As we begin a new school year and consider more ways in which to address health equity for children and teens, HC3 partnered with HC3 member Novo Nordisk for a virtual discussion on Thursday, September 14 focused on The Weight of Health Equity On Our Youth in recognition of National Childhood Obesity Month. In this discussion, leadership provided insights into some of the challenges and opportunities to address the physical and mental health factors that are contributing to obesity and other risk factors.
Mindy Klowden, Managing Director For Behavioral Health, Third Horizon Strategies
Uzoma Okeagu, PharmD, BCPS, Senior Medical Science Liaison, Novo Nordisk
Justin Ryder, PhD, Vice Chair of Research, Department of Surgery at Lurie Children’s Hospital of Chicago and Associate Professor at Northwestern University Feinberg School of Medicine
Camille Williams, LCPC, CEDS-S, Eating Disorder Coordinator, Timberline Knolls Residential Treatment Center
Watch the Recap
Moderator’s Introduction Mindy Klowden (MK): We are experiencing an epidemic in childhood obesity and simultaneously a crisis in youth mental health disorders. The CDC estimates that nearly 20 percent of youth in America are obese, and there are disparities when looking through racial and ethnic lenses. We are also experiencing an epidemic of children/youth presenting with eating disorders. During this session, we will explore what it will take to address these concurrent issues.
Justin Ryder (JR): I am a pediatric obesity research scientist and advocate for obesity care. I also serve as the chair of the pediatric obesity section for the Obesity Society, which is the largest national organization of obesity science. My research program focuses on understanding what contributes to childhood obesity, why some interventions work, and why some interventions don't work. Our research spans the continuum of care, lifestyle programs, medications, and bariatric surgery. All of those tools need to be in our toolbox to successfully treat each individual with obesity and all of the millions of children in the United States who currently suffer from the disease of obesity.
From an advocacy lens, we have a big challenge in that there is not equitable access to care for individuals who suffer from the disease of obesity. Most of that is at the state and federal level, so our advocacy efforts are aimed at changing laws and getting appropriations of funds for medical assistance programs so that everybody, regardless of their socioeconomic status, can have the same access to treatments.
Camille Williams (CW): I am a licensed clinical professional counselor and a certified eating disorder specialist. I work at Timberline Knolls as their eating disorder program coordinator. Timberline Knolls is a treatment facility with a residential level as well as partial hospitalization and intensive outpatient treatment available for co-occurring disorders. We treat eating disorders, substance use, and mood disorders and have some adolescent units as well as adults. Overall, we [Timberline Knolls] focus on the intersection of health and wellness, including the mental and emotional health of the people that we're working with.
Uzoma Okeagu (UO): I am a trained pharmacist and currently a medical liaison with Novo Nordisk. As a medical liaison, my role is to be an educational resource to providers around obesity. Different stakeholders are interested in optimizing obesity care in Illinois and around the country, so my day-to-day includes conversing with those providers to educate them more on obesity management and also to glean insights from them so that we can work together to optimize obesity care for individuals and populations that suffer from the condition.
Novo Nordisk has had to do some self-reflection over the past few years. Although we are developing therapies and optimizing obesity care for patients, we realized that our data did not include black and brown populations most affected by this condition. Two out of five white individuals suffer from obesity as opposed to one out of two black individuals. So, we have been working to diversify our clinical trials to ensure we have appropriate data as we move forward. There have been many initiatives that we've been involved in to increase these numbers, collaborating with more Black and brown principal investigators, doing things like partnering with organizations such as the National Medical Association, which is a large national organization that represents African-American physicians and their patients, and also using technology such as digital surveys to gauge interest from these providers and physicians, their interest in connecting and collaborating with Novo to participate in future trials.
MK: What are some of the reasons behind disparities in childhood obesity?
UO: Historically, patients in these communities have mistrusted the health care system, often delaying seeking medical care. They have less information about the types of diets and activities that will lead to healthy body composition, and then they present to providers when it’s too late, and they have developed the disease. Collaborating with providers serving these underrepresented communities will be very important to address these disparities.
CW: There is a lot of fear in going to providers among individuals categorized as obese/overweight. There can be a sense of feeling like they will be shamed or judged. BMI (Body Mass Index) was created around white men. It’s important to better understand health among other cultures and races to make the conversation of health really different.
JR: There is a societal component, and racism contributes to that. When the American Academy of Pediatrics came out with its recent guidelines, they called out racism as a big barrier and contributor to childhood obesity and disparities. There's also a strong biological component to that as well. In the Hispanic/Latino community, there is just as high of a prevalence of obesity in black communities, some of which is due to what we like to call a gene-environment interaction where you have susceptible genetics or individuals from populations who are more susceptible to carrying excess weight, and then
we also have a toxic environment where food is more readily available than ever. Subsequently, one’s genes and their environment can interact with one another in a negative way.
MK: What changes are needed to ensure kids have access to nutritious food and be more physically active? What are the kind of preventive factors that we need to be building on to address childhood obesity and the policy levers that we can use to support public health?
JR: We’ve recognized since the late 1970s that obesity is a problem. Approaches that have been taken look at obesity as the person’s fault, not a disease. There are almost 200 contributing factors to obesity. Just telling people to get out there, be active, and eat differently hasn’t worked for 50 years but will probably continue to be the main strategy for a long time until we wise up.
CW: Beginning to let go of shame around food is something we recommend. Having labels of “bad” and “good” foods creates a shame-based relationship, and it leads to overeating or binging as people delay consumption of “bad” foods. There can be a lot of education for parents and schools about having access to all types of foods. When working with kids, I recommend finding a movement they enjoy. If a kid doesn’t like sports, it’s better to find an alternative activity they do enjoy, such as spending time at a park. It’s important for health to be very individualized.
UO: It’s important to educate schools and parents on the multifactorial nature of the disease so that they are aware of that. Just telling kids to eat more broccoli is not going to tackle the issue. Parents need the knowledge to support children who are suffering from this condition. Education on the disease for both parents and institutions is critical so that they can provide appropriate support.
MK: The American Academy of Pediatrics (AAP) says that kids with obesity should get more serious treatment sooner. Knowing that treatment can consist of lifestyle treatment, medication treatment, surgery, behavioral therapies, and cognitive behavioral health therapies, what are some of the things that are important for folks to know and for clinicians to consider?
CW: If they are experiencing depression or anxiety, those might be things the person is managing with food. It’s important to notice what is happening to them and address it in therapy.
There is a strong need for dieticians to be covered by insurance. And because it’s not covered by insurance, people can’t necessarily afford to see one. If we are going to address lifestyle struggles, it’s important to see a dietician consistently.
JR: As was mentioned, the new AAP guidelines came out saying that intensive treatment is needed earlier on, or as soon as obesity is diagnosed. We can start with intensive lifestyle modification therapy, but it's not going to be effective for everyone because of the biological underpinnings of obesity. We need to use the other tools in our toolbox, which can include medications and potentially bariatric surgery. There are several FDA-approved medications in the pediatric space. Some of them are oral medications, and some of them are injectable medications. We're in an exciting time where we're starting to see weight loss on average in the double digits in terms of the percent weight loss that somebody can expect to achieve in a year. However, access to those medications and the cost of those medications is something that we need to work on.
Medication treatment should be continuous even after taking kids from obesity to normal weight because they still have the disease of obesity. These are not short-term treatments because obesity is a disease like hypertension. If you were to put somebody on a medication, their blood pressure goes down. They need to maintain that medication for the rest of their life because the medication is treating the disease. It's the same thing with medications for obesity and bariatric surgery.
Surgery is still the most effective treatment we have for severe obesity in pediatrics and in adults. On average, kids and adults can expect about 30 percent weight loss with either of the two procedures. With bariatric surgery, the comorbidity resolution (things like hypertension) is better than we have with any other treatment. So, for kids who suffer from severe obesity and have multiple comorbidities, bariatric surgery should be considered a treatment option.
UO: Obesity is a gateway to 200 other diseases and co-morbidities, and children with obesity are at higher risk for developing these comorbidities into adulthood. The watch-and-wait approach hasn't been effective in preventing the development of those comorbidities.
Regarding available options, Justin mentioned that the first line of treatment for all patients with obesity, especially pediatric obesity, is a family-centered, non-stigmatizing, holistic approach that includes lifestyle interventions and behavioral therapy. There are also pharmacotherapy options that are approved for adolescents 12 and older. Many providers don't feel comfortable utilizing these options in pediatric patients because they don't have the education around it and are not sure about the long-term implications. Once again, it goes back to education. It will be very important to continue to empower our providers with more information so that they can feel comfortable treating patients with this condition appropriately.
MK: All three of you have alluded to behavioral concerns. As I mentioned in the beginning, we do have crisis levels and higher acuity levels of youth behavioral health needs in the country. There's a high co-morbidity between depression and eating disorders and between depression and obesity. How do you think these challenges should be addressed or mitigated?
JR: One of the biggest challenges is that most studies exclude children with depression, anxiety, or serious mental health conditions. One of the things that we really struggle with clinically is that kids on antipsychotics may experience weight gain. That’s one of the reasons why I'm such an advocate for medications because I think that medications can counteract the other medications that they're getting to treat the other symptoms that they have. Of course, you need to take a holistic approach and use everything that's in our toolbox so that we can make sure that we're addressing all of the challenges that kids face to help them live long, successful lives.
OU: We still have a lot of data gaps in populations. There’s not a one-size-fits-all solution, so increasing diversity is important.
CW: We’ve been taking a holistic approach and looking at how all the different factors are coming together. For example, has depression impacted somebody's relationship with food, or has the relationship with food caused a lot of anxiety? We try to see how all of these pieces come together and work for that individual and then what needs to be addressed.
Looking at the emotional and mental health piece can address stress, which greatly impacts the body physically, mentally, and emotionally. Looking at stress levels and helping youth have effective coping skills is also an important piece of this puzzle.
MK: What other policy recommendations are needed to take into consideration?
UO: There needs to be better Medicaid coverage for obesity treatment options. And not just for pharmacotherapy but also for intensive lifestyle therapy as well. Many of the health equity disparities are exacerbated by the fact that individuals in these demographics don't have appropriate access to treatment options. This could be mitigated by increasing coverage through the state and Medicaid.
JR: Coverage could be better across the board. The recommendation for obesity treatment is 26 contact hours in a year, and I've yet to see a single private or public insurance that comes even close to that. And it's really a failure to recognize the necessary comprehensive care. They'll cover the physician, but they won't cover the dietician, or they won't cover the behavioral health specialist.
It’s also a really big challenge on the medication side of things. Currently, Illinois does not cover any anti-obesity medications for treatment. Something we're working very hard on and hopefully will be changed by the end of this year. Even though seven anti-obesity medications are FDA-approved, states can restrict access by only offering one and have varying rules around them from a federal perspective. There is a bill on the floor of Congress right now -- which has been for the last 11 years -- called the Treat and Reduce Obesity Act, which would require Medicare and Medicaid to cover comprehensive care for obesity treatment, lifestyle, pharmacotherapy, and bariatric surgery. It doesn't get approved every year because representatives of Congress say it costs too much. However, what is the cost of not covering this? Most states cover bariatric surgery, but usually only in adults. And if they cover it in pediatrics, the rules and restrictions around those are complicated, so there are many denials of bariatric surgery.
MK: Many families are forced to take their children out of state when seeking inpatient facilities for children. There are limited options because those facilities aren’t covered by insurance. Can you speak to this issue?
CW: There are a lot of really great eating disorder treatment centers, but only a few inpatients. Even in the Chicagoland area, there are a lot of residential and a lot of outpatients, but only a few inpatients.
The Eating Disorder Coalition works really hard with policies, and I believe there was an eating disorder bill recently passed, so there’s been some momentum in insurance coverage. Hopefully, that will continue to improve because eating disorders have the second-highest mortality rate of all mental health struggles. It's a very deadly disease for somebody to struggle with.
MK: Can you share any research and/or success for physicians to incorporate coaching models into their practice to address obesity?
CW: One of my recommendations is to use the “health at every size” framework when working with individuals, which promotes non-judgmental language about health rather than looking at somebody's body. It’s important when we're talking to individuals about their bodies that it's not in a shaming way. The Association of Size, Diversity, and Health is a really great organization that offers information and education on how to talk about people's bodies in a way that's going to help them feel empowered to create health changes rather than feel shamed and potentially like hiding from providers or from health practitioners.
UO: We educate providers using patient-first language. Instead of saying “obese patient,” you would say “patient with obesity”. You’re not defining a patient as their disease state, but acknowledging that they have this condition that you're helping to treat and then approaching them in an appropriate manner. We advise asking questions such as, “Can we talk about your weight today?” and making them comfortable so they're not shying away from coming in for treatment and not feeling stigmatized or blamed for the disease.
JR: At Lurie Children’s, we focus on understanding why it's so hard to keep weight off. It's difficult because there are counter-regulatory responses - the body likes to be in homeostasis, and when you lose significant weight, it fights to regain it. So we're studying what some of those mechanisms are trying to help develop better therapeutics and treatment techniques to help kids keep the weight off after they've done the hard work of losing it.
When someone comes into your clinic, you are still determining what they will respond to. Rather than trying different things, we advise using precision medicine, which would involve a blood test to determine what treatment might be the best for that person. This shows a strong genetic component that indicates that bariatric surgery and medications are a better approach than waiting several years for them to try and fail multiple times on treatments, which can be psychologically very challenging and damaging.
MK: There is increasing dialogue about how we make a definition of obesity that moves away from shaming and is not built on BMI. The World Health Organization defines obesity as having excess fatty tissue associated with negative impacts on quality of life or physical health. Does anyone want to add anything to that or comment on that?
UO: I think another thing that needs to be emphasized is that it's a chronic condition. The thing that makes it such a difficult disease to treat is the relapsing nature of it, the chronic nature of it. That's also something to keep in mind when defining the disease.
JR: We've tried to replace BMI many times using things to measure body composition, but it’s really hard. BMI is such a clinically useful tool. And unlike in adults, BMI data in children is racially and ethnically diverse. BMI charts were not developed originally to study obesity but to track healthy weight and growth for kids between the fifth and the 95th percentile. From a clinical perspective, the growth charts developed by the CDC and the WHO are very useful for most of the population.
It is a challenging question. Whenever anybody poses an alternative to BMI, I always think of the clinical implications. And I just think that it's just not practical to replace. And it would be too costly for most health systems to replace BMI with anything else.
MK: When you think about the long-term health outcomes, how do childhood obesity disparities affect long-term health outcomes and quality of life, especially in those communities with limited resources?
OU: Aside from co-morbidities such as the development of hypertension, cancer, or diabetes, it also affects them through internal stigma. Many of these individuals, especially children, feel discriminated against because of their condition. When they're continuously discriminated against, they start to internalize those beliefs, which can be disruptive biologically. It can increase stress, increasing mental health conditions, depression, eating disorders, and body dysmorphia.
As a society, we need to educate those outside of the health care world so that they can understand and they're not contributing to some of this stigma and some of these external influences that these patients are experiencing that make them exacerbate some of the co-morbid comorbid conditions that come along with the disease.
JR: We've known for about 20 years that kids with obesity have the same quality of life as kids with cancer. However, the treatments available have all been shown to improve quality of life with or without successful weight loss. So bariatric surgery, medications, and lifestyle interventions, whether they lose weight or not, have shown an improvement in weight-related quality of life. It’s also important to measure quality of life from a weight-centric perspective.
CW: It is important to focus on somebody's health goals and what they want health to look like. Health is an individual practice where everybody's getting to have their own beliefs. It’s important to be client-centered and consider their goals and how to help them achieve them.