short communicationS
nature publishing group
epidemiology
A Pediatric Weight Management Program for High-risk Populations: A Preliminary Analysis Joseph A. Skelton1–3,8, Laure G. DeMattia4,5 and Glenn Flores6,7 Objective: To determine whether a multidisciplinary pediatric weight management program effectively improves BMI, BMI z-score, and cardiovascular risk factors (CVRFs) in high-risk populations. Methods and Procedures: A retrospective chart review was performed on children seen in the NEW Kids Program at the Children’s Hospital of Wisconsin, a family-based clinic that treats pediatric obesity using medical management, nutrition education, behavioral intervention, and physical activity. Inclusion criteria were program participation for ≥9 months and >4 visits. Analyses were performed to identify factors associated with pre- to postintervention changes in BMI, BMI z-score, and CVRF laboratory values. Results: A total of 66 patients met inclusion criteria; the mean age was 11 years (s.d. ± 3.4), 56% were racial/ethnic minorities, 45% were Medicaid recipients, 48% resided in impoverished communities, and 38% had a BMI ≥40 kg/m2. Of the 66 patients, 91% had more than one weight-related comorbidity, 88% had CVRFs, and the preintervention mean BMI was 37 kg/m2. After the intervention, there was an overall increase in absolute BMI, but a small, yet significant decrease in BMI z-score (mean –0.03 ± 0.16; P < 0.05). There were significant pregroup to postgroup improvements in total cholesterol, low-density lipoprotein, and triglycerides levels (P < 0.05). Insurance coverage, race/ethnicity, gender, age, and initial BMI were not significantly associated with changes in BMI or BMI z-score. Discussion: A multidisciplinary pediatric weight management program can improve the weight status of high-risk populations, including minorities, Medicaid recipients, patients with multiple comorbidities and CVRFs, and the severely obese. Obesity (2008) 16, 1698–1701. doi:10.1038/oby.2008.243
Obesity has become pandemic in the United States, among both children and adults (1). Unfortunately, few effective treatment options exist for obese children. Interventions that include behavioral change (2) and multidisciplinary treatment teams (3) have yielded some success, but effective options for childhood weight management are still limited, especially for high-risk populations (1,4). Also, little is known about effective obesity treatments for children who are poor, have multiple comorbidities, or are morbidly obese (5). The objectives of this study were to determine whether a tertiary-care, multidisciplinary pediatric weight management program (i) reaches high-risk populations, including those who have multiple comborbidities, are poor, and are from racial/ethnic minorities; and (ii) improves BMI, BMI z-score, and cardiovascular risk factors (CVRFs).
Research Methods And Procedures The NEW Kids Program The NEW Kids Program at the Children’s Hospital of Wisconsin is a multidisciplinary weight management clinic that features cognitive behavioral modification in a team setting. Staffed jointly by a pediatrician, nurse practitioner, dietitian, psychologist, and physical therapist, this program is limited to 2- to 18-year-old children who are either overweight or obese with one or more obesity-related comorbidities (6), including dyslipidemia, insulin resistance, fatty liver, orthopedic problems, pseudotumor cerebri, sleep apnea, or hypertension. Children are seen in individual clinic appointments by the multidisciplinary team; based on the initial visit, individualized care plans are formulated for patients and families, with the entire household encouraged to adopt healthy lifestyle changes. Therapy is based on a cognitive behavioral model, in which the health psychologist works to increase patient and family awareness of daily lifestyle habits, and transforms maladaptive thoughts about lifestyle change into beneficial thoughts, feelings, and
Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; 2NEW Kids Program, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA; 3Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA; 4 Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; 5DeMattia Medical Group, Milwaukee, Wisconsin, USA; 6 Division of General Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; 7Children’s Medical Center, Dallas, Texas, USA. 8Present address: Section of Pediatric Gastroenterology, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA. Correspondence: Joseph A. Skelton (
[email protected]) 1
Received 21 February 2007; accepted 1 October 2007; published online 24 April 2008. doi:10.1038/oby.2008.243 1698
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short communicationS epidemiology behaviors. Nutrition and physical activity education, training, and support are provided to assist caregivers in implementing behavioral change. Problem areas in nutrition and activity are identified and prioritized, with specific recommendations focused on deficient areas. Advancement to more rigorous dietary and exercise treatment (portion control, increased complex carbohydrates, exercise prescriptions) is attempted after progress has been made in addressing the problem areas. Most families make visits every 1–3 months. As patients and families demonstrate success (i.e., positive social, emotional, and/or behavioral change, improvements in laboratory studies, and/or improved BMI), appointment intervals are increased until patients no longer meet program criteria, resulting in referral back to their primary care physician. Study design and chart abstraction A retrospective chart review was performed by program physicians and trained research assistants on patients initially evaluated in the NEW Kids Program from 1 June 2003 to 1 April 2005. Inclusion criteria were program participation for ≥9 months, and more than four visits to the clinic; these criteria were chosen to examine specifically the program’s effect on patients who adhered to follow-up recommendations and had adequate exposure to the clinic and its interventions. It typically takes >4 visits to complete basic nutrition education and establish behavioral change patterns, with treatment duration typically ~12 months. Sociodemographic data collected during program enrollment (baseline) included birth date, self-reported parental height and weight, zip code, race/ethnicity, and guardianship. Additional baseline data collected included initial fasting serum laboratory studies (insulin, glucose, hemoglobin A1C, aspartate transaminase, alanine transaminase, total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides) from the referring physician, and also height and weight. Weight-related comorbidities were diagnosed by the NEW Kids clinicians through review of laboratory studies, initial evaluation, past medical history, and medical records. Laboratory studies and anthropometric data were collected at each follow-up visit. All height and weight measurements were performed by trained NEW Kids team members using a Harpenden stadiometer (Holtain, Dyfed, UK) and Health o meter Pro Plus electronic wheelchair scale (Pelstar, Alsip, IL), with the child’s shoes removed and in light clothing. Data analysis Wilcoxon test and ANOVA were used to analyze significant changes in BMI, BMI z-score, and laboratory values before and >9 months postprogram initiation. χ2- and paired t-tests were used to examine associations between sociodemographic factors and changes in BMI, BMI z-score, and laboratory values. All statistical analyses were performed using SAS version 8.2 (SAS Institute, Cary, NC). Results Study sample and participant characteristics
Initial evaluations of 398 patients were done between June 2003, and April 2005; 23 patients were excluded who were seen for a single-visit consultation to evaluate endogenous obesity causes, 127 patients were excluded because of program enrollment for 35 mg/dl
29
Total cholesterol (mg/dl)
63
180 (±34)
≤170 mg/dl
41
HDL, high-density lipoprotein; LDL, low-density lipoprotein. a Some patients did not have all laboratory studies performed, due to incomplete records from referring physicians or missed opportunities by staff.
Table 4 Pre- to postintervention changes in BMI and BMI z-scores among study children (N = 66) in the NEW Kids Program Weight status change Overall BMI change Overall BMI z-score change
Mean change (±s.d.)
Median change (range)
1.0 kg/m2 (±2.7)*
0 kg/m2 (–6,11)
–0.03 (±0.16)**
–0.03 (–0.7, 0.3)**
*P = 0.005 by Wilcoxon test, **P < 0.05 by Wilcoxon test.
Insurance coverage, race/ethnicity, gender, age, and initial BMI were not significantly associated with either BMI or BMI z-score changes. Discussion
The findings of this preliminary analysis suggest that a multidisciplinary pediatric weight management program can improve weight status and CVRFs in a diverse population. The study intervention was as effective for racial/ethnic minority children as it was for white children in reducing BMI and 1700
–6.5 (±21)
†
Median change (range) –12.5 (–69, 36)* –15 (–251, 176)**
–2 (–90, 24)†
CVRFs. This finding is noteworthy given that minority children continue to have the highest obesity rates (1,4,7). Several features might account for the success of the study program among minority children and families, including approaches tailored to each family, and emphasis on culturally appropriate education and information. The most successful pediatric weight management interventions have been evaluated in predominantly dual parent, middle-class white populations with few comorbidities (2), but few studies exist for diverse populations. One study reported successful outcomes among children whose mean BMI was 35.6 kg/m2, with 32% African American and 32% receiving Medicaid (8). A recent randomized, controlled study demonstrated improvement in weight status and insulin resistance, with over half of participants being racial/ethnic minorities (9). Our study had a high attrition rate (73%) across all groups. A high rate (83%) was noted initially in the recent controlled study (9), falling at the upper range of reported rates in pediatric programs (33–83%) (8–13). Programs have begun to explore attrition determinants (12,13), as this is an important part of behavioral medicine, and could improve overall treatment efforts. Certain study limitations should be noted. Although there were several statistically significant findings, the sample size and overall change in BMI of this preliminary study was relatively small. The statistical power of this study was insufficient to determine whether change in BMI z-score was associated with changes in laboratory values. In-depth analyses could not be performed for subjects who withdrew or were lost to follow-up, so the findings may have been subject to potential distortion due to lack of data on these subjects, although analyses revealed no differences between participants and dropouts. Because this preliminary analysis evaluated a relatively small sample size of patients, these findings may not necessarily generalize to other populations, and randomized, controlled trials of the program effectiveness are needed to confirm the findings of this retrospective study without a control group. Although the statistically significant changes in BMI and BMI z-score were not substantial, we believe that they are of clinical significance, as the growth trajectory of children enrolled in the program was quite steep, often outstripping the growth curve. Given that most obese children are likely to become overweight or obese adults (14), programs are needed VOLUME 16 NUMBER 7 | JULY 2008 | www.obesityjournal.org
short communicationS epidemiology that are efficacious in reducing BMI, BMI z-scores, and CVRFs, particularly among hardest-to-reach populations and greatest risk populations. In summary, a multidisciplinary pediatric weight management program can achieve success in high-risk populations, including racial/ethnic minorities, the poor, the severely obese, and patients with multiple comorbidities and CVRFs. The findings of this preliminary analysis suggest that a multidisciplinary pediatric weight management program could be an effective means of reaching and treating high-risk populations of obese children. Acknowledgments We thank Maureen Otto, Qun Xiang, Jing-nan Mao, George Kay and the Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin for their statistical and organizational help in this project. This study was presented in part as a poster at the annual meetings of the Pediatric Academic Societies, 30 April 2006, in San Francisco, CA, and the North American Association for the Study of Obesity, 18 October 2005, in Vancouver, British Columbia, Canada.
Disclosure The authors declared no conflict of interest. © 2008 The Obesity Society
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