Download Stephen Cook, MD, MPH, FAAP, FTOS: Pediatric Obesity

Pediatric Obesity Prevention &
Treatment
National Hurdles & Opportunities
Stephen Cook, MD, MPH, FAAP, FTOS
Associate Professor, Department of Pediatrics
Disclosures
Grant funding:
• NYS Dept of Health
• Greater Rochester Health Foundation
• NIH CBPR project
• CDC Prevention Research Center
Data Safety Monitoring Boards
• ATN & Novo Nordisk
Boards: ABOM, AAP IHCW
..…and I used to work at a TJ’s Big Boy
Objectives
• Discuss the impact of early childhood obesity
• Discuss recommendations for prevention and treatment
• Review possible community / clinical linkages to address childhood
obesity
• Discuss innovative care delivery & payment models to address
childhood obesity
3
CDC Framework for Addressing Obesity
5
Can you see risk?
YES!
We are not asking you to deal with this
Can you see risk?
• This girl is 4 years old.
• What is her BMI-for-age?
• < 85th percentile Normal
• >85th to <95th percentile:
Overweight
• > 95th or Obese
Photo from UC Berkeley Longitudinal Study, 1973
Plotted BMI-for-Age
BMI
BMI
Measurements:
Age=4 y
Girls: 2 to 20
years
Height=99.2 cm
(39.2 in)
Weight=17.55 kg
(38.6 lb)
BMI=17.8
BMI-for-age= between
90th –95th percentile
Overweight
BMI
BMI
One city’s communities of solution
Note: Political boundaries, shown in
solid lines, often bear little relation
to a community’s problem-sheds or
its medical trade area.
Reproduced and adapted with permission from: Folsom M. Health
is a Community Affair: Report of the National Commission on
Community Health Service. Cambridge, MA: Harvard University
Press; 1967:3, Fig 1.
Annals Family Medicine, May/June 2012
Vol. 10 no. 3 p 250-260
9
Severe Obesity (>99th %tile) among US Children &
Teens, or 3.8% or 2.7 million
10
Mismatching between directly measured and parental perceived body weight
status.
Andrew R. Hansen et al. Pediatrics 2014;134:481-488
Obesity:
Health Risks Now and Later
Psychosocial
Eating disorders
Poor self-esteem
Social isolation and stigmatisation
Depression
Pulmonary
Exercise intolerance
Obstructive sleep apnea
Asthma
Gastrointestinal
Gallstones
Gastro-esophageal reflux
Non-alcoholic fatty liver disease
• Obese children Neurological
are more likely to
Pseudotumour cerebriobese adults
become
o
(idiopathic intracranial
Children (age
12) with BMI>99%
hypertension)
followed into adulthood (age 27)
Cardiovascular
 100% BMI>30
Hypertension
 90% with BMI>35
Dyslipidaemia
Coagulopathy
 65% with BMI>40
Chronic inflammation
Endothelial dysfunction
• Adult obesity is associated
with a
Endocrine
resistance conditions
number of seriousInsulin
health
Impaired
fasting
glucose
or
Renal
including:
glucose intolerance
Glomerulosclerosis
Musculoskeletal
Ankle sprains
Flat feet
Tibia vara
Slipped capital femoral epiphysis
Forearm fracture
Type 2 diabetes
o
Precocious puberty
Menstrual irregularities
Polycystic ovary syndrome
(females)
Heart disease
o Diabetes
o Cancers
Freedman et al., 2007, J Pediatr; Ebbeling, 2002, Lancet
Prevalence & Incidence of Obesity BOYS between
Kindergarten & Eighth Grade.
Cunningham SA et al. N Engl J Med 2014;370:403-411.
Adolescents’ Perceptions of Peers Being
Teased or Bullied: Observed Frequency
14
Percentage of teen girls who report frequent weight
teasing
Neumark-Sztainer. J Adolesc Health. 2009;44:206-213.
15
Weight Bias
Persists in Universities
Candidates for undergraduate
admission
• Identical but for weight status
• Candidates with obesity judged less qualified
Study of graduate psychology
programs
• Interviews favored thinner candidates
• Regardless of qualifications
Five Fruits and Vegetables per day
Assess Behaviors & Attitudes
Assess Medical Risks
-
Eating,
Physical Activity, Sedentary Time, Motivation
Family History, Review of Systems, Physical Examination (BMI, BP)
Overweight
Healthy Weight
BMI 85 - 95%ile
Obese
BMI 5 - 84%ile
BMI 95 - 98%ile
BMI >=99%ile
Health Risks?
No
Yes
Prevention Counseling
Maintain Weight Velocity
Empathize/Elicit - Provide - Elicit
Stage 1 Prevention Plus
& Reassess Annually
Maintain Weight or
Decrease Velocity
& Reassess Every
3-6 Months
Maintain Weight or
Gradual Loss &
Reassess Every 3 - 6
Months
Gradual to
Moderate Weight
Loss & Reassess
Every 3 -6 Months
Stage 2 Structured Weight Management
Assessment
Prevention
Stage 3 Comprehensive Multidisciplinary Intervention
Treatment
Stage 4 Tertiary Care Intervention
Health Risks?(1)
No
Yes
Assess ALT, AST, Fasting Glucose(2)
Overweight
Healthy Weight
BMI 85 - 95%ile
BMI 5 - 84%ile
Obese
>=99%ile
Other
as IndicatedBMI
by Health
Risks
BMI
95 - Tests
98%ile
Prevention Counseling - Empathize/Elicit - Provide - Elicit
Stage 1 Prevention Plus(3)
Maintain Weight Velocity &
Reassess Annually
Maintain Weight or
Decrease Velocity
& Reassess Every
3-6 Months
Primary Care
Setting
?
Maintain Weight or
Gradual Loss(4) &
Reassess Every 3-6
Months
Gradual to
Moderate Weight
Loss(5) & Reassess
Every 3-6 Months
Stage 2 Structured Weight Management(3)
Stage 3 Comprehensive Multidisciplinary Intervention(3)
Assessment
Prevention
Treatment
Stage 4 Tertiary Care Intervention
Stages of Care from Guidelines
Weight Loss Targets
Age 2-5
Years
BMI 85-94%ile BMI 85-94%ile BMI 95-98%ile
No Risks
With Risks
Maintain weight Decrease weight Weight
velocity
velocity or
maintenance
weight
maintenance
BMI >= 99%ile
Gradual weight
loss of up to 1
pound a month if
BMI is very high
(>21 or 22 kg/m2)
Age 6-11
Years
Maintain weight
velocity
Age 12-18
Years
Maintain weight
velocity. After
linear growth is
complete,
maintain weight
Decrease weight
velocity or
weight
maintenance
Decrease weight
velocity or
weight
maintenance
Weight
maintenance or
gradual loss (1 lb
per month)
Weight loss
(average is 2
pounds per
week)*
Weight loss
(average is 2
pounds per
week)*
Weight loss
(average is 2
pounds per
week)*
* Excessive weight loss should be evaluated for high risk behaviors
21
US Preventive Services Task Force
RECOMMENDATION. The USPSTF recommends that clinicians screen children
aged 6 years and older for obesity and offer them or refer them to intensive
counseling and behavioral interventions to promote improvements in weight status
(grade B recommendation.) Pediatrics
Recommended Interventions
Refer patients to comprehensive
moderate- to high-intensity programs
(>25 contact hours) that include
dietary, physical activity, and
behavioral counseling components
Height and weight, from
which BMI is calculated,
are routinely measured
during health maintenance
visits
.
USPSTF, 2010, Pediatric.
The Affordable Care Act Improves Prevention and
Obesity Coverage
ACA includes several provisions that promote preventive care including obesityrelated services and coverage.
These provisions include an enhanced federal match for states that cover all U.S.
Preventive Services Task Force (USPSTF) grade A and B recommended preventive
services with no cost-sharing. Obesity screening and counseling for children,
adolescents and adults is a USPSTF recommended service.
The law calls for states to design public awareness campaigns to educate Medicaid
enrollees on the availability and coverage of preventive services, including obesityrelated services. To help states, CMS will host calls and webinars regarding
coverage and promotion of preventive services, develop fact sheets that address
Medicaid coverage of preventive services, and share examples of state Medicaid
program efforts to increase awareness of preventive services.
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-ofCare/Reducing-Obesity.html
Treating Overweight & Obesity
Stage 1 – a prevention program managed by a primary care physician
Stage 2 – a structured weight management program managed by a primary care
physician together with a pediatric health care provider, such as a dietitian
Stage 3 – a comprehensive intervention involving a multidisciplinary obesity care team
that can provide structured monitoring, counseling and assessment at specified
intervals and interventions as needed, often at a children’s hospital. **
Stage 4 – tertiary care interventions that can include medication, very low calorie diets
or bariatric surgery
Treatment Goals - Weight Loss Targets
Age 2-5
Years
BMI 85-94%ile BMI 85-94%ile BMI 95-98%ile
No Risks
With Risks
Maintain weight Decrease weight Weight
velocity
velocity or
maintenance
weight
maintenance
BMI >= 99%ile
Gradual weight
loss of up to 1
pound a month if
BMI is very high
(>21 or 22 kg/m2)
Age 6-11
Years
Maintain weight
velocity
Age 12-18
Years
Maintain weight
velocity. After
linear growth is
complete,
maintain weight
Decrease weight
velocity or
weight
maintenance
Decrease weight
velocity or
weight
maintenance
Weight
maintenance or
gradual loss (1 lb
per month)
Weight loss
(average is 2
pounds per
week)*
Weight loss
(average is 2
pounds per
week)*
Weight loss
(average is 2
pounds per
week)*
* Excessive weight loss should be evaluated for high risk behaviors
Treatment of Obesity in
Children and Adolescents
Stage
Delivery
Treatment
of Obesity
in support, with
Stage 1 –
Office-based
Children
Prevention
Plusand Adolescents
scheduled follow-up
Behaviors
5 fruits and vegetables
About 15% of 2< 2 hrs of screen time
19 yr olds
> 1 hr of physical activity
Stage 2 –
Structured Weight
Management
Specially-trained staff in office
with support from referrals (RD)
Stage 3 –
Comprehensive
Multidisciplinary
Intervention
Dedicated weight management
program or registered dietician
referral; weekly follow-up for 8-12
weeks
More frequent contact, more f
If 1/4th continue,
1/3rdstructured
monitoring,
then
~ 1%
goal-setting
Stage 4 –
Tertiary Care
Pediatric weight management
center with multidisciplinary team;
clinical or research protocol
Medication,
meal
If 1/4th surgery,
continue,
replacement, ongoing behavior
then ~ 0.2%
change
Reduced-calorie
If 1/4th w/eating
Ob plan
< 1 hr of screen time
come / follow up
Monitoring
= 4%
(>6yr)
Adapted from Barlow
2007
Think Global / Act Local
27
Parents estimation of child’s weight
status vs. measured weight, 2-9yo
Estimation of weight 193 parent/child dyads from
Strong Pediatrics
Tschamler, et al, Clin Peds, 2010;49:470
28
Children and Adolescents age 2 to 18 yo, 2007
29
Retail Food Environment Index (RFEI)
• RFEI measure used for local food environment1
RFEI =
Fast Food + Convenience stores
Grocery Stores + Produce Vendors
30
1. Designed for Disease, April 2008
Results
Monroe County, NY
Unhealthy
Food
Source
RFEI =
Healthy
Food
Source
Obesity by
Neighborhood
5.0% - 10.0%
10.1% - 15.0%
15.1% - 20.0%
20.1% - 24.0%
31
Results: Individual
Odds of obesity for a 5 unit increase in RFEI
1.50
Odds
Ratio
1.25
1.00
0.75
0.50
* P < 0.05
32
Unadjusted *
Urban *
Income
Children and Adolescents age 2 to 18 yo, 2012
Percent of Obese Children in Monroe County by Towns
33
Obesity Study 2012:
Table 5: Comparison of Obesity Rates by age group, gender and location in Monroe County 2007 to 2012. 2007
2012
Normal
5,468
69.9%
Over Weight
1,189
15.0%
Obese
1,193
15.1%
Normal
5,287
68.1%
Over Weight
1,253
16.4%
Obese
1,215
15.2%
P‐value
Age
2‐10 yrs.
11‐18 yrs.
71.2%
67.4%
14.3%
16.2%
14.5%
16.5%
68.0%
68.1%
16.4%
16.5%
15.6%
15.4%
0.008
0.60
Gender
Male
Female
68.9%
70.3%
14.9%
15.4%
16.2%
14.3%
67.4%
68.6%
17.0%
15.9%
15.6%
15.5%
0.07
0.31
Practice Location
Suburban
74.5%
Urban
60.7%
13.8%
17.5%
11.7%
21.8%
71.0%
62.2%
16.1%
17.1%
12.9%
20.7%
0.001
34
0.58
N
All
0.08
Community Policy strategies
Childhood Obesity Community
Coalition for Policy Change
HEALTHI Kids:
Healthy Eating and Active Living THrough policy and
practice Initiatives for Kids
36
Partnerships:
•Finger Lakes Health
System Agency
•University of
Rochester
• Dept of Pediatrics
• Center for
Community Health
•Children’s Agenda
Photo Source: The Prevention Institute
37
5 Main Policy Approaches
1.
Improve the safety of, the perception of safety of, and access to recreational
facilities, bike trails, parks, and green spaces, while expanding after-hour
access to schools and promoting safe play.
2.
Require that K-12 grade students are provided with 45-minutes of moderate to
intense physical activity daily.
3.
Create policies that are supportive of breastfeeding throughout the community
and all hospitals in Monroe County meet the WHO Baby Friendly Hospital
Criteria (Ten Steps to Successful Breastfeeding for Hospitals).
39
Before
40
……after
41
5 Main Policy Approaches
4.
Eliminate the availability of food in schools that compete with the national
school breakfast and lunch program. Mandate the development and execution
of nutritional standards so all food available on school campuses is consistent
with a set of community standards.
5.
Mandate the development and execution of nutritional standards for
preschools, childcare centers, and school-age childcare programs, so that food
and drinks available comply with Dietary Guidelines for Americans or
equivalent community standards.
42
When can policy Back Fire????
43
We need safer parks
Rec on the Move
What does Recreation on the Move offer?
The Recreation on the Move vehicles and their engaging staff bring recreation and much
more to underserved neighborhoods:
• Sports and group games like Jurassic Park, a dino-sized version of capture the flag!
• Read-aloud program & free book giveaways
• Health and wellness info and free fresh and healthy snacks
• Homework help
• Arts, music, and creative fun
• Environmental and horticultural projects and games
• Information about City R-Centers and youth programs, libraries, and other City 45
facilities and services
• And more!
What other community partners can do
Screen for Food Insecurity in Medical Home
Add to EHR
Refer to community resources
46
Childcare level strategies
Good resources:
Childcare standards
48
Toddler Food Images
Breakfast for Toddler
Lunch for Toddler
Dinner for Toddler
Snack for Toddler
49
Infant Food Images
Breakfast for Infant
Lunch for Infant
Dinner for Infant
9month old foods
50
Screen time
Clinical level strategies
The Expanded Care Model
• Build healthy
public policies
• Create supportive
environments
• Strengthen
community
action
Activated
Community
Community
Health System
• Information
• SelfSystems
Management
• Delivery System
Support/Develop Design/Reorient • Decision
Support
personal skills
health services
Informed,
Activated
Patient
Productive
Interactions &
Relationships
Prepared
Proactive
Practice
Team
Population Health Outcomes /
Functional & Clinical Outcomes
Prepared
Proactive
Community
Partners
53
Drink and Cereal Display
BMI Charts on the back of exam room
door
Smaller size laminates for easy reach at
desk
Food Models!
Parents remark about
portion size, realizing that
the portions served are
much larger than
recommended.
57
What other community partners can do
58
Newer Clinical Tools
There’s an APP for that
Change Talk: Childhood
Obesity
60
61
Pediatric e-Practice:
Optimizing Your Obesity Care
WHERE DOES PAYMENT
REFORM FIT?
Transition in Both Payment and the
Delivery systems
64
What is FFS and what is total capitation
Fee for service: Puts all the risk on the Payer / rewards the provider for high
volume
Full Capitation: Puts all the risk on the payer, provide all the care needed for
one price, whether it’s enough or not. If you have healthy population = great, if
you have a sick population = NOT great.
Leads to cherry picking and lemon dropping
65
The Medical Home model to
promote coordinated care
• A “medical home” or “health home” -- clinical setting that
serves as a central resource for a patient’s ongoing care.
• Currently no Medicare payment for many activities that
facilitate the provision of patient-focused, longitudinal,
coordinated care
• Payment reforms
– Per-member, per-month medical home fee, in addition to fee-for
service payments.
– Payment would vary depending on the severity of illness of the
enrolled patient.
– Support increased access to primary care services, more time
spent with patients, and a team approach to care.
• Allows for physicians to get paid for increased level of
care coordination.
*Source: Robert Wood Johnson Foundation. Accountable Care Organizations: Testing Their Impact. 2012 Call for Proposals.
Value-Based Payment
(Pay for performance, P4P)
•
•
•
•
Align payments with value, not volume
Stimulate improvements in the quality of care and, in
some cases, reductions in costs.
Variety of performance measures
Funding:
• Hold a portion of current payments for future
payment increases
• Add new money to existing payments
• Share savings from cost reductions.
• Increase payment for each service delivered.
*Source: Robert Wood Johnson Foundation. Accountable Care Organizations: Testing Their Impact. 2012 Call for Proposals.
What is happening with Medicaid (NY)
NYS Medicaid Roadmap – moving away from FFS toward VBP
• Bundling payments for chronic care conditions
• Example: Depression is both episodic and continuous
• Can the same be done for childhood obesity services?
Population Health focus on
overall Outcomes and total
Costs of Care
Sub-population focus on Outcomes and Costs
within sub-population/episode of Care
Can Brief Motivational Interviewing in Practice
Reduce Child Body Mass Index?
Results of a 2-year
Randomized Controlled Trial
Ken Resnicow, PhD, Alison Bocian, MS, Donna Harris, MA, Robert Schwartz, MD,
Linda Snetselaar, PhD, RD, Esther Myers, PhD, RD, Jaquelin Gotlieb, MD,
Susan Woolford, MD, MPH, Richard Wasserman, MD, MPH
Funding provided by a grant from National Heart Lung and Blood Institute (R01HL085400), PROS
core funding from the Health Resources and Services Administration Maternal and Child Health
Bureau (R60MC00107) and the American Academy of Pediatrics
MI Delivery and Training
Group 1
Usual care only
Group 2
Group 3
Up to 4 MI sessions Up to 4 MI sessions
with pediatricians
with pediatricians
and up to 6 MI
sessions with
registered dietitians
Group 2 and 3 pediatricians and dietitians attended
a 2-day MI training session and received follow up
skill assessments by phone with MI experts
70
Year 2 BMI Percentile and Percentile Change
N
Year 2 BMI Percentile^
(SE)
BMI Percentile
Difference#^ (SE)
Group 1
Usual Care
158
90.31 (0.94)
1.82 (0.98)
Group 2
Pediatricians
145
88.1 (0.94)
3.8 (0.96)
Group 3
Pediatricians & RDs
154
87.11 (0.92)
4.92 (0.99)
Study Group
1,2
Groups with matching superscripts differ p < .05
# Subtracting post-intervention BMI percentile from baseline BMI percentile
^ Adjusted for age, race, sex, baseline BMI, household income, parent BMI, pediatrician age, and practice effects (clustering)
71
MI SESSIONS COMPLETED
Number and Percent of MI Contacts Completed
Study Group
Group 2
Pediatricians
(n =145)
Group 3
Pediatricians
(n =154)
Group 3 RDs
(n =154)
0
1
2
3
4
5
6
3
2.1%
14
9.7
8
5.%
14
9.7%
106
73.1%
NA
NA
3
1.9%
18
11.7%
17
11.0%
12
7.8%
104
67.5%
NA
NA
21
13.6%
24
15.6%
29
18.8%
30
19.5%
22
14.3%
9
5.8%
19
12.3%
72
Treatment Outcomes of Overweight Children and
Parents in the Medical Home
73
3yr old WCC w/ pt Not Mykid
74
Pt NW, first seen at 3yrs and noted to be obese
PNP informed pt in ‘Red zone’ as unhealthy. Can we discuss?
75
Pt MN
76
Center of Excellence
SCREENING FOR OBESITY IN CHILDREN AND ADOLESCENTS:
CLINICAL SUMMARY OF USPSTF RECOMMENDATION 2010
Population
Children and adolescents 6 to 18 y of age
Recommendation
Screen children aged 6 y and older for obesity.
Offer or refer for Moderate (>25 hrs over 6 months) to High (>75hrs
over 12 months) intensive counseling and behavioral interventions.
Grade: B
Grade B Definition: The USPSTF recommends the service. There is high certainty that the net benefit is
moderate or there is moderate certainty that the net benefit is moderate to substantial.
Suggestions to practice: Offer/provide this service.
For a summary of the evidence systematically reviewed in making these recommendations, the full
recommendation statement, and supporting documents please go to
www.preventiveservices.ahrq.gov.
Community Collaboration Model from
Autism
79
What we all can do
Advocate for payment of tertiary care / referral services for obesity treatment at a
children’s hospital / department of pediatrics
Advocate for Evidence based guidelines as part of policies for early childcare
Think outside the box for new roles in clinic
Ask / screen parents Wt for height just of obesity
SW or Cert Health Educator to deliver parenting style or behavioral health or Master’s
level mental health provider
Try to link with commmunity resources like YMCA, but also bring/bridge those resources
to other community setting like after school programs
Pediatrician’s Positive Influence
• Encourage parents, schools, and communities to find rewards other than food.
• Help families and schools create “tease-free” environments, especially because
weight-related teasing starts in the home and spreads to the community and school,
with potentially devastating effects on a child’s self-esteem.
• Teach media literacy to decrease the “pester power” of children for high-calorie,
low nutrient-dense food choices.
• Join a school health advisory board or other community collaborative network to be
an agent of change.
• Link with academic medical centers to help with program design and evaluation
that can measure impact and disseminate evidence-based best practices and
policies.
81
82
83
Questions??
@DrSteveCook
The Effect of Maternal Obesity on the Offspring.
Prevalence of childhood body mass index (BMI)>=95th percentile by maternal pre‐pregnancy BMI and breastfeeding. US National Longitudinal Survey of Youth, Child, and Young adult data 2 to 14 years of age (n=2636).
Li et al. Obesity Research.2005;13:362–371.
2
Stigma of Child Obesity
“The lot of fat children is a sad one. They are bashful
and ashamed of their shapeless figures, yet unable
to conceal them. Wherever they go they attract
attention…..Obesity is a serious handicap in the
social life of a child, even more so of a teenager.
Obesity does not have the dignity of other
diseases…”
Bruch H. Pediatric Annals: 1975
Framework for Integrated Clinical and Community
Systems of Care
88
Treatment of Obesity in
Children and Adolescents
Stage
Delivery
Behaviors
Stage 1 –
Prevention Plus
Office-based support, with
scheduled follow-up
5 fruits and vegetables
of
< About
2 hrs of 30-35%
screen time
yr oldsactivity
> 1 2-18
hr of physical
Stage 2 –
Structured Weight
Management
Specially-trained staff in office
with support from referrals
Reduced-calorie
eating plan
If 1/3rd come
/
< 1 hr of screen time
follow up= 10%
Monitoring
Stage 3 –
Comprehensive
Multidisciplinary
Intervention
Dedicated weight management
program or registered dietician
referral; weekly follow-up for 8-12
weeks
More frequent contact, more f
If 1/3rd continue,
1/3rdstructured
monitoring,
then
~3%
goal-setting
Stage 4 –
Tertiary Care
Pediatric weight management
center with multidisciplinary team;
clinical or research protocol
Medication,
meal
If 1/3rdsurgery,
continue,
replacement, ongoing behavior
then ~1%
change
Adapted from Katzmarzyk
2014
Why are we here?
90
Payment Reform
Payment reform
Bundled payments for acute care episodes (Hip
replacement)
Value-based payment (Pay for Quality P4Q)
Accountable care organizations
Patient-centered medical home
Medicaid (Medicare)
ACO
Employer / Commercial Plan
Accountable Care Organizations
• A coordinated network of providers with shared
responsibility for providing high quality and low
cost care to their patients.*
• Couples risk-based provider payment with
health care delivery system reform
• Accepts performance risk for quality and cost
*Source: Robert Wood Johnson Foundation. Accountable Care Organizations: Testing Their Impact. 2012 Call for Proposals.
How Obesity might fit
• Prevention model with PCP as lead and within the patient centered medical home. • Use ESDPT codes and less severe or less complicated level of obesity
• PCP would have to be on board/trained.
• Could link to community service or embed therapists into PCP/Medical home
• Could be Value‐based payment?
How Obesity might fit
• Treatment model with referral to specialty ctr
• Could link w/ community resource but must be high enough level of intensity/dose with right specialty and approach
• Would accommodate more complicated or more severe children/teens with obesity
• This might still be FFS but could move to discounted FFS or PMPM?
Who are we really treating?
Those with Overweight and above?? 25-30%
Those with Obesity only?? 12-22%
OW or OB and a parent w/ OW or OB?  2/3 of youth w/ OW or OB
Or
Those with Severe Obesity (>99th percentile or > 120% of Obesity)
• 3-4 % of youth in your region.
95