Abstract
US obesity and overweight rates are among the highest in the world, affecting two-thirds of adults and one-third of youth, with a disproportionate grip on minorities. 2 Minorities now comprise one-third of the US population and are expected to become the majority in 2042, with the nation projected to become 30% Hispanic, 14% black, and 9% Asian by 2050. 3 Obesity prevalence among blacks and Hispanics is 50% and 21% higher, respectively, compared with whites. 4 Obesity is responsible for many of the chronic disorders that tax the US healthcare system and results in more than 112,000 deaths each year, at an annual cost of $147 billion. 5 Despite a substantial investment of resources, most nonsurgical obesity interventions fail to reduce excess weight in the long term; even intensive multidisciplinary programs produce only modest weight loss, and most of the lost weight is regained within a few years. Bariatric surgery does produce more enduring weight loss, but results are also disproportionately worse for minorities than whites, regardless of procedure type. 6
The factors underlying racial/ethnic variation in obesity are complex and reflective of the multiplicity of culturally based beliefs, traditions, weight norms, level of acculturation, and the larger social contexts in which individuals live. Race, ethnicity, and socioeconomic status are intimately intertwined, and contributions to disparities hard to disentangle. Minorities are more likely to live in poor neighborhoods with fewer amenities, lower-performing schools, higher crime rates, and decreased availability of affordable good food and clean spaces that support healthy active living. Additionally, despite legislative strides since the Civil Rights Act of 1964, an unacceptably high number of minority individuals continue to experience overt or covert prejudice and discrimination, with adverse impacts on social functioning, health behaviors, stress physiology, and cardiovascular health. In this context, impoverished minorities find solidarity in ethnocentric social networks that promote in-group cohesion and identity, but may inhibit their integration into broader social systems. The latter may perpetuate stereotypes and mistrust, complicate outreach efforts targeting minority populations, inhibit their participation in the full spectrum of services available to the general community, and contribute to disparities. Racial/ethnic gaps in obesity prevalence and risk factors manifest in the earliest stages of life and are troubling given the unrelenting long-term ramifications of childhood obesity. Unless current trends are disrupted, a third of all children, and half of black and Hispanic children born in 2000, are predicted to develop diabetes. The current generation will become the first one to have a lower life expectancy than its parents. 7 Decisive action is needed to curb the current obesity epidemic and safeguard the health and future of all American children, with special attention given to those from underserved backgrounds who face disproportionate challenges.
In 2001, the Institute of Medicine called for fundamental healthcare change in its report “Crossing the Quality Chasm: A New Health System for the 21st Century.” This landmark document stipulated that care should be safe, timely, efficient, effective, equitable, and patient-centered, defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” 8 With its inclusion in the Affordable Care Act (ACA), the concept of “patient-centeredness” has renewed polemic in discussions of quality—what it means, who defines it and from whose perspective, how to implement and measure it, and whether and how it impacts “hard” health outcomes.
Although the concept of culturally competent care is well established in the literature, the “patient-centeredness paradigm” is still evolving, particularly as it relates to the longitudinal care of individuals with chronic health conditions including obesity. The Patient-Centered Medical Home (PCMH) has been proposed as a practical solution to the primary care crisis and holds promise in the delivery of better obesity care. Patient-centered obesity management cuts across cultural and psychosocial domains to engage children and families in health behavior change that is achievable within their own unique contexts. Early evidence links patient-centered care to improved outcomes, including enhanced adherence to medical recommendations, and decreased health care utilization 9 ; patient-centeredness should be applied to the care of all children, including those from disadvantaged backgrounds. The inception of the ACA-funded Patient-Centered Outcomes Research Institute (PCORI) now provides a historic opportunity for the rigorous evaluation of critical national health questions, so that patients, families, and clinicians can make good decisions in alignment with their desired health outcomes. 10 Such questions are particularly pressing in the case of childhood obesity.
With this backdrop, we propose to advance the concept of patient-centeredness as a crucial element of a national health agenda directed at eliminating childhood obesity disparities and improving child health. Patient-centeredness in such a framework would consider the unique needs of children, especially those from disadvantaged backgrounds, and would encompass care that is respectful, accessible, coordinated, multifaceted, comprehensive, developmentally appropriate, family-based, culturally competent, and linguistically sound. To this end, exemplary clinical care and research agendas would:
1. Demonstrate an empathetic understanding of the social, cultural, and environmental contexts from which patients and families originate and in which they now live,
11
2. Actively seek the input of families and develop health-promoting activities that are responsive to their needs and values,
12
3. Engage patients and the families/caregivers of young children as care partners, using language they can understand, to help them develop customized, feasible, developmentally appropriate, family-based, health plans they would actually follow,
13
4. Utilize an integrated team-based approach (nursing, ancillary staff) to improve the timeliness, quality, and cost-effectiveness of care delivery and research conduct,
14
5. Use a medical home model to provide accessible, comprehensive services for patients and families,15,16 6. Use a life-course approach to proactively address the origins of disease and disrupt its trajectory across the life span,
17
7. Employ technology to efficiently gather, analyze, and share information regarding outcomes that matter to patients,9,18 8. Engage community partners [Women, Infants, and Children (WIC)] to deliver consistent evidence-based messaging to support healthful behaviors (limiting sugar-sweetened beverages and sedentary behaviors, optimizing sleep and diet quality),
19
9. Coordinate efforts across the multiple locales where children spend time (school, daycare settings),
20
10. Develop multisector partnerships (community, public health, policy, private sectors) to mitigate inequalities in the social determinants of health.
21
Moving from Principle to Practice
One of the most important lessons learned from the first National Demonstration Project (NDP) about transformation to a PCMH model is the requirement for “epic whole-practice re-imagination and redesign… Transformation includes new scheduling and access arrangements, new coordination arrangements with other parts of the health care system, group visits, new ways of bringing evidence to the point of care, quality improvement activities, institution of more point-of-care services, development of team-based care, changes in practice management, new strategies for patient engagement, and multiple new uses of information systems and technology.” 22
Moving patient-centered obesity care from principle to practice will likewise require significant cultural change and practice redesign to overcome logistical challenges, but is possible, as evidenced by demonstration projects being implemented by pioneering groups across the country. Primary care practices participating in the Harvard Academic Innovations Collaborative (AIC), 23 for instance, have embarked on large-scale practice overhaul through innovation in four key areas—team-based primary care, chronic disease prevention and management, population health, and patient empowerment strategies. The Boston Children's Hospital Primary Care Center (CHPCC), an AIC participant, is undergoing a radical makeover from a traditional academic practice to a PCMH practice model. The large group of over 80 primary care providers that annually serves more than 14,000 children from predominantly low-income and racial–ethnically diverse backgrounds (44% of whom are overweight or obese and 65% of whom are insured through Medicaid), has reshaped itself into six multidisciplinary “teamlets” comprising medical providers, nurses, clinical assistants, social workers, and administrative assistants who together deliver coordinated care to roughly 2300 patients per teamlet. To build capacity and support the transformation, the practice has reassigned roles, reconfigured workflows, hired additional support staff, and invested in enhanced information technology to facilitate communication, improve clinical processes, and track outcomes. To deliver high-quality patient-centered obesity care, the practice has devised a multipronged strategy that includes fine-tuning of patient empanelment procedures to ensure accurate identification of each patient's primary care provider, creating an obesity patient registry, testing novel patient-engagement modalities such as health coaches, patient navigators, and mobile technology, and developing evidence-based clinical decision support systems to alert clinical staff to out-of-range measurements, such as BMI and blood pressure levels. This reminds providers to order appropriate labs and referrals and guides them in the delivery of patient-centered behavioral counseling, including facilitation of customized goal-setting with patients and families using motivational interviewing concepts. Each clinic session now begins with a 5-minute “teamlet huddle” led by a nurse to discuss outlier patients and action items as a team. Until the CHPCC electronic clinical decision-support system is fully operational, a clinical assistant (CA) welcomes families and enters clinical information, including child anthropometrics into the electronic medical record that then calculates the BMI. The CA then attaches a healthy weight plan to the billing slip to remind providers to complete lifestyle counseling, and either the physician or team nurse engages families in setting healthy lifestyle goals using “The STEPS to Health Toolset,” 24 which includes a customizable written family health plan, color-coded BMI curves, and visually appealing patient education materials designed with the input of patient families. The introduction of the “STEPS to Health Plan” into routine care has been linked to an increase in the performance of HEDIS quality measures for nutrition and physical activity counseling in the practice. In addition, pilot data suggest that patient satisfaction with counseling by nurses is equivalent to that performed by physicians.
While clinical interventions are limited in their ability to alter the social–cultural milieu underlying the development and persistence of obesity, teams of pediatric healthcare providers are uniquely positioned to form trusting healing relationships with patients and their families and have the potential to influence lifelong health behaviors, particularly if strong connections are forged in early life. Such patient-centered efforts, combined with proactive health policies and interventions across the multiple spheres that influence health are important elements of a robust national strategy to curb childhood obesity and eliminate disparities.
Footnotes
Author Disclosure Statement
The authors have no financial relationships or conflicts of interest relevant to this article to disclose.