Childhood Obesity Research Summit: What Was Different About this Conference?
Pub Date: Monday, March 30, 2009
Author: Sarah E. Barlow, MD, MPH
Daniels SR, Jacobson MS, McCrindle B, et al: American Heart Association Childhood Obesity Research Summit: Executive Summary. Circulation 2009. Published online before print March 30, 2009. 10.1161/CIRCULATIONAHA.109.192215.
This meeting could have been the same old story: "Childhood obesity is a big and growing problem, no pun intended [pause for laughter]. The country will be overwhelmed by health care costs. The causes of this problem are complex interactions between genetics, environment, and behavior, best represented by the bioecological model. We must do something, but nothing seems to work. More research is needed." People involved in addressing this complex problem may find themselves examining and trying to change one piece of the elephant, reading scientific literature and attending meetings about their area of focus. The summit brought into one room a wide range of professions and disciplines, with a goal not to solve the problem but to broaden the perspective on the possible paths to reducing the obesity prevalence.
The purpose of this meeting was to inform the American Heart Association in setting a research agenda for childhood obesity and the Alliance for a Healthier Generation, a collaboration between the American Heart Association and the William J. Clinton Foundation, as they developed the health care initiative. The meeting focused on the role of health care in childhood obesity. Because obesity is a health condition, many look to health care to take care of obese children and adults. Yet the system, as it now stands, is poorly designed to address this problem. Not only are resources lacking (time and reimbursement), but the model of health care visits (identify, evaluate, prescribe) works poorly in this condition.
After a brief review of pathophysiology and medical and psychosocial consequences of obesity, the conference moved quickly into practical issues around current state of management: first how to assess children (lifestyle, clinical, psychosocial), then how to implement programs to improve diet, exercise, and behavior change in general. Most of the speakers in these areas not only are well known for their experience conducting research, but they also are part of clinical programs designed to serve the needs of patients coming to the institutions. As a result, they see practical challenges of offering these programs and the challenges patients may experience in participating in them.
The session on barriers to care included lack of access to insurance and health care disparities. Insurance is a frequent scapegoat for the challenges to health care in this condition, but Dr. Lisa Simpson set out a framework for collaboration between patients/families, health care, health care payers, and community, and described some innovative programs initiated by insurance companies. The barriers at the family level, including lack of motivation and environmental challenges, were described, but also programs to modify these barriers were presented.
Perhaps the most exciting section of the conference was on Models from Other Disciplines. The adult chronic care model, heart failure, type 2 diabetes, childhood asthma, and tobacco all offer lessons on how to take care of obesity. None are perfect parallels, but together they offer a vision that conditions that are influenced by environment, that require a combination of health care and personal change, and that receive attention from social marketing and public policy to change environment, can improve with persistence and time.
Finally, the conference focused on research issues. These issues included selecting appropriate targets for research, including different stages of life and selection of appropriate outcomes to study, and the process of engaging relevant stakeholders in multilevel interventions, such as the Somerville project and Pennsylvania's approach to preparing both schools and health care practices for school-based body mass index assessment. Research to improve health care systems requires "translating" approaches that are efficacious in ideal settings into the reality of clinical practice, and Dr. Helen Binns' experience with Practice-Based Research emphasized the related challenges. The evaluation and documentation that high quality research requires is often inconsistent with the needs and goals of most practices, which is individualized care, efficiency, and patient satisfaction. Obesity prevention topics compete with many other anticipatory guidance topics at each well child visit, and currently pediatric practitioners devote 2 to 4 minutes to growth, diet, and activity in normal weight children. Small wonder that they feel their efforts are futile.
The summit ended with review of priorities from important funding agencies, including the National Institutes of Health and Centers for Disease Control and Prevention, and information on dissemination, including governmental policy initiatives and the National Initiative for Child Healthcare Quality's work to share toolkits on childhood obesity.
In sum, this meeting focused on the practical; what we know about programs and tools that show promise, what barriers threaten those programs, how, in practical terms, best practices can be implemented, because it is more than just "proving they work," and some models for success when looked at beyond the 3 years of a funded grant.
The recently announced Alliance Healthcare Initiative from the Alliance for a Healthier Generation puts into action many of the points emphasized in this conference. The initiative addresses a practical issue, lack of insurance coverage for obesity. It arises from collaboration between stakeholders, including major insurance companies, large employers who contract with the insurance companies for employee benefits, and the American Academy of Pediatrics and American Dietetic Association who will provide education to practitioners. And it pays attention to dissemination, making sure that consumers know about the new benefit. During the first year of this program, it is anticipated that nearly 1 million children will have access to this benefit option. The long-term goal of the Alliance Healthcare Initiative is that within the first 3 years, 25 percent of all overweight children (approximately 6.2 million) will have access to this benefit. Although expanding health care coverage is not the single answer to the obesity epidemic, it is a step in the right direction. More importantly, the initiative demonstrates the possibility of multilevel, multi-partner approaches that connect clinical care, research, the private sector, foundations, and individual families. We will pay close attention to the outcome of the Alliance initiative and hope that this summit and others like it will generate new collaborative approaches to childhood obesity.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --