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Weight Loss Center Aims to Help Rural, Obese Children Improve Mental and Physical Health by Integrating Medical, Psychosocial, and Nutrition Services


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Summary

The Pediatric Healthy Weight Research and Treatment Center, operated by the Brody School of Medicine's Department of Pediatrics, provides comprehensive, multidisciplinary, family-centered evaluation and treatment for overweight and obese children by addressing the mental and physical health needs of these children and their parents/caregivers. The center collaborates with local health care providers, provides resources and expertise to area clinicians, and provides funding and staff support to community-wide events, including educational outreach efforts and a summer weight loss camp. A preliminary evaluation of 69 children who received care at the center found no overall decline in mean body mass index score, although 51 percent of study participants (primarily older children) did lower their scores. These results may in part be attributable to the small sample size of the study and to low compliance with followup psychotherapy and nutrition appointments. Leaders continue to refine the program to improve compliance.
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Developing Organizations

Eastern Carolina University's Brody School of Medicine
end doIn 2006, the center began providing onsite integrated care. In 2007, the center began offering a summer weight loss camp.begin ppxml

Patient Population

Approximately 63 percent of the children in the program are African American; the children range in age from 2 to 18.Vulnerable Populations > Children; Impoverished; Rural populationsend pp

Problem Addressed

Childhood obesity is a growing problem that has significant long-term consequences for physical and mental health, especially among minority, low-income children living in rural areas. Despite increasing awareness of the problem and the availability of effective evaluation and treatment methodologies, few children in these areas have access to services that can help.1
  • High obesity rates among rural, African-American children: According to the 2007 to 2008 National Health and Nutrition Examination Survey, 31 percent of children and adolescents aged 2 to 19 were at or above the 85th percentile for body mass index (BMI) for age (i.e., overweight, obese, or severely obese).2 Rural children were more likely to be obese than urban children, and African-American youth have the highest rate of obesity.3,4,5 Specifically, youth populations that have been found to have increased prevalence for obesity include Hispanic males and African-American females.5 Rural children were more likely to be obese than urban children, and African-American children were more likely to be overweight than Hispanic and white children.2 In eastern North Carolina, one study found that half of all children in the region were overweight or obese, much higher than the national average.6
  • Poverty, poor nutrition, and lack of physical activity as contributing factors: Eastern North Carolina has high rates of poverty (15 percent), with up to 30 percent of families with children receiving food stamps in some counties. Studies of the region's youth show they have little or no daily physical activity, half watch 3 or more hours of television daily, and many youth consume unhealthy levels of sugar-sweetened beverages and high-fat, low-nutrient foods.7
  • Negative consequences to physical and mental health: Young, obese people are at risk of developing serious obesity-related psychosocial issues in a society that stigmatizes this condition, often fostering shame, self-blame, and low self-esteem that may impair academic and social functioning. These problems often last well into adulthood.
  • Lack of access to effective evaluation and treatment: Evaluation and treatment can help overweight and obese children to lose weight, but many low-income, rural children lack access to these services. For example, one study found that a 4-week stay at a weight loss camp enabled obese adolescents to lose weight, reduce BMI (a measure of weight proportionate to height), and improve self-esteem, self-worth, athletic competence, and the level of satisfaction with their body shape.8 However, many low-income, rural children lack access to these kinds of camps and other effective weight-loss services.9

What They Did

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Description of the Innovative Activity

Pediatric Healthy Weight Research and Treatment Center, operated by the Brody School of Medicine's Department of Pediatrics, provides comprehensive, multidisciplinary, family-centered evaluation and treatment for overweight and obese children by addressing both the mental and physical health needs of these children and their parents/caregivers. The center collaborates with local health care providers, provides resources and expertise to area clinicians, and provides funding and staff support to community-wide events, including educational outreach efforts and a summer weight loss camp. Key elements of the program are described below:
  • Initial referral to center: Providers in the 44-county area of eastern North Carolina can refer children between the ages 2 and 18 who are above the 85th percentile for BMI. Most referred children have or are at risk of developing weight-related complications.
  • Indepth initial medical examination: The center's physician performs a full medical examination of the child, which includes testing cholesterol levels, insulin resistance, liver and thyroid function, and cardiovascular health. A physical activity assessment is performed jointly by the physician and a registered dietitian. If physical therapy is needed, the child is referred to an offsite physical therapist affiliated with the university.
  • Psychosocial screening: Providers perform indepth psychosocial screening of children and parents/caretakers using various tools, including the PedsQL™ Measurement Model, to examine quality of life at home and in school, and to identify any potential risk factors that might signal depression and/or increased risk of suicide. Children who are found to be depressed or to have other psychological problems are referred to the center's onsite medical family therapist, who specializes in obesity treatment. If parents are found to be depressed or have other psychosocial issues, they are referred to an offsite family therapy clinic affiliated with the medical school.
  • Motivational nutrition and physical activity interviewing and screening: Patients and caregivers review their typical daily and weekly eating habit with a nutritionist. The nutritionist identifies deficiencies and uses motivational interviewing strategies to highlight opportunities for changing diet. Together, a plan is made to address nutrition changes (e.g., eating in front of the television and consumption of sweetened beverages) and to increase physical activity.
  • Use of an indirect calorimetry in patients age 7 and older: The center uses indirect calorimetry with children, a tool commonly used with obese adults to evaluate daily caloric needs. This method renders a more accurate assessment of the children's daily caloric needs than does use of conventional metabolic charts, which due to racial differences can overestimate the needs of African-American children.
  • Dental and other medical services and referrals: The center has a full dental clinic to serve the many children who do not have access to dental care. (Many dentists in the region do not accept Medicaid reimbursement.) Referrals are also made to pediatric subspecialties, such as endocrinology, cardiology, and sleep studies, as needed.
  • Open-ended followup treatment: By treating obesity as a chronic condition, clinicians currently plan for 2 years of treatment and followup. The center's physician typically sees each patient every 1 to 3 months. The following occurs during the typical return visit:
    • Measurement and monitoring of diet and physical activity: During followup appointments, children's weight and BMI are measured. Providers consult with the patient and parents about diet and physical activity levels through continued motivational interviewing and goal-setting.
    • Psychosocial monitoring and coping skills intervention: During every followup visit, an onsite family medical therapist performs quality-of-life screening and accompanies the child to visits with the center's doctor to facilitate communication and coordinate the treatment plan. The therapist teaches general parenting skills to caregivers, and instructs children on how to handle negative social situations, such as teasing and bullying, and how to develop a positive outlook on weight-loss goals and improve self-image and self-esteem. Therapy also addresses how mental health issues might be influencing eating and exercise behaviors.
    • Nutrition education: The patient meets with the nutritionist monthly, if possible, to review eating habits and food choices, as in conventional weight loss management programs.
  • Community education and outreach to the public and clinicians: The center sponsors and supports a variety of activities designed to raise awareness among clinicians and the public at large, as described below:
    • Community-wide events: The center participates in a number of community-wide events, such as health fairs at local malls and the KIDSFEST designed to increase awareness of educational, health, and social services for young children and their families. The center has also sponsored annual Pediatric Health Weight Summits since 2005 to introduce the center to the local community, regional clinicians, and East Carolina University faculty. In addition to the conference, the center sponsors a Web site, and area clinicians, researchers, and public health professionals interested in obesity can join an e-mail list to receive obesity-related information.
    • Standardized referral and treatment protocols: Center staff spearheaded the formation of a Pediatric Medical Nutrition Therapy Group in Pitt County. This group has developed standardized referrals, medical nutrition therapy protocols, and patient education materials to be used by providers throughout the county and state with overweight and obese children.
    • Summer weight loss camp: To provide children with an intensive combination of physical activity, nutrition counseling, and coping skill support that was not available through the center's outpatient clinic, the center sponsored the Take Off 4-Health summer camp in 2007. Campers participate in recreational programs (e.g., swimming, boating, hiking), and attend interactive and hands-on educational sessions focused on healthy eating, increasing physical activity, and boosting self-esteem and body image.

Did It Work?

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Results

A preliminary evaluation of 69 children who received care at the center found no overall decline in mean BMI score, although 51 percent of study participants (primarily older children) did lower their scores. These results may in part be attributable to the small sample size of the study and to low compliance with followup psychotherapy and nutrition appointments.
  • No overall decline in BMI score, but 51 percent of patients did experience a decline: The center followed 69 patients for 7.8 months after their initial evaluation and found no change in the mean BMI score across all patients. However, 51 percent of the children experienced a decline in their BMI score, with an average reduction of 9.2 percent. The remaining 49 percent saw their BMI scores increase, with an average gain of 4.3 percent.
  • Age associated with BMI score improvements: The children who lowered their BMI score tended to be older (average age of 11.4 years) than those whose BMI score increased (average age of 9.2 years).
  • Poor adherence with followup appointments likely a contributing factor: The failure of participants to adhere with recommended followup appointments and services may have contributed to the program's apparent lack of success.
    • Limited uptake of psychotherapy due to transportation barriers: Since 2006, psychotherapy has been recommended to more than half of children and parents. However, to date, only about 10 percent of children have received the recommended services. Families commonly travel long distances to reach the clinic—about 45 to 60 minutes each way.
    • Limited uptake of nutrition counseling due to transportation and cultural barriers: Only half of participants return for the recommended monthly appointments. Additional barriers, such as culture and cost, may exist.

What They Learned

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  • Integrate onsite mental health services into the treatment approach: Because of geographic barriers and a shortage of psychotherapists in the region, parents and children often did not followup and receive the mental health services recommended by the center's staff. To address this issue, in 2007 the center began offering onsite medical family therapy followup appointments.
  • Consider offering a summer camp option: Anecdotal reports and evidence from other settings suggest that this kind of summer camp can have a positive impact.
  • Fine-tune treatment strategies and develop patient registries: The center is continually fine-turning its treatment protocols and developing patient registries to evaluate patient outcomes. For example, the center has begun following patients and caretakers who receive mental health counseling—as well as other weight loss education counseling—to see how effective the addition of psychosocial services has been in generating reductions in BMI and improvements in quality of life for the child and caregiver.
  • Use a variety of staff to provide comprehensive services: The center employs a wide variety of professionals, including a full-time program manager and the following part-time employees: a scheduler/administrator, licensed dietitian, and a medical family therapist (a doctoral student).
  • Obtain funding to support clinical and nonclinical components: The Medicaid program in North Carolina recently expanded reimbursement for medical family therapy services, which may provide more funding for obesity treatment services provided by physicians, licensed dietitians, and medical family therapists. The medical school also provides funding for the center's clinical care. As noted earlier, the center provides summer camp scholarships to low-income children that are funded by external donors. (The camp costs $600 per week.)
  • Bridge cultural disconnects between staff and patients: Although all staff at the center are white, they serve a predominantly nonwhite population. The cultural "disconnect" introduces an additional barrier to providing culturally sensitive care, which is especially important when addressing issues such as food choices. It is unclear if this disconnect is partially responsible for the low adherence rate with recommended visit frequency. Low compliance may also be the result of poverty and limited access to transportation.

More Information

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Contact the Innovator

David N. Collier, MD, PhD, FAAP
Director, Pediatric Healthy Weight Research and Treatment Center
Assistant Professor and Vice Chair for Research, Department of Pediatrics
Adjunct Assistant Professor of Family Medicine and Exercise and Sport Science
LSD 174
Brody School of Medicine at East Carolina University
Greenville, NC 27834
Phone: (252) 744-3538
E-mail: collierd@ecu.edu

Keeley J. Pratt, PhD, LMFT, AAMFT Approved Supervisor
Visiting Assistant Professor, Couple and Family Therapy Program
Department of Human Sciences
The Ohio State University
151H Campbell Hall
1787 Neil Ave
Columbus, OH 43210
Phone: 614-247-7883
E-mail: pratt.192@osu.edu

Suzanne Lazorick, MD, MPH, FAAP
Assistant Professor, Pediatrics
Associate Director of Community Research and Prevention, Pediatric Healthy Weight Research and Treatment Center
Brody School of Medicine, East Carolina University
600 Moye Blvd., 3E-139 Brody Building
Greenville, NC 27834
Phone: (252) 744-9075
E-mail: lazoricks@ecu.edu

Innovator Disclosures

Drs. Collier, Pratt, and Lazorick have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Walker M, Gately P, Bewick B, et al. Children's weight-loss camps: psychological benefit or jeopardy? Intl J Obes Relat Metab Disord. 2003;27(6):748-54. [PubMed] Available at: http://www.nature.com/ijo/journal/v27/n6/full/0802290a.html

Crawford Y. Childhood obesity: how do children in eastern North Carolina measure up? Department of Pediatrics, Brody School of Medicine at Eastern Carolina University and University Health Systems. May 2006. Available at: http://www.ecu.edu/cs-dhs/pedsweightcenter/upload/Childhood%20Obesity_White%20Paper2006_web.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)

Footnotes

1 O'Brien S, Holubkov R, Reis E. Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics. 2004;114(2):e154-9. [PubMed]
2 Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA. 2010;202:242-9. [PubMed]
3 Liu J, Bennett K, Harun N, et al. Overweight and physical inactivity among rural children aged 10-17: a national and state portrait. South Carolina Rural Health Research Center. May 2007. Columbia, SC. Available at: http://rhr.sph.sc.edu/report/SCRHRC_ObesityChartbook_Exec_Sum_10.15.07.pdf
4 Freedman D, Dhan L, Serdula M, et al. Racial and ethnic differences in secular trends for childhood BMI, weight, and height. Obesity. 2006;14:301-8. [PubMed]
5 Freedman DS, Wang J, Thornton JC, et al. Racial/ethnic differences in body fatness among children and adolescents. Obesity. 2008;16(5):1105-11. [PubMed]
6 Pediatric Healthy Weight Research & Treatment Center. East Carolina University Department of Pediatrics, The Brody School of Medicine. Available at: http://www.ecu.edu/cs-dhs/pedsweightcenter/
7 Crawford, Y. Childhood obesity: how do children in eastern North Carolina measure up? Department of Pediatrics, Brody School of Medicine at Easter Carolina University and University Health Systems. May 2006. Available at: http://www.ecu.edu/cs-dhs/pedsweightcenter/upload/Childhood%20Obesity_White%20Paper2006_web.pdf
8 Institute of Medicine of the National Academies. Childhood Obesity in the United States, Facts and Figures. September 2004. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2004/Preventing-Childhood-Obesity-Health-in-the-Balance
/FINALfactsandfigures2.pdf
9 Walker M, Gately P, Bewick B, et al. Children's weight-loss camps: psychological benefit or jeopardy? Intl J Obes Relat Metab Disord. 2003;27(6):748-54. [PubMed] Available at: http://www.nature.com/ijo/journal/v27/n6/full/0802290a.html
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Original publication: October 13, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 13, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.