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Service Delivery Innovation Profile

Multidisciplinary Program Combining Medical, Counseling, and Behavior Modification Services Helps Overweight Children and Adolescents Lose Weight, Reduce Body Mass Index


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Snapshot

Summary

The Optimal Weight for Life (OWL) program is a comprehensive, multidisciplinary clinic that provides an initial evaluation and ongoing medical, nutritional counseling, and behavior modification services to overweight and obese children and adolescents and their families. The OWL-developed low glycemic index diet has been shown to positively impact weight-related clinical outcomes, including body mass index, fat mass, body weight, insulin resistance, energy expenditure, and cardiovascular disease risk factors

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial, a retrospective cohort study and a mechanistic study evaluating key outcomes measures related to OWL's low glycemic diet.
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Developing Organizations

Boston Children's Hospital
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Date First Implemented

1996
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Patient Population

The patient population served is aged 2 to 21 years.Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Childrenend pp

Problem Addressed

Childhood obesity is a widespread, growing problem that has devastating health consequences, particularly among low-income and minority populations; primary care providers and hospital-based clinicians have not yet developed effective strategies for combating this growing epidemic.1
  • A growing epidemic: Data from the National Health and Nutrition Examination Surveys (NHANES) show that the prevalence of overweight among children aged 2 to 5 years old increased from 5 to 10.4 percent between the 1976 to 1980 and 2007 to 2008 periods; for those aged 6 to 11, prevalence increased from 6.5 to 19.6 percent; and for those aged 12 to 19, prevalence increased from 5 to 18.1 percent.2
  • Problem especially severe in low-income and minority populations: Ethnic minority populations (especially African Americans, Hispanics, and Native Americans) and children in low socioeconomic status families tend to have higher rates of obesity than do the rest of the population. For example, up to 24 percent of African-American and Hispanic children are above the 95th percentile in terms of body mass index (BMI), with Hispanic boys and African-American girls having the highest rates of overweight/obesity.3
  • Severe health consequences: In a population-based sample, approximately 60 percent of obese children between the ages of 5 and 10 years had at least one risk factor for cardiovascular disease, such as elevated total cholesterol, triglycerides, insulin, or blood pressure, while 25 percent had two or more cardiovascular disease risk factors.3 Overweight and obesity put children at current and future risk of a number of serious health problems, including cardiovascular disease, type 2 diabetes, and mental health conditions such as anxiety and depression.4 Type 2 diabetes now accounts for up to half of all new pediatric cases of diabetes, compared with less than 4 percent of cases before 1990.3
  • Comprehensive approach can help, but often unavailable: Pediatric weight management programs based on an adult model of weight loss and exercise may not be effective. In contrast, comprehensive programs incorporating behavioral modification targeted at children and adolescents can improve outcomes. One report found that participation in behavioral management programs can help obese children and teens lose weight or prevent further weight gain.5 However, few primary care providers or hospital-based clinicians offer these types of services today.
  • High program dropout rates: According to a literature review, the typical pediatric weight management program, which tends to be based on an adult model of weight loss and exercise, experiences a dropout rate of approximately 50 percent (ranging from 35 to 80 percent); a multidisciplinary program that addresses the patient's lifestyle more comprehensively and that builds a connection between the patient, family, and treatment team can reduce dropout rates.6

What They Did

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Description of the Innovative Activity

OWL is a comprehensive, multidisciplinary clinic that provides an initial evaluation and ongoing medical, nutritional counseling, behavior modification services, and physical activity counseling to overweight and obese children and their families. Key elements of the program include the following:
  • Eligibility and referral: The program receives referrals of overweight or obese patients ages 2 to 21 years from parents and physicians. Approximately 6,000 patient visits are expected in the 2012 academic year, consisting of approximately 800 new patients and a varying number of returning patients; the active number of patients in the program in any 1 year is estimated to be approximately 1,500.
  • Medical evaluation: During the initial 4-hour visit, the patient and family meet with the OWL physician, dietitian, and behavioral psychologist in succession. The physician conducts a comprehensive medical evaluation, as described below:
    • Evaluation content: This evaluation includes a personal and family history; a physical examination; fasting laboratory testing; and type 2 diabetes education, monitoring, and management, when applicable.
    • Treatment and referral: If the evaluation uncovers any underlying medical causes (e.g., hormone imbalances) and/or complications of overweight/obesity (e.g., high cholesterol), the physician provides appropriate management and/or treatment, and/or refers the patient to a specialist.
  • Nutritional counseling: Also, as part of the visit, an OWL dietitian conducts a complete dietary analysis and provides nutritional counseling.
    • Focus on healthy eating: The counseling focuses on encouraging the child or adolescent to adopt a healthy eating plan that is flexible and establishes long-term healthful eating patterns rather than a restrictive diet that might produce short-term weight loss but cannot be maintained over the long term. Emphasis is placed on healthy, natural foods rather than processed or fast foods.
    • Dietary modification: Dietary modification measures may include the prescription of an OWL-developed low glycemic index diet (to stabilize the postmeal surge in blood sugar, thereby promoting a sense of fullness) and/or other dietary advice tailored to the patient's needs. The dietitian consults with the family regarding practical approaches to adopting the recommended diet and preparing healthy foods.
  • Behavior modification services: During the final part of the visit, an OWL behavioral psychologist conducts an initial assessment of the patient to identify the behavioral, motivational, and family dynamic issues that relate to lifestyle change. When appropriate, the psychologist may recommend additional sessions. Patients with significant mental health issues who require long-term psychotherapy are referred to a mental health provider.
    • Psychotherapy: The psychologist works with the patient and family via short-term individual and family psychotherapy sessions, as needed, to address motivation for change, help children cope with emotional stresses, and help families break entrenched habits, resolve conflicts, and develop good parenting practices.
    • Recommended strategies: One strategy often recommended is to declare the home a "nutrition-safe zone" where only healthy foods will be provided and consumed. Another strategy is to promote modeling, in which parents exhibit healthy eating behaviors to be emulated by their children. Other strategies include praise, rewards, anticipation of obstacles, and self-monitoring.
    • Financial assistance: When financial barriers to healthy eating are uncovered, a social worker (considered one of the program's behavioral therapists) helps families obtain financial support from community and governmental organizations and/or purchase healthful foods in bulk to increase affordability.
  • Lifestyle-oriented physical activity: Information provided in February 2012 indicates that participants work with behavioral counselors to identify ways to increase physical activity and decrease sedentary time (especially television viewing). In addition, staff help identify resources near the family's residence (e.g., gyms, sports programs, outdoor recreation opportunities) and lower barriers to sustainable physical activity.
  • Ongoing management plan: The physician, dietitian, and psychologist develop a coordinated, individualized management plan to guide the care of the patient in a family context. Followup care on a monthly basis is typically recommended, with different aspects of care provided as needed by the child and the family.

Context of the Innovation

OWL is a multidisciplinary outpatient clinic operated as part of Boston Children's Hospital, a 400-bed comprehensive medical center for children and adolescents. The greater Boston metropolitan area is a culturally, ethnically, and economically diverse area that reflects the pediatric obesity prevalence seen throughout the country. The rapid increase in childhood obesity over the last 20 years in the Boston area spurred the development of OWL. OWL primarily serves children in the Boston area but also receives referrals from across New England and, occasionally, internationally. The program handles approximately 4,000 patient visits per year and anticipates approximately 600 new patients in 2009.

Did It Work?

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Results

A randomized controlled trial (RCT) and a retrospective cohort study demonstrated the positive effects of the OWL-developed low glycemic index diet on BMI (expressed in kilograms of body weight divided by height in meters squared, or kg/m2), fat mass, body weight, insulin resistance, energy expenditure, and cardiovascular disease risk factors.
  • Greater reduction in BMI, fat mass, and weight: An RCT involving OWL participants found that those participants on the OWL low glycemic index diet had a greater reduction in mean BMI (–1.3 kg/m2 vs. +0.7 kg/m2) and greater loss of fat mass (–3 kg vs. +1.8 kg) than did those on a reduced-calorie, reduced-fat diet. A separate retrospective cohort study of OWL participants conducted between September 1997 and December 1998 found that those on the OWL low glycemic index diet exhibited greater declines in BMI (–1.53 kg/m2 vs. –0.06 kg/m2) and body weight (–2.03 kg vs. +1.31 kg) than did those children on a reduced fat diet. In addition, a significantly greater number of patients in the low glycemic index diet group experienced a decrease in BMI of at least 3 kg/m2 (17.2 vs. 2.3 percent).7
  • Less insulin resistance: The RCT showed that insulin resistance increased less during the intervention period in the low glycemic index diet group than it did in the control group (–0.4 vs. 2.6).8
  • Positive impact on resting and total energy expenditure and cardiovascular disease risk factors: Information provided in February 2012 indicates that a mechanistic study (a controlled three-way crossover design) involving 21 overweight and obese young adults conducted at Boston Children's Hospital and Brigham and Women's Hospital supported the efficacy of the low glycemic load diet versus a low-fat diet in terms of impact on both resting and total energy expenditure (reduced energy expenditure following weight loss is believed to contribute to weight gain) and cardiovascular disease risk factors during weight loss maintenance.9
Note: Because both groups in the RCT received the comprehensive OWL intervention (e.g., behavioral support, physical activity recommendations, etc.), the results experienced by the low glycemic diet group can be said to represent the full program.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial, a retrospective cohort study and a mechanistic study evaluating key outcomes measures related to OWL's low glycemic diet.

How They Did It

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Planning and Development Process

The OWL program developed incrementally over time; the director suggests the following key steps in planning and developing the program:
  • Assess local need and referral sources: Most likely, the local need for the program will be high, given the prevalence of pediatric obesity. Establish whether most patients are likely to come from self-referrals, community physicians, or other providers.
  • Clarify the model: Design the model to reflect patient needs as well as organizational circumstances. For example, as part of a hospital that serves a high proportion of patients with significant comorbidities, OWL operates with a medical model, conducting full medical evaluations. Less emphasis on the medical component may be needed, however, in programs developed in a primary care location. As a result, group rather than individual sessions may be more cost-effective in these settings.
  • Generate a strategic plan: Determine anticipated patient demand, staffing and funding needs, marketing strategy, payment sources, and other elements required for program implementation.
  • Identify donors: Identify philanthropic organizations that can fill the gap between reimbursable and non-reimbursable services for low-income patients.
  • Publicize services: Publicize the program to hospital specialists and community physicians to solicit referrals.
  • Pursue program expansion: Information provided in February 2012 indicates that in 2011, OWL received a 7-year grant from New Balance Foundation, part of which supports the program's ability to offer supplemental services to participants free of charge. This funding allows for a case worker and physical activity consultant, who work with patients/families to reduce barriers to successful and sustainable behavior change.

Resources Used and Skills Needed

  • Staffing: Program staffing includes five physicians, two nurse practitioners, five dietitians, three behavioral therapists (including one social worker), and two administrative assistants. Information provided in February 2012 indicates that a case worker and physical activity consultant have also been added to the staff. This staffing level is appropriate for serving approximately 1,000 active patients annually.
  • Costs: Data on total program costs are unavailable. Program expenses consist primarily of the salaries and benefits of the OWL team; other expenses include overhead, administrative costs (e.g., printing, mailing), and a small fund for patient gifts.
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Funding Sources

Boston Children's Hospital; New Balance Foundation
The bulk of funding for the program comes from Boston Children's Hospital. A major grant was received from the New Balance Foundation, with small grants provided by other philanthropic organizations. Some program services are reimbursed, but reimbursement policies vary significantly across insurers. Many private insurers, including the state's Medicaid program, reimburse for OWL services. Non-reimbursed services are either paid by the patient/family or absorbed by Boston Children's Hospital through a program that provides free care to families in need.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Convince senior management of the program's value: Public and private insurers tend to undervalue the significance of programs that address pediatric overweight/obesity, creating a challenging economic environment. Senior organizational leaders should be convinced to support the program and ultimately to become a strong voice in lobbying for improved reimbursement and funding of these programs, which can reduce the long-term costs of care for society.
  • Adapt the model to the population and organizational circumstances: For example, holding group rather than individual sessions may be more cost-effective in community (nonhospital) settings.

Sustaining This Innovation

  • Judge results in the context of the population: Heterogeneity within the patient population can lead to high variability in program outcomes. For example, because there are no barriers to who can participate, the OWL program treats some highly motivated patients, while others are participating only because of their physician's insistence (and thus have little motivation to change behaviors).

More Information

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Contact the Innovator

David Ludwig, MD, PhD
Director, Optimal Weight for Life (OWL) Clinic
Director, New Balance Foundation Obesity Prevention Center
Boston Children's Hospital
Professor of Pediatrics, Harvard Medical School
Professor of Nutrition, Harvard School of Public Health
333 Longwood Avenue
Boston, MA 02115
Phone: (617) 355-4878
Fax: (617) 730-0183
E-mail: david.ludwig@childrens.harvard.edu

Innovator Disclosures

Dr. Ludwig reported that Boston Children's Hospital received funding from the National Institutes of Health and New Balance Foundation, in support of work related to this profile.

References/Related Articles

(added February 2013) Ludwig DS. Weight loss strategies for adolescents: a 14-year-old struggling to lose weight. JAMA 2012;307:498-508.

(added February 2013) Ebbeling CB, Swain JF, Feldman HA, Wong WW, Hachey DL, Garcia-Lago E, Ludwig DS. Effects of dietary composition on energy expenditure during weight-loss maintenance. JAMA 2012;207:2627-2634.

Ludwig DS. Childhood obesity—the shape of things to come. N Engl J Med. 2007;357(23):2325-7. [PubMed]

Ebbeling CB, Leidig MM, Sinclair KB, et al. A reduced-glycemic load diet in the treatment of adolescent obesity. Arch Pediatr Adolesc Med. 2003;157(8):773-9. [PubMed]

Spieth LE, Harnish JD, Lenders CM, et al. A low-glycemic index diet in the treatment of pediatric obesity. Arch Pediatr Adolesc Med. 2000;154(9):947-51. [PubMed]

Ludwig DS. Weight loss strategies for adolescents: a 14-year-old struggling to lose weight. JAMA 2012; 307:498-508. [PubMed]

Footnotes

1 O'Brien SH, Holubkov R, Reis EC. Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics. 2004;114(2):e154-9. [PubMed]
2 U.S. Centers for Disease Control and Prevention. Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963-1965 Through 2007-2008. June 4, 2010. Available at: http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm
3 Institute of Medicine of the National Academies. Childhood Obesity in the United States, Facts and Figures. September 2004. Available at: http://www.iom.edu/Reports/2004/Preventing-Childhood-Obesity-Health-in-the-Balance.aspx (link to fact sheet provided in "Report at a Glance")
4 Koplan J, Liverman C, and Kraak V, editors. Preventing childhood obesity: health in the balance. Washington, DC: National Academies Press; 2005.
5 Whitlock EP, O'Connor EA, Williams SB, et al. Effectiveness of weight management programs in children and adolescents. Agency for Healthcare Research and Quality Evidence Report Number 170. September 2008. Available at: http://www.ahrq.gov/childweight.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)
6 Skelton JA, DeMattia LG, Flores G. A pediatric weight management program for high-risk populations: a preliminary analysis. Obesity (Silver Spring). 2008;16(7):1698-701. Epub 2008 Apr 24. [PubMed]
7 Spieth LE, Harnish JD, Lenders CM, et al. A low-glycemic index diet in the treatment of pediatric obesity. Arch Pediatr Adolesc Med. 2000;154(9):947-51. [PubMed]
8 Ebbeling CB, Leidig MM, Sinclair KB, et al. A reduced-glycemic load diet in the treatment of adolescent obesity. Arch Pediatr Adolesc Med. 2003;157(8):773-9. [PubMed]
9 Ebbeling CB, Swain JF, Feldman HA, Wong WW, Hachey DL, Garcia-Lago E, Ludwig DS. Effects of dietary composition on energy expenditure during weight-loss maintenance. JAMA 2012;207:2627-2634. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 13, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 24, 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.