer the program to the children and families in need.  

The Central Texas program is free for families and for children aged 7 to 13 years. Participants must attend 20 sessions that are 2 hours each, occurring twice a week.¹⁵ Most of the children participants were African American (41%) and came from families earning $20,000 or less annually.¹⁵ While 9% were uninsured, most either had employer-based coverage (41%) or public health insurance (40%).¹⁵ The remaining 10% of the participants' insurance status was unknown. 

While most of the participants did not state that they had issues with transportation to the program, many had limited access to healthy foods. Most of the children in the program were recipients of free or reduced-price school meals and relied on that public benefit for one to two of their daily meals (breakfast or lunch or both). While these meals meet minimum federal and state nutritional requirements, they do not comply with MEND program recommendations (according to email communication from C. Ramm, September 2011). This was a challenge as most of the children's families had limited financial resources and experienced difficultly providing separate healthy meals to take to school for these children. As a result, the program worked with the children on how to make healthier choices among what was available at school and continued to work with their families on making better choices for food served at home that was still within their budgets. 

The initial data reveal mean positive changes across all the evaluated variables: BMI, waist circumference, physical activity, sedentary activity, resting heart rate, nutrition, total difficulties, body image, and self-confidence.¹⁵  

Conclusion

Childhood obesity is caused by a complex combination of nutritional, health, educational, economic, cultural, and social factors. No single approach can serve as a "magic bullet" cure. Instead, strategies by which persons with expertise address these factors in a specialized, thoughtful, and culturally competent manner are the best way to tackle this difficult issue. Although obesity is a complex health condition, it is also preventable and most importantly, reversible, if the afflicted child makes the correct nutritional and lifestyle modifications. In a multifaceted approach, each stakeholder has its own expertise and can focus on that issue. 

For example, health care professionals can focus on progressive screening by using recommendations such as the AMA's "Recommendations on the Assessment, Prevention, and Treatment of Childhood Obesity." Once a child is identified as at risk for or afflicted with obesity, health care professionals can concentrate on evaluating whether the child has other health conditions and, if so, initiate proper treatment. Due to their regular contact with families, position of trust with parents, and expertise in health, practitioners can also work with parents in creating healthier nutrition plans for their families.  

Similarly, health plans can focus on creating opportunities and incentives for families to initiate healthier lifestyles and receive any necessary treatment to address their obesity. By specifically offering coverage for weight-loss programs, obesity-related procedures, and medications as well as mental health services specific to obesity, health plans make it financially possible for children and families to receive the health care they need to lead healthier lives. Additionally, by offering financial incentives in the form of premium discounts, vouchers for healthy lifestyle modifications, and proper reimbursement for health care professionals who specialize in this type of care, health plans can provide a powerful motivation for families to change their nutrition and lifestyles. This can be particularly effective in the current lean economic landscape.  

Community-based organizations can focus on their strengths of close ties to the community, trusted relationships, and unique access to day-to-day experiences and perspectives that lead to childhood obesity, as well as firsthand knowledge of the community-specific barriers and the most effective means to overcome limitations. These organizations play a pivotal role because they are usually located in communities of need and are composed of people from that community. Thus, they are in the best position to advise on what social and cultural factors should be addressed in an obesity program and the best strategies for doing so. They can often serve as the physical house for the programs as they are generally accessible for community members and can offer specific linguistic and cultural services needed by area families. Community-based organizations can also serve as advocates to improve the physical and social environments that lead to obesity in their areas by advocating for affordable, healthy food options such as public green markets, healthier foods served at schools, restrictions on unhealthy food and soft drink vending machines in schools and places where children play sports, and improved and safer green spaces in which children can play and exercise.  

By employing the strengths of each stakeholder to create a multifaceted partnership, the varied factors that lead to obesity in children can be addressed in a concerted effort that is largely prevention based. The Central Texas MEND Partnership is an example in which health care, health plans, and community-based organizations have come together to lend their specific expertise for a common cause that has initially yielded positive results. Such models are important to study and replicate across communities of need and those disproportionately affected by obesity. Through such collaboration, the entire society can benefit financially, ethically, and morally by reversing current trends and creating healthier future generations.   

1. Michael & Susan Dell Center for Healthy Living. Childhood Obesity Factsheet. 2010. https://sph.uth.tmc.edu/content/uploads/2011/12/Obesity-fact-sheet-2010-9.21.2010.pdf. Accessed October 25, 2011. 
2. American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity. Updated October 1, 2011. www.aap.org/obesity/about.html. Accessed September 15, 2011. 
3. Medicaid Child Obesity Prevention Pilot. Report to the Texas Legislature. Austin, Texas: Health and Human Services Commission Report; 2011. 
4. Ogden CL, Carroll MD, Flegal KM . High body mass index for age among US children and adolescents, 2003-2006. JAMA. 2008;299(20):2401-2405.
5. American Medical Association. Recommendations on the Assessment, Prevention, and Treatment of Childhood Obesity. 2011. http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/obesity/childhood-obesity/assessment-prevention-treatment.page. Accessed September 15, 2011. 
6. Thompson Medstat. Childhood Obesity: Costs, Treatment Patterns, Disparities in Care, and Prevalent Medical Conditions. 2006. http://www.medstat.com/pdfs/childhood_obesity.pdf. Accessed October 25, 2011.
7. State survey of coverage of obesity interventions finds coverage of treatment options limited for overweight and obese populations across the United States. STOP Obesity Alliance, George Washington University Department of Health Policy. Spring 2011. http://www.stopobesityalliance.org/wp-content/assets/2011/05/Spring-2011-Obesity-and-the-States-Bulletin-FINAL.pdf. Accessed September 15, 2011. 
8. Krebs NF, Jacobson MS; American Academy of Pediatrics Committee on Nutrition. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112(2):424-430. 
9. Tershakovec Am, Watson MH, Wenner WJ Jr, Marx AL. Insurance reimbursement for the treatment of obesity in children. J Pediatr. 1999;134(5):573-578. 
10. Cowley J. The economics of childhood obesity. Health Aff. 2010;29(3):364-371. 
11. Goold SD. Money and trust: relationships between patients, physicians, and health plans. J Health Polit Policy Law. 1998:23(4):687-695. 
12. Engaging parents in education: Lessons from five parental information and resource centers. US Dept of Education, Office of Innovation and Improvement Report. 2007. http://www2.ed.gov/admins/comm/parents/parentinvolve/report_pg14.html. Accessed September 15, 2011.
13. Besculides M, Trebino L, Nelson H. Successful strategies for educating hard-to-reach populations: Lessons learned from Massachusetts' train-the-trainer project using the Helping You Take Care of Yourself curriculum. Health Education Journal. March 14, 2011. 0017896911398982. First published on March 14, 2011 as doi:10.1177/0017896911398982.
14. Outreach strategies for Medicaid and SCHIP: an overview of effective strategies and activities. Kaiser Commission on Medicaid and the Uninsured Report. April 2006. http://www.kff.org/medicaid/upload/7495.pdf. Accessed September 15, 2011. 
15. Hogg R, McNeal C. Temple & Waco MEND. PowerPoint presentation, April 26, 2011. Meeting at Scott & White Healthcare. 

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