The pediatric multidisciplinary obesity program: An update

Abstract

The dramatic increase in obesity over recent decades has been well documented. In response, the need for pediatric multidisciplinary obesity programs when efforts within the primary care setting fail to produce the desired results has been recognized. This review describes the components, outcomes, barriers and future of pediatric multidisciplinary obesity programs. These programs are able to offer preventive care, medical weight management programs, medications, and bariatric surgery. A team of physicians, dietitians, health educators, exercise physiologists, surgeons, and psychologists usually delivers services, each with varying proportions of involvement. Interventions are provided to participants at individual visits, group sessions or a combination of both. The majority of programs report very modest decreases in anthropometric measures, with improvements in metabolic and cardiovascular risk factors. However, the long-term impact of slowing a child's growth trajectory for a significant amount of time is not well known and demands further study. Challenges faced by the pediatric multidisciplinary obesity program include poor reimbursement, lack of evaluation and outcomes data, low parental and child motivation, and high attrition rates. As the number of pediatric multidisciplinary obesity programs increases, their relevance will be largely determined by i) efficacy of the intervention; ii) the need for their services; and iii) support from families, healthcare providers, the community, and public policies.

Introduction

Among US children, the prevalence of obesity has more than tripled since the mid-seventies, increasing from less than 5% for children 6–17 years old in 1970 to over 17% in 2004 [1], [2], [3], [4]. Concurrent with this dramatic increase, there has been a rise in the number of children with co-morbid conditions such as type 2 diabetes, cholelithiasis, essential hypertension, dyslipidemias, and non-alcoholic steatohepatitis [5], [6], [7], [8], [9]. Obese children are also at increased risk for psychosocial sequelae, including depression [10], [11]. These comorbidities result in the significant costs associated with obesity, which begin to accrue during the childhood years. A growing number of studies have revealed an impact on both inpatient and outpatient charges for obese children compared to those who are not obese [12], [13], [14]. In June 2007, an American Medical Association (AMA) expert committee released recommendations indicating the need for pediatric multidisciplinary obesity programs when efforts within the primary care setting fail to produce the desired results [15]. These programs are deemed to be the most appropriate environment to provide intensive weight management therapies, including behavioral interventions, medications, very low calorie diets and bariatric surgery [15].

The basis for recommending treatment in a multidisciplinary program reflects the multifaceted etiology of obesity, which should be addressed in a comprehensive manner. This premise underlies the Institute of Medicine [16], the American Dietetics Association [17] and the Centers for Disease Control and Prevention's [18] use of the Social-Ecological Model (Fig. 1) as the framework for obesity treatment guidelines. Stemming from Bronfenbrenner's Ecological Systems Theory [19], this model emphasizes the relationship of individuals to the different environments within which they exist. It recognizes the wide range of influences on individuals and behaviors, and promotes a multi-level approach to intervention [20]. The social-ecological model combines two important aspects: (1) the influence of social, institutional, physical and cultural contexts of the person-environment relationship, and (2) the impact of a variety of personal attributes, including genetic heritage, psychologic disposition and behavioral patterns. The social-ecological model hinges on the dynamic interplay between these situational and personal factors which together impact health [21].

Although optimal treatment and prevention of obesity requires input from a variety of sectors–including the family, schools and media — the healthcare system plays a significant role. Families look to their healthcare providers as a primary resource for addressing weight concerns. Eneli et al found that two-thirds of parents in a primary care practice felt the physician's office was the best place to address weight concerns [22]. Studies suggest physicians can be effective agents for change [23], [24]; for example, overweight adolescents who were counseled by their physician reported attempting weight loss strategies at rates similar to recommendations [23]. Yet, primary care providers are often reticent to diagnose and treat obesity, citing limited resources, inadequate knowledge and skills needed to counsel patients on weight loss, futility of available interventions, time constraints, and lack of reimbursement for obesity-related services [25], [26], [27].

In contrast, pediatric multidisciplinary obesity programs are well positioned to address these barriers. These programs are equipped with appropriate resources and experienced personnel, and have their greatest impact at the individual and interpersonal level of the social-ecological continuum. In addition, they are often viewed as a key resource for healthcare providers, families, and communities. In the following sections, we will review components, barriers, outcomes and future of pediatric multidisciplinary obesity programs.