Pediatric obesity clinics aiming to get children healthy are springing up across the country. Although pediatricians and endocrinologists hope the trend continues, the programs are not without problems: a hefty price tag, for one, and a dearth of long-term data.
One program that does have long-term data is the nationwide KidShape, founded in 1986 at Cedars-Sinai Medical Center in Los Angeles by Dr. Naomi Neufeld. The program, which focuses on healthy lifestyles, results in an average 0.6-point decrease in patients' body mass index over the 9-week course, with 80% of the youngsters maintaining or continuing to improve their BMI at 2 years, she said.
“I don't think any of these programs cure obesity,” said Dr. George Datto, a pediatrician and director of the adolescent bariatric program at Alfred I. duPont Hospital in Wilmington, Del. “If parents think they will drop their kid off, and at the end of 8 weeks the problem will be gone—that's not the way these things work.
“But they're good for education,” he added. “It's a tool to help you change your lifestyle.”
One of the newer programs is Boston-based Great Moves! According to Dr. Erinn Rhodes, a pediatric endocrinologist and chief medical officer of Great Moves!, “We intentionally don't focus on weight in the program. What we focus on are healthy lifestyles,” she said in an interview.
According to both Dr. Rhodes and Dr. Neufeld, a pediatric endocrinologist in Los Angeles, the most successful programs provide support in four key areas: healthy diet and physical activity, to be sure, but also mental health support and—perhaps most crucially—the importance of parental involvement in weight loss.
“If you're getting the whole family to buy in, that's really the key,” said Dr. Neufeld. “You can show parents where they're sabotaging their child's best efforts.” Clinics that don't have parental involvement waste 50% of their effort, she said in an interview. At Great Moves!, the parents' BMIs are monitored right alongside those of the children.
Both programs employ on-site dieticians and nutrition experts. At Great Moves!, clinic director and dietician Suzanne Rostler said, “We do a basic Nutrition 101.” In the on-site kitchen, children and parents learn how to make healthy, balanced meals or snacks—“a healthy carbohydrate, plus a lean protein or a healthy fat.”
Dr. Neufeld echoed Ms. Rostler. “Clearly, people don't know very much about nutrition. Maybe in the aggregate they know a lot, but they have so many conflicts that they are afraid to act, act out of habit, or don't act at all,” she said.
The mental health professionals employed by both clinics are another reason for their success, said Dr. Neufeld. “A lot of kids who are overweight are turning to food for a lot more reasons than just boredom. And it's good to have other people around that they can talk to about it.”
Physician involvement also is important to both Great Moves! and KidShape.
At Great Moves!, families meet individually with a physician at least three times throughout the program. “The beginning [visit] is intended to evaluate whether there is any underlying medical reason that may be contributing to [the child's] overweight or obesity, look for complications as a result [of the obesity], and make sure that if there are any secondary medical issues that they have that are unrelated to obesity, we know about them,” said Dr. Rhodes. Other visits are for follow-up.
Although KidShape clinics do not schedule mandatory visits with on-site physicians, many of the clinics have MDs serving as director, “spearheading the program,” said Christiane Wert Rivard, a program director at KidShape. They also coordinate with referring physicians.
The weekly physical activity sessions, involving nontraditional, “kid-friendly” sports and games, also are key.
At Great Moves!, Dr. Rhodes stressed that there are no treadmills or exercise bikes. Rather, the children participate in dancing competitions in a video game where the player's correct moves on an electronic mat earn points.
There is also the “SportWall,” originally designed as a tennis aid, where balls hit at the correct mark cause lights to flash and make noise.
“So the kids will need to run up and hit different lights that show up on the different mats. There are different games and routines that the kids do: races, throwing balls at the mat, and using different kinds of gym equipment to interact with the wall as it lights up,” added Dr. Rhodes, who also is the director of the type 2 diabetes program at Children's Hospital, Boston.
KidShape, similarly, involves its participants in weekly karate, kickboxing, and tae kwon do sessions.
This kind of exercise approach is essential for pediatric weight loss success, said Dr. Donald Bergman, an endocrinologist in private practice in New York who is not affiliated with the clinics. “Children need to be active in small doses; they need to vary the activity so that it is fun.” Parents who seek to exercise with their children should vary activities every 15 minutes, he said in an interview.
Pediatric weight loss clinics like these are not all fun and games, however. There is the matter of the bill. In an interview, Dr. Jay Cohen, a pediatric endocrinologist in Memphis, said he knows of many clinics similar to Great Moves! and KidShape around the country, which offer different combinations of nutrition, fitness, and behavioral instruction. “The main challenges are: Insurance companies have been reluctant to cover these programs, [and] they are expensive, especially to the socioeconomic population that would truly benefit from them.”
Indeed, at Great Moves!, the cost is significant: $300 for an initial assessment followed by six payments ranging between $300 and $450, depending on the degree of program participation, said Stanley Goldstein, Great Moves! CEO.
A reduced-cost version of the program without physician supervision is in the works, as are negotiations with insurers.
At KidShape, Dr. Neufeld has been somewhat successful at getting private insurers to cover at least some of the cost. To do so, she works to identify some of the comorbidities that obese and overweight children face, or are at risk for. “They will pay if you can show a clinical diagnosis,” she said. “If [the kids] have asthma, that can be aggravated by their weight. Or, depending on the health plan, [it will pay] if they have type 2 diabetes, or are at risk for diabetes or hypertension.” Additionally, “Children eat because of depression. This is a form of treatment.”
Another issue that Dr. Cohen raised regarding these programs is the lack of long-term outcome data, especially for the newer centers.
Great Moves!, which has seen about 30 families since it opened in April 2008, does not have any data yet, said Dr. Rhodes.
In any case, commented Dr. Datto, programs like this can yield significant outcomes in areas other than BMI, such as decreases in cholesterol, blood pressure, and insulin level. The impact on “the metabolic markers of obesity are usually more significant than BMI,” he said. Dr. Datto runs an individual pediatric weight-management program at Alfred I. duPont Hospital.
There are some differences between the programs: KidShape runs for 9 weeks, versus 24 at Great Moves!, for example. But both programs rely on constant feedback from participants—which has been positive. “The kids ask their parents, ‘When are we coming back?’” said Dr. Rhodes.
Dr. Rhodes and her team of physicians and specialists at Great Moves! are optimistic. “The information that we're trying to impart is more about being healthy and having a healthy lifestyle, and less about their weight on the scale, because that will come along—if they focus on the other things.”
Dr. Neufeld said the response is typical among physicians to her program, KidShape, as well.
“Pediatricians love us. They are asking us to set up the program in their area,” she said. “They're our strongest supporters.
FULL TEXT
