Wellness coaches in Buffalo pediatric offices helped kids lose weight. Could this work across the US? [The Buffalo News, N.Y.]
Aug. 8—Pediatricians for a quarter century have considered child obesity a health condition that — left unaddressed — raises the risk for chronic illnesses that shorten life.
The first comprehensive treatment guidelines, issued this year by the
But it is more likely that child primary care providers try to squeeze in what advice they can during occasional 15-minute office visits. They encourage heavier patients to eat better, provide handouts with nutritional and exercise tips, and refer them to a dietitian when weight gain persists.
That is why some pediatricians have high hopes that families, health insurers and government officials pay heed to a new
The study showed that other family members benefit from more directed help, too.
"It's more effective for both parent and child," said Dr.
Epstein, who pioneered the family-based approach to weight loss, was awarded a five-year,
Related work has taken place in
The approach involves pediatricians, nutritionists, exercise physiologists, psychologists and social workers trained to nurture nutritional behavior change. The work usually takes place at specialty clinics, including a site on the UB South Campus.
Epstein and research collaborators have conducted previous studies that show their intensive, family approach to weight loss works better than traditional appointments in primary care practices, which lack staff to closely monitor patients and their families.
The latest study was the first to put trained coaches in pediatric offices, including
Study results
Researchers enrolled 452 children ages 6 to 12 with one parent in practices across the four metro regions.
Half were randomly assigned to family-based treatment, and half received more typical pediatric care. Nearly 60% of patients were white, more than a quarter were Black and nearly 10% were Hispanic.
Patients and parents in family-based treatment met weekly with coaches for the first four months as they got used to the program, then every other week, then monthly.
Coaches laid out eating and activity plans, and regularly encouraged parents to use those plans to forge behavior changes. Regular meetings involved seeing the patient and parent together to set weight and behavioral goals; go over self-monitored eating and activity levels; and review treatment manuals and handouts.
The coaches received standardized training to prepare them for their role, said Dr.
"This shows that you can take a college graduate and give them jobs that are feasible in the primary care setting," said Quattrin, associate dean for research integration in the
Roughly a third of the visits were in person. Two-thirds were conducted online because of the Covid-19 pandemic.
"We've never done a telemedicine study before," Epstein said.
The study found 27% of children in the family treatment group, compared to 9% in the traditional pediatric care group, had a clinically meaningful reduction in body mass index (BMI), which is tied to improved cardiovascular health, as well better regulation of the amount of fat compounds and blood sugar needed to best fuel the human body.
Children enrolled in the family-based treatment had a greater reduction in change in weight — relative to height for children, their age and sex — of almost 6.5%, in comparison to usual care. Parents in family-based treatment lost 4% more than parents in usual care, and siblings, who were not seen in treatment, lost 5.4% more than siblings in usual care families.
The study — published in June in the
"This research shows that the healthy behaviors the treatment promotes extend beyond the parent and child being treated to potentially make the whole family healthier," said
Family dynamics
The family focus is key, Epstein said.
Children who are obese are much more likely to be obese as adults, raising the risk of diabetes, heart disease and poor mental health, Epstein said.
Nearly one-third of children in the state are overweight or obese, and the new study landed after a steady, alarming climb in the percentage of
The latest and related studies underline the need for added time and attention required to address not only weight loss, but other health challenges that require behavioral change, Quattrin said.
Rates for children seeking mental health services also climbed during the pandemic — and a top
Roughly half of participants lost weight in previous studies conducted at specialty clinics, including the one on the UB South Campus — and a majority maintained most of that weight loss after a decade, Epstein said.
Those research studies included more specialists, not just a single coach, as well as more in-person contact, which was impossible during the most recent study because of the pandemic.
The pandemic also limited the ability of providing group education and support offered in specialty clinics.
"Many of these children are a little bit socially isolated," Epstein said. "They're heavy. They may be teased. They may not have as many friends, so coming to a group with other children with the same problem allows them to develop new social relationships, and those oftentimes persist way past when the study is over."
Still, he and others consider the threefold success rate for an embedded coach in a pediatric office significant, compared to the 9% rate for children and families who got traditional treatment as part of the latest study.
Other limitations
Research is clear that it is more effective to lose weight when a parent is directly involved in a process focused on positive messaging, keeping junk foods outside the home and modeling healthy behaviors, including regular exercise, Epstein said.
"All of those things are easy to tell people to do," he said, "but hard to implement."
That helps explain why success rates in related studies aren't higher still.
Epstein and others also pointed to the social determinants of health on weight loss and success. Those include neighborhood crime and decay that leaves less opportunity for outdoor exercise, along with the lack of transportation to medical appointments and nearby grocery stores that sell fresh, healthy, affordable foods.
Those challenges can be especially hard for single parents with a limited income and demanding work and home lives.
Those disparities lead to higher rates of overweight and obesity among those who are poor, less educated and Black or Hispanic — though Epstein said the differences narrowed considerably for those groups in the family-centered UB specialty weight loss clinic and recent study.
"We are cognizant of the fact that this may not work for everybody," Quattrin said, "and then other things have to be considered. I would say, before you get bariatric surgery, consider pharmacologic treatment, but the first step is to try to teach people how to lose weight."
The biggest limitation may be that primary health care practices don't have the financial means, skill set or the time to undertake such a comprehensive approach to weight loss.
Dr.
Patients and families benefited from both, he said, but reimbursements, including from Medicaid, leave profit margins so thin in primary care practices that they cannot afford to keep such specialists in their offices and stay afloat financially.
When the studies ended, it was back to the former approach of referring patients out to mental health counselors and weight-loss specialists — in a health care climate where patients who need such support can expect to wait two months or more for a first appointment that may not be reimbursed, at least entirely, through health insurance, Lana said.
"We were able to offer a tangible resource," he said. "A lot of it was getting people motivated, getting people to buy in, because it's not easy, and the results are not quick. But if you make that commitment over time, you see the benefit.
"There were a lot of success stories, which was very gratifying to us as a practice, and, obviously, the families were also very grateful," he said. "I wish we could still have access to those resources, but it's time intensive, it's labor intensive, it's access to education. You just can't write a prescription for this."
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