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Children's National

Obesity

Institute

Diana L. and Stephen A. Goldberg Center for Community Pediatric Health Proposed Plan for Development

25 million

Today there are more than overweight or obese children, a number that has

tripled since 1980

and

quadrupled since 1970.

The Centers for Disease Control and Prevention

Table of contents

Executive Summary Introduction Institute Overview Prevention and Behavior Modification Clinical Intervention Research Public Policy and Advocacy Education and Training Appendix: Organizational Chart

1 5 7 15 23 31 37 47

executive summary

Today's children are likely to be the

first

generation

to live shorter,

less healthy lives

than their parents.

F as in Fat (2007)

executIve suMMaRy

Introduction

The District of Columbia Department of Health estimates that between 40% and 50% of the city's children are overweight or obese. This represents the highest rate in the nation. But the problem has grown everywhere slowly and incrementally, and today the Centers for Disease Control and Prevention estimates that our overall population is three to four times heavier than 40 years ago. (See Figure 1.) Children in particular are victims of the complex interaction of environmental, cultural, social and nutritional factors that contribute to the etiology of the obesity epidemic. Children's National's clinicians have long been concerned by the rising number of overweight

and obese children who suffer from conditions related to their weight. Painful and deformed joints, impaired glucose tolerance or diabetes, fatty liver disease, hypertension, high cholesterol, sleep apnea, fatigue, and depression are just a few of the challenges patients present to today's clinicians. Over 35 scientists and clinicians are actively studying the many problems associated with childhood obesity at Children's National. Their work is supported by many more researchers and health care professionals in health centers, laboratories and the community. Our researchers seek to unveil the connections and find effective treatments for these patients through genetic, translational, clinical and public health projects. Our advocacy team

fIGuRe 1 Prevalence of overweight* among u.s. children and adolescents

ages 2­5 ages 6­11 18.8% ages 12­19 17.4%

13.9% 11.3% 7.2% 5.0% 5.0% 4.0% 10.5% 6.1%

6.5%

5.0%

1988­94

1988­94

2003­04

2003­04

1988­94

1976­80

1976­80

1976­80

1971­74

1971­74

1971­74

SOURCE National Health and Nutrition Examination Surveys *Sex- and age-specific BMI 95th percentile based on the CDC growth charts.

2003­04

works closely with D.C. government officials to identify advocacy and public policy interventions

DefInInG cHIlDHooD obesIty

In this proposal, the term obesity is used to refer to children and youth between the ages of 2 and 18 years who have body mass indexes (BMIs) equal to or greater than the 95th percentile of the age- and gender-specific BMI charts developed by the Centers for Disease Control and Prevention. SOURCE Institute of Medicine, Preventing Childhood Obesity (2005)

that can be taken to slow and eventually reverse current obesity trends. Our clinicians have taken the lead in establishing comprehensive hospital-based clinical intervention and community-based behavior modification programs. Children's National created The Obesity Institute in order to bring together the talent, the ideas and the creative energy we already possess with the goal of developing an innovative and strategic approach to the childhood obesity crisis here in the nation's capital. Its structure recognizes five interdependent and overlapping areas of work: prevention and behavior modification, clinical intervention, research, public policy and advocacy, and education and training.

Prevention and Behavior Modification

Factors that contribute to childhood overweight and obesity include some combination of family history of overweight, family income and education level, ethnicity, cultural norms, sedentary and exercise behaviors, peer influence, family eating patterns, and the "built" and school environments. The Institute will foster the design and implementation of creative prevention and behavior modification strategies. We will validate them, and work with government and the community to make them available throughout the District. These strategies will also facilitate our advocacy efforts for policy changes in schools and urban planning to make those environments less overweight "friendly" and thereby address the issue of long-term prevention. Finally, recognizing that regaining weight and maintaining lifestyle change can present significant challenges, we will pilot a post-intervention program designed to support long-term weight loss and maintenance.

Clinical Intervention

The core of our clinical intervention program will be an expanded multi-specialty I.D.E.A.L. Clinic (Improved Diet, Exercise, and Activity for Life). Currently meeting one afternoon a week, the clinic will expand to six sessions a week and include a multi-disciplinary tertiary care clinic and a clinic for obese children with special health needs. This expansion will allow us to serve more obese and at-risk children and eliminate our 18-month waiting list. Importantly, the clinic will provide clinical research and training opportunities.

Public Policy and Advocacy

Taking a public health approach to the childhood obesity epidemic promises to yield better results than one that focuses solely on personal responsibility. Therefore, while we will provide direct prevention and intervention services to children, we will also keep our eye on the big picture by intervening at the local and national public policy levels. We will continue to support local initiatives through advocacy, and respond to research reports and proposed relevant legislation. We will also create a community "report card" to measure progress and identify trends and opportunities for action, including evaluating and improving the hospital environment itself. Finally, we will create a database to calculate the real cost of treatment, information we can use to negotiate a restructuring of reimbursement rates with managed care organizations and Medicaid for long-term sustainability.

Research

Children's National's interventions, educational programs and public policy recommendations must be grounded in solid research. To have an impact on the obesity epidemic our work must be evidencebased and data-driven. The Institute will bring together a community of researchers and clinicians to study questions such as the potential of genetic information for weight loss program design, the ways in which fat hormones affect the functioning of our kidneys, and the adaptation of ultrasound instruments for use with obese children to obtain radiation-free images and accurate diagnoses. Our overarching approach will be integrative systems biology, moving seamlessly from bench to bedside to community and back again for constant study and discovery.

Education and Training

The diverse challenges posed by overweight and obesity require physicians to learn techniques for constructive communication, accurate diagnosis and effective treatment. The Institute's proposed Obesity Professional Education Network (O.P.E.N.) will consist of a multi-level comprehensive education and training program for health care professionals both in the Washington metropolitan area and in the hospital. O.P.E.N. will focus on educating local and regional providers, training the next generation of practitioners, and serving the greater community.

Conclusion

The Institute's goal is to lead the effort nationally and within the Washington metropolitan area to create innovative solutions to preventable threats to children's health caused by overweight and obesity through effective and compassionate treatment, advocacy and public policy, research, and education. We will bring to bear committed leadership, strategic alignment, creativity, and, above all, a sense of urgency to this crisis, whose repercussions threaten to last many decades.

tHe obesIty InstItute

This variation on the "Möbius strip" represents creative thinking, efficiency, continuity, interdependency, innovation and sustainability--all qualities associated with the collaborative, interdisciplinary Obesity Institute at Children's National Medical Center.

introduction

The remarkable growth of

obesity

in the

young population

in many parts of the world in a

relatively short time span

represents one of the

defining public health challenges

of the

21st century

.

Institute of Medicine

IntRoDuctIon

A National Crisis

After decades of creeping weight gain in the nation, overweight and obesity have become major health issues. The numbers of children affected are staggering:

n The Centers for Disease Control and Prevention

Morgan Spurlock famously tested first-hand the effects of a typical American fast food diet on his own body as documented in 2004 in his film SuperSize Me. The Washington Post devoted a series of multi-media articles to the topic of childhood obesity in May 2008, and Time Magazine published a 56-page spotlight on the issue in June 2008. Yet even as this "epidemic" has been recognized as real, parents do not necessarily realize that their own children are overweight or that they may be suffering from related medical conditions. Childhood obesity also has significant consequences for the U.S. health care system, as obese children tend to use more resources--including hospital days, outpatient and emergency department visits, and pharmaceuticals--and are more than twice as likely to be hospitalized as compared with non-obese children.

(CDC) estimates that today there are more than 25 million overweight or obese children-- a number that has tripled since 1980 and quadrupled since 1970.

n The 2004 National Survey of Children's Health

and the CDC estimate that an average of 13% of youth ages 10 to 17 are obese.

n Data from D.C.'s Medicaid well child visits

indicate that in fact over 40% of D.C.'s estimated 120,000 children are overweight or obese.

fIGuRe 2 estimated lifetime Risk of Developing Diabetes for Individuals born in the united states in 2000

Men 45.4% 40.2% 32.8% 26.7% 38.5% 31.2% Women 49.0% 52.5%

n Total n Non-Hispanic White n Non-Hispanic Black n Hispanic SOURCE Narayan et al, JAMA, 2003

Taking Action

It has been suggested in F as in Fat: How Obesity Policies are Failing in America (2007) that, "Today's children are likely to be the first generation to live shorter, less healthy lives than their parents." One reason for shorter lives will be type 2 diabetes, which is strongly associated with obesity. The Centers for Disease Control and Prevention estimates the lifetime risk of developing type 2 diabetes for individuals born in 2000 is 32­39% with an associated loss of up to 20 quality-adjusted life years. Hispanic children have the highest lifetime risk of diabetes, followed closely by AfricanAmerican children. (See Figure 2.) Nationally, more than 40% of African-American teenagers are overweight, and nearly 25% are obese. According to a 2005 U.S. Government Accountability Office report, obesity-related health expenditures are estimated to have accounted for more than 25% of the growth in health care spending between 1987 and 2001. The factors that contribute to childhood obesity are complex and many. Home and play environments, family traditions and attitudes toward food, and psychological and social issues all play a role in childhood overweight and obesity. Children's National's interdisciplinary Obesity Institute will therefore address the crisis in a comprehensive manner, coordinating prevention and intervention, research, advocacy, and education initiatives. We have been able to identify only two other similarly comprehensive programs in the nation: Stanford University's Lucile Packard Children's Hospital's Center for Healthy Weight and Children's Memorial Hospital of Chicago's Center for Obesity Management and Prevention. While the Institute will share many characteristics with them, some of our features will be unique due to our location, our faculty and our population.

A Record of Accomplishment

Our clinicians, researchers and staff are actively engaged in clinical programs, advocacy for effective obesity-related public policies, and research studies and education programs throughout the greater Washington metropolitan area. The following represents a few of their recent accomplishments and successes:

n On September 19, 2007 Children's National co-

sponsored Washington, D.C.'s first Obesity Summit, which produced the 2008 "District of Columbia Childhood Obesity Action Plan," one of the first in the nation.

n In February 2008, Dr. Denice Cora-Bramble

testified successfully before the Maryland House of Delegates in support of House Bill 1176, "Public Health--Task Force on Childhood Obesity," which was also drafted by Children's National. The bill passed, and Children's National's Dr. Anjali Jain was appointed to the new committee. Its charge is to provide advice and recommendations to the Governor and the General Assembly of Maryland by the end of 2009.

n On April 24, 2008, Children's National's Board

approved a Policy Statement on Childhood Obesity expressing the institution's commitment to combat obesity both within the hospital and in the community.

n Early results from Dr. Nazrat Mirza's

research with overweight and obese children in our prevention, behavior modification and clinical programs indicate that comprehensive interventions, especially with the very young, can have positive outcomes and bring lifestyle change to the whole family.

n Dr. Eric Hoffman and his research team in the

Center for Genetic Medicine have been working to define the genetic risk factors for type 2 diabetes and the physiological response to muscle training in young adults. The next phase of this study customizes therapeutics for the prevention of type 2 diabetes in the same population. The recruitment goal of 10,000 students every year into this study will yield a clinical trial pool that will be available to other researchers nationally and internationally.

institute overview

We need to

find ways

to make

healthy

choices

easy

choices.

F as in Fat (2008)

InstItute oveRvIeW

The Obesity Institute

Vision Statement

The Obesity Institute will be a recognized national and regional leader in developing and disseminating best practices for the prevention and treatment of overweight and obesity.

Mission Statement

The Obesity Institute will lead the effort to create innovative solutions to preventable threats to children's health caused by overweight and obesity through effective and compassionate treatment, advocacy and public policy, research, and education.

Purpose

The obesity epidemic has been fueled by a complex interplay of environmental, social, economic, and behavioral factors acting in concert with genetic susceptibility. It did not emerge overnight; nor will simple answers suffice. This crisis will take a dedicated group of clinicians, researchers and health care professionals from many medical specialties and interests collaborating together to identify issues and seek solutions, to communicate findings to government officials and community leaders, and to work creatively and constructively with parents and families. Children's National has launched The Obesity Institute led by the Diana L. and Stephen A. Goldberg Center for Community Pediatric Health to bring together the best and the brightest to find strategic and innovative solutions to childhood obesity. The Institute will provide an invaluable service by addressing the challenge "to develop a robust evidence base of effective obesity prevention interventions and practices," as recommended by the Institute of Medicine. Our initial goals are:

n to continue to validate our interventions through

Institute Structure

A Framework for Creating New Knowledge

The challenge posed by childhood obesity is daunting. New approaches will be critical to making an impact in a time span that is meaningful. To that end, we will replicate successful management principles from the business world and apply proven methods for innovation.

Innovative Management Principles

Defined as the successful exploitation of new ideas and change that creates a new dimension of performance, "innovation" offers a framework for facilitating and expediting revolutionary new therapies and technologies to address the health care challenges of children and adults. From studying the business sector we can identify a set of characteristics for a successful culture of innovation:

n leadership that models and rewards a commitment

to pursue innovative research;

n effective management through rigorous tools and

processes that track and measure advances;

n strategic alignment with organizational priorities

and services;

n properly allocated talent management; n an acceptance of risk; n a sense of urgency and need for speed in

research and evaluation and expand their reach within the District;

n to seek long-term financial sustainability for

developing new processes and products; and

n creativity, as individuals and teams engage

our prevention, behavior modification and clinical programs by advocating for increased funding from local and federal governments, and for a new reimbursement structure from managed care organizations; and

n to develop new modalities for research and

in discovery and invention as a starting point for translating those discoveries into innovative applications.

treatment in our quest for the most cost-effective and impactful approaches to the obesity epidemic.

InnovatIon scoRecaRD (saMPle)

METRIC 1. Measures of Commitment to Innovation

n Number of new ventures and initiatives

STATUS

5

2. Measures of Innovation Output

n Number of new collaborations, partnerships n Number of conferences, events

2 6

3. Measures of Market Success

n Increase in number of children and families served

10%

4. Measures of a Culture of Change

n hours of training/mentoring on new technologies, processes n number of rewards and recognition for ideas n % of employees belonging to more than one team n number of peer knowledge sharing sessions

100 10 20% 6

5. Measures of Collaboration

n Number of initiatives from cross-disciplinary collaboration

2

STATUS KEY Excellent Progress Satisfactory Progress Progress Needed

Focused Leadership

With the help of focused leadership by an executive director and by directors of the research, prevention and intervention, public policy and education programs, the Institute will bring together the efforts of over 35 scientists and clinicians currently studying the many questions associated with childhood obesity at Children's National. In the process, the Institute will break down traditional silos between disciplines, establish a dynamic environment for interaction and collaboration, and create new internal communication tools for sharing knowledge.

n ease the translation of bench research to clinical

and community applications

n prove the effectiveness of scalable prevention

and behavior modification programs

n spearhead implementation throughout the

community

n educate providers in best practices n identify resources for Institute sustainability

Innovation Scorecard

Careful management of the innovation process will drive the success of the Institute. The creation of an Innovation Scorecard to measure and monitor progress on the key metrics for innovation--such as the number of peer-reviewed scientific articles and the number of new processes and products--will be instrumental to the management of the process.

A Strategic Approach

Designed to maximize cooperation within Children's National and produce the greatest benefit to the community at large, the Institute's overarching strategy will be to:

Creating an Innovative Culture--Innovation Fund for Interdisciplinary Initiatives

Discovery and invention are essential precursors to providing a pipeline of ideas and sustaining an innovative culture. To encourage researchers and physicians, the Institute will award seed funding for promising new ideas. By focusing on knowledge creation, transfer and use, this Institute will act as a interdisciplinary "incubator" that engages directly with community, government, industry, schools and families. Our aim is to bring the collective power of basic, translational and clinical research to bear on solving the wide range of individual and environmental issues involved in childhood overweight and obesity. Projects that are interdisciplinary will receive priority consideration to encourage collaboration.

n Geneticists will work with clinicians to design

Factors that contribute to childhood overweight and obesity include some combination of family history of overweight, family income and education level, ethnicity, cultural norms, sedentary and exercise behaviors, peer influence, family eating patterns, and the "built" and school environments.

hospital- and community-based programs that will allow us to better understand heredity's role in childhood overweight and obesity, evaluate the programs' effectiveness, and bring the results to local providers and neighborhoods

n Psychiatrists and psychologists will develop,

validate and teach intervention programs for overweight toddlers and young children to area pediatricians

n Researchers in public health and epidemiology

will collaborate with government officials to help set evidence-based policy in schools and neighborhoods

0

tHe obesIty InstItute Goals anD actIvItIes

Host regional and national obesityrelated summits, symposia and conferences

Conduct and publish cutting-edge and innovative interdisciplinary bench-to-bedside-tocommunity childhood obesity research

Contribute seminal publications and documents in basic science, clinical science, translational science, health services, communitybased science, and public health and policy to the obesity literature

Collaborate with the Center for Clinical and Community Research and the Center for Genetic Medicine Research to design, implement and disseminate rigorous research relevant to childhood obesity

Children's National cannot eradicate overweight and obesity in the District in isolation. But the Institute can act as a think tank and a catalyst for slowing, stopping and eventually reversing the trend of childhood obesity in the District and nationally. To that end, the Institute will: Design, test and validate model interventions and guide implementation in the community

With reliable, evidence-based information, raise awareness among managed care organizations and Medicaid officials on the real overweightand obesity-associated health care costs to providers and hospitals as well as prevention and treatment benefits

Provide formal and informal educational opportunities and materials to health care professionals both at the hospital and in the community

Identify effective public policy and advocate for its implementation in the District of Columbia

Deriving Synergies from Existing Capabilities and Facilities

The Institute will coordinate activities in ways that will encourage and build on collaboration between disciplines and departments, and develop new ventures among the pillars of clinical care, advocacy, research and education.

n Our Goldberg Community Centers and our

emergency department are ideal locations for identifying research questions and for recruiting families for our programs.

n The Children's Research Institute provides

infrastructure and research teams in bionutrition, data analysis, genetic medicine and community medicine to help design and coordinate interdisciplinary approaches to seeking answers and producing, revising and validating clinical protocols.

n The Child Health Advocacy Institute identifies

and studies threats facing children, advocates for

PRoven DeDIcatIon to coMMunIty HealtH

Children's National Medical Center's community-based infrastructure and programs give us unique access to the youth in the Washington metropolitan area:

n One of the busiest emergency departments

public policy changes that can improve pediatric health outcomes, and disseminates best practices and best policies to children, their families and the community. Our clinical and laboratory work provides an educational framework to train providers in the community as well as a new generation of practitioners within the hospital. As our understanding of childhood obesity grows, so will the effectiveness of our advocacy efforts.

in the nation

n Seven primary care health centers located

in the hospital and in underserved areas of the District of Columbia

n A thriving mobile health program with

three medical units

n A primary care service program for children

in foster care in the District of Columbia

n The Children's School Services'

Comprehensive School Health Program providing nurses to public schools

n Seven regional outpatient centers

delivering specialty care in Maryland, Virginia and Washington, D.C.

Reaching Across All Age Groups and Needs

Recent research shows that "the infancy and preschool years may constitute a key period for the development of overweight and its longterm health consequences." (Juhee Kim et al. See Appendix 2: References.) Through public-private partnerships, our network of overweight and obesity prevention and intervention programs will address the full spectrum of need by age group, with a special focus on the youngest to encourage prevention. These programs will provide data for further study and improvement so they remain evidence-based even as they grow.

n Infants and toddlers--Plans are underway to

Web-Based and Electronic Services

As the internet is fast becoming the default source for gathering information, and more and more children base their learning on electronic resources, the Institute will create an interactive website with both internal and public pages. This site will be culturally and linguistically appropriate, contemporary, sophisticated, and tailored to suit the many users it will attract. Interactive features could include:

n a virtual support group for children in our

prevention and intervention programs

n a BMI calculator for both children and adults n fun learning tools for children that could

develop a short behavior modification program for psychologists and providers, so they can sensitize parents to their child's behaviors and development and to the role parents can play in creating positive change.

n Toddlers and preschoolers--Through new

help them stay motivated and involved in their own health The Institute's webpages will also be the portal for web-based obesity management coordinated with our education program as well as referral resources for providers, community groups and school nurses. The site could include a "wiki" or member-driven database to which individuals can contribute along with links to medical information and other online resources. Finally, we will oversee the development of obesityspecific disease management electronic medical record templates to record, track and link data to other D.C. Department of Health registries.

collaborations with organizations such as Head Start and Early Head Start, the pilot program Start Early, Start Right will reach the most vulnerable children.

n Ages 7 to 18--Our collaboration with The Boys

and Girls Club of Greater Washington brings C.O.O.L. Kids (Combating Overweight and Obesity among Latino Kids) to African American children in Southeast D.C. in a new program called FitFamily.

n Clinical Intervention--Through the expansion

of our I.D.E.A.L. Clinic (Improved Diet, Exercise, and Activity for Life), we will be able to give the children who are the most adversely affected by their weight the tools and resources they need to improve their health. We will work closely with children's primary care physicians to ensure continuity of care. Through public-private collaborations and partnerships our community-based prevention and behavior modification programs could reach a maximum number of children living in the District.

Operational Plan

Year 1

n Create leadership and appoint Directors

Year Four

n Evaluate all aspects of I.D.E.A.L. n Establish I.D.E.A.L. Special Health Needs Clinic

for the Institute

n Create a "map" of individuals working on

Year Five

n Measure overall effectiveness of community-

obesity-related projects at Children's National

n Establish innovation scorecard and guidelines

based programming, identify gaps, assess outcomes and impact

n Disseminate and apply research findings locally,

for implementation

n Expand the I.D.E.A.L. Clinic; establish Tertiary

Care Sub-Specialty Clinic

n Establish obesity research forum to foster

nationally and internationally

n Establish I.D.E.A.L. Clinic program sustainability

collaboration, and augment existing research in a coordinated, strategic fashion

n Establish Fellowships in Community Health

(COPC) with an emphasis on childhood obesity; begin process of recruiting fellows

n Plan Obesity Summit and other outreach

activities

n Design community "report card" for the

District of Columbia and guidelines for implementation

Year Two

n Build data analysis capacity n Design and implement a web-based program

to support Institute initiatives

n Publish first community report card for the

District of Columbia

n Fund new pilot studies using a model that

encourages innovative and interdisciplinary approaches (on-going)

Year Three

n Expand most effective, scalable prevention and

behavior modification programs throughout the city with key partners, and create directory

n Evaluate public policy successes and establish

strategy for future initiatives

Prevention and Behavior modification

Obese students

are

significantly

less likely

to be accepted to college

despite comparable

academic records.

F as in Fat (2008)

PReventIon anD beHavIoR MoDIfIcatIon

Context: Childhood Obesity: A "Refractory" Problem

Obesity is widely recognized as one of the most pressing health threats to children and families both across the country and around the world. Since food in the United States is relatively plentiful with little current threat of famine, and physical activity is no longer essential to survival, this crisis likely resulted from a mismatch between our biology and the environment. Because of the refractory nature of this epidemic, there is no one "cause" of obesity, and therefore no easy solution or remedy. The built environment, new patterns of diet and physical activity all play a contributing role. Government officials, researchers and clinicians across the nation are actively seeking ways of stemming this obesity crisis. At the Obesity Institute, a collaborative, scientific and interdisciplinary approach to understanding the issue will permit us to determine what strategies work best in which combinations, and for which individuals and families. But there will be no quick fixes. Changing what has almost become its own culture--new, unhealthy ways of eating and behaving--will take time, resources, expertise and commitment.

c Int linica erv ent l ion

tHe obesIty InstItute

ation educ aining tr and

Prevention and behavior Modification

culture and ethnicity, income level, education, and

cy oli cy c P oca bli v Pu ad nd a

Re s

ea

rc h

Our overriding goal is to focus on the minority and low-income populations in the District.

Techniques that Work

Our community-based prevention and behavior modification pilot programs are staffed by pediatricians, nurses, psychologists, nutritionists, health educators and physical activity trainers, and include the following proven techniques for children:

n Implementing multi-phase programming

getting at least one hour of vigorous physical activity a day, and drinking almost no sugary beverages.

Environmental Scan

While there are many examples to be found of childhood obesity prevention and behavior modification programs throughout our nation's towns and cities, few, like ours at Children's National, combine bench, clinical and community research and demonstrate effective interventions. Lucile Packard Children's Hospital's Pediatric Weight Control Program at Stanford University, Children's Memorial Hospital of Chicago's Consortium to Lower Obesity in Chicago Children and the Center for Healthy Weight and Nutrition at Nationwide Children's Hospital of Columbus, Ohio represent three examples. None, however, have developed support services to help children maintain their weight loss and lifestyle changes beyond the program itself, and none focus primarily on minority low-income populations. Our programs are unique in that they have been designed to be culturally and linguistically sensitive to Washington, D.C.'s African Americans and Latinos, who make up four-fifths of the children of the District. (See Figure 3.) We also take into

followed by long-term maintenance of changes through support groups

n Teaching parents and families how to modify

their diets in culturally sensitive ways through nutrition and cooking demonstrations

n Providing families with parenting and

modeling skills

n Generating motivation and commitment by

setting eating behavior and physical activity goals and establishing personal contracts

n Self-monitoring with tools like a daily food and

activity diary

n Identifying and resolving both actual and

potential barriers to success

n Promoting messaging mnemonics such as

5-2-1-Almost None--found to be very effective as a reminder of healthy behavior, it stands for eating at least five servings of fruits and vegetables a day, engaging in two or fewer hours of screen time a day,

fIGuRe 3 Percent of total D.c. Population: children by Race

16% White 4% other 9% Hispanic

71% black

SOURCE U.S. CPS 2005­2006; Total D.C. Population = 582,049

fIGuRe 4 Percent of D.c. children: bMI

ages 2­5 64.3% 55.5% 49.8% ages 6­10 ages 11­15

16.1% 17.2% 2.4% 1.9%

24.2% 18.4% 3.2%

25.5% 21.5%

n Less than 5th (underweight) n 5th­85th (healthy) n 85th­95th (overweight) n Greater than 95th (obese) SOURCE D.C. Partnership to Improve Children's Healthcare Quality (DC PICHQ)

WHat Is bMI?

Body Mass Index (BMI) is a number calculated using a formula that divides a child's weight by After BMI is calculated for children and teens, the BMI number is plotted on the CDC BMI-forage growth charts (for either boys or girls) to obtain a percentile ranking according to sex and age ( < 5th percentile is underweight, 5th to 85th percentile is healthy weight, > 85th percentile is overweight, and > 95th percentile is obese). The CDC and the American Academy of Pediatrics recommend the use of BMI to screen for overweight and obesity in children beginning at two years old.

80 his or her height. BMI is used as a screening tool 70 to identify possible weight problems for children. BMI 60 not measure body fat directly, but does research has shown that BMI correlates to direct 50 measures of body fat, and it is an inexpensive and 40 easy-to-perform method of screening for weight categories that may lead to health 30 problems. 20 10 0

account their largely low-income status--about one in four children live in poverty, the highest rate in the nation--and the associated socio-economic challenges they need to overcome to change their lifestyle. [See Appendix 6: Environmental Scan for details.]

Our success will be validated by research and clinical outcomes developed in collaboration with colleagues at institutions such as the National Institutes of Health and other children's hospitals and schools of medicine, and with District of Columbia and regional governmental and public policy organizations.

Opportunity Assessment

Commitment and Leadership

We envision a community-based approach that commits resources to obesity identification, prevention and treatment, ensures that healthy food choices are available in schools and in neighborhoods, makes physical education mandatory in schools, creates easily accessible and safe recreational activities and play spaces in all neighborhoods, and develops culturally competent health education messaging.

Unmatched Community-Based Infrastructure

Serving the nation's capital for more than 135 years, Children's National is a leader in the development and application of innovative treatments for childhood illness and injury. We are the regional pediatric referral center for the Washington, D.C. metropolitan area, and one of the top pediatric providers in the nation. The Diana L. and Stephen A. Goldberg Center for Community Pediatric Health is also the largest provider of primary care services

fIGuRe 5 socio-economic Model

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(approximately 80,000 patient visits per year) in the District of Columbia, and Children's National is the largest provider of specialty care in the midAtlantic region. The Diana L. and Stephen A. Goldberg Center for Community Pediatric Health, which includes the Institute, is one of six clinical Centers of Excellence at Children's National. The Goldberg Center includes five community-based and two hospitalbased primary care health centers, three mobile medical units and multiple community-focused, culturally and linguistically competent programs. All Children's National's primary care health centers are strategically located in federally designated health professional shortage areas (or HPSAs). [See Appendix 4: Goldberg Centers] Our overriding goal is to focus on the minority and low-income populations in the District. We will rely on our infrastructure and our many community partnerships to continue to pilot and validate our prevention and behavior modification programs, and to serve as a starting point for their implementation District-wide. The Institute will also draw on our well-established infrastructure to design a new component: a post-intervention support program for long-term healthy weight maintenance. We collaborate with key partners and community organizations such as the Boys and Girls Club of Greater Washington to make our programs a success. Early results have been very promising:

n A decrease in BMI n An increase in knowledge of good nutrition,

toDay at cHIlDRen's natIonal

Our comprehensive community-based obesity prevention and behavior modification programs in Adams Morgan and Southeast D.C., spearheaded by Dr. Nazrat Mirza, focus on Latino toddlers and on Latino and African American children ages 7 to 18 and their families.

the benefits of physical activity, and effective parenting skills

n A reduction in daily calorie intake n An increase in vegetable and fruit consumption n A decrease in TV viewing and computer usage n A decrease in systolic and diastolic blood pressure

causes of obesIty

Being seriously overweight is not caused by one single factor. There are a number of things that may interact and contribute to someone becoming morbidly obese. These include:

n Genetics n Culture n Physical inactivity n Emotional or psychological factors n Gender n Age n High Fat / High Calorie diet n Medical problems

Moment of Opportunity in the Nation's Capital

African American and Hispanic adults tend to rank teen pregnancy, drug abuse and bullying higher on their top-ten list of problems than whites. They do share, however, a strong concern about obesity among their children, and are frustrated with the lack of opportunities for physical activity in their neighborhoods. Their heightened concern coupled with the unrelenting obesity epidemic provides us with the opportunity to bring together researchers, clinicians, advocates and educators to tackle this enormous public health problem. Children's National has a track record of effective collaborative

SOURCE St. Vincent Health

work, and has joined with city government, academic institutions, managed care organizations and community leaders to promote children's health through D.C.'s Partnership to Improve Children's Healthcare Quality. In addition, the over-subscribed Obesity Summit of September 2007, innovative collaborations between the Department of Health and the Department of Parks and Recreation, and the invitations Children's National has received from local chapters of The Boys and Girls Club of Greater Washington and Head Start to collaborate in program delivery, all point to a readiness to act in the District.

Institutional Readiness

Our goal is to develop culturally responsive interventions that are effective and to support their dissemination throughout the community. Recently we initiated and implemented three promising pilot programs through our health centers in Adams Morgan and Southeast D.C. These programs focus on Latino preschoolers and their families, and on Latino and African American children ages 7 to 18 and their families. Early positive results indicate that the returns on these programs could be significant (see below for details). The programs' expansion has therefore the potential of impacting thousands of children and their families in the District.

Program Attributes

A key piece of our community-based strategy to identify, prevent and treat childhood overweight and obesity, is to lead the effort in the District to modify children's and families' behaviors in a culturally sensitive, medically responsible and evidence-based manner. The Institute will serve as a think tank for developing new, innovative, and scalable protocols and will make it possible to move quickly to design and validate programs that can be customized to differing cultural, physical and genetic needs.

0

The Best Medicine: Prevention

Obesity and its adverse health-related consequences are preventable, being almost entirely the consequence of unhealthy, high calorie diets combined with limited physical activity or a sedentary lifestyle. To make changes to unhealthy lifestyles, families and children need tools and resources to help them think creatively and proactively about how to overcome barriers they face to maintaining a healthy weight--such as those posed by income level, habitual behaviors, and the built environment. To that end, Children's National has taken the lead in the District of Columbia by piloting comprehensive educational prevention and behavior modification programs for both preschoolers and older children in Latino and African American communities. Our goal is to help these children halt their weight gain and, if possible, lose weight. We will direct and advocate for their replication in all neighborhoods using a train-thetrainer model.

reductions in sedentary conduct (child) compared to their baseline assessments. Early results from this comprehensive community-based approach have been very promising:

n A decrease in BMI n An increase in knowledge of nutrition,

the benefits of physical activity, and effective parenting skills

n A reduction in daily calorie intake n An increase in vegetable and fruit consumption n A decrease in TV viewing and computer usage n A decrease in systolic and diastolic blood

pressure Our preliminary data therefore show that many of our techniques and approaches do work, at least during the limited time span of our programs.

Post-Intervention Support Program

As children and their families continue to need motivation and support to maintain weight loss and lifestyle change, we intend to add a postintervention support program to our current prevention and intervention programs. We will use a variety of promising techniques, including the following: motivational interviewing, taking a "mindful" approach to eating, interactive webbased activities, support groups and mentoring. Mentors may also be recruited from among program graduates to help motivate current participants.

Evidence-Based Pilot Programs

Our prevention and behavior modification programs have enrolled more than two hundred children and their families. [See Appendix 5: Pilot Programs for short descriptions.] To evaluate children's progress and program success, Children's National's clinical researchers have collected medical and anthropometric data such as weight, height and blood pressure measurements, and blood lipid, insulin, and glucose assays. They have also administered pre- and post-program questionnaires for information on sociodemographics, birth history, physical activity and sedentary behavior, food frequency and eating behavior, and assessment of depression and self-esteem. By the end of one or two years, depending on the program, families are expected to achieve reductions or maintenance of body mass index (child and parent), improved nutrition and physical activity knowledge and behavior (parents), and

Validation for Long-Term Success

Our preliminary data therefore show that many of our strategies and approaches are effective. While a longitudinal study may not now exist to prove that initiatives such as making our parks safer for families to use and increasing both structured and unstructured physical exercise in schools will result in less overweight among children, we conclude that they are desirable and will be proven to be effective.

Children's National will therefore continue to provide the important leadership in the District of evaluating programs, processing data, and producing evidence of success. After the broadscale implementation of prevention and behavior modification programs in the community, we will conduct longitudinal studies of their effectiveness. Because the number of genetic and environmental variables at play may make it difficult to assess which factor is causative and which associative, we will engage in additional short- and long-term studies with a limited number of variables.

Operational Plan

Year one

n Appoint a Director for the Prevention and

Behavior Modification, and Clinical Intervention programs

n Identify and coordinate current programmatic

efforts

n Expand collaboration between basic and clinical

research staff to translate findings to prevention program design

n Evaluate current and seek out new public-

private collaborations

Impact Projections

Care Delivery

No single nonprofit organization or governmental entity can in isolation impact the rate of childhood overweight and obesity. But working together we can reach many thousands of children and their families. Statistically validated prevention and behavior modification programs have the potential to change the lives of our most disadvantaged citizens. Our existing collaborations with organizations such as the Boys and Girls Club of Greater Washington and Head Start establish the basis for local and regional success. We plan to make our proven interventions available to be offered throughout the city, so they may produce a positive impact on children's lives and those of their families. Our work will contribute to the District's stated goal of fighting and reversing the trend in childhood obesity rates by 2010 through innovative programming, improvement of nutritional options available in communities, and new partnerships.

Year Two

n Identify optimum, scalable prevention and

behavior modification intervention programs and establish strategy for broad implementation

n Work with District of Columbia government

to identify funding, partners, and locations for interventions throughout the city

n Design and plan implementation of post-

intervention support program

Year Three

n Expand most effective, scalable programs

throughout the city with key partners

n Create directory of program locations and

schedules for distribution to providers and the community

n Establish parameters for longitudinal studies

Year Four

n Evaluate program implementation; expand

to new locations

n Renew commitment to community-based

programs

Year Five

n Measure overall effectiveness of programming,

identify gaps, assess outcomes and impact

clinical intervention

More than

80 percent of people with

type 2 diabetes

are overweight.

diabetes

is the seventh leading cause of death in the United States.

two million adolescents

aged 12­19 are

pre-diabetic.

Centers for Disease Control and Prevention

clInIcal InteRventIon

Context: Offering a Comprehensive Clinical Solution

Severely overweight and obese children are at risk for co-morbidities that can have very serious short- and long-term health consequences. Particularly disturbing are those children who suffer from complications of obesity that are normally exhibited by adults, such as impaired glucose tolerance or diabetes, hypertension, dyslipidemia, liver disease or non-alcoholic steatohepatitis, sleep apnea syndrome, and heart disease. Other diseases seen increasingly among obese children include polycystic ovary syndrome, metabolic syndrome, slipped capital femoral

arc

tHe obesIty InstItute

d n an tion a entio Prev Modific vior beha

clinical Intervention

epiphysis, and pseudotumor cerebri. There are several potential medical causes of childhood obesity. The main endocrine problems are hypothyroidism, Cushing syndrome and growth hormone deficiency, all of which are associated with short stature. Genetic syndromes such as Prader-Willi and Fragile X display developmental delay signs. Rare neurologic causes like craniopharingioma usually have additional signs and symptoms. Certain medications, especially steroids or psychotropics, can also cause weight gain. However, if these categories can be ruled out, then the obesity is most likely due to the complicated interplay of environment, lifestyle, diet and genetic inheritance.

Re se

n tio g ca in du rain e t d an

h

P an ub d lic a P dv o oc licy ac y

waiting list, but can only operate one afternoon a week in a borrowed space with many clinicians and staff volunteering their time. The program is also challenged by our inability to provide the optimal conditions for psychological and social work services. By expanding the clinic's hours and increasing

The Improved Diet, Exercise, and Activity for Life (I.D.E.A.L.) Clinic at Children's National seeks to help obese children and those overweight children who are suffering from co-morbidities. This interdisciplinary clinic is not, however, a sustainable model for care given current reimbursement policies. At this time the clinic has an 18-month

our patient load from our current 70 children a year, we will be able to provide evidence that this clinical intervention is effective. Moreover, we plan to renegotiate the current reimbursement structure with managed care organizations and the D.C. Medicaid program. Such changes, coupled with

an expansion of physical space, could make the clinic accessible to all who need it in a more timely manner.

intervention support program for healthy weight maintenance that will create opportunities for longterm success and longitudinal research projects.

Environmental Scan

If children's hospitals sponsor a weight management or obesity program, it is usually in the form of an outpatient clinic. Sometimes exclusively medically oriented for assessment purposes, it is more often part of a multi-week family-oriented program whose aim is lifestyle change and longterm improvement in health. Few hospitals like Children's National seek to offer comprehensive medical, weight loss and support services to all children ages 7 to 18 who need it, and fewer still integrate a tertiary care clinic within their program. None offer services to children with special health needs, and none offer support services beyond the program itself to help children maintain their weight loss and lifestyle changes. Children's National currently offers the only comprehensive, multi-disciplinary treatment program in the greater Washington, D.C. area. [See Appendix 6: Environmental Scan for details.]

Program Attributes

The core of our clinical intervention program will be an expanded multi-specialty I.D.E.A.L. Clinic. Currently, the I.D.E.A.L. Clinic conducts medical assessments and provides treatment for obese children referred by their primary care providers. Almost all of them have obesity-associated medical complications such as hyperlipidemia, hypertension, fatty liver disease, obstructive sleep problems and orthopedic problems. Coordinating our efforts in a multidisciplinary approach to the treatment and management of childhood obesity ensures that the causes--not just the symptoms--of each child's condition are addressed. An obese child referred to the I.D.E.A.L. Clinic with hypertension does not receive treatment for that one symptom, but rather a complete physical, behavioral and psychosocial evaluation that aims to understand all of the illness's potential causes and complications. Indeed, the interrelated and complex nature of obesity thwarts efforts to make a difference when the focus is too narrow.

Opportunity Assessment

Leadership and Capacity

Children's National's clinicians and researchers have partnered to find innovative approaches and solutions to study and treat what is essentially a new disease. What was once a rarity--an obese child--has become all too common. No longer can parents just assume that their overweight children will "grow into" their weight over time as in the past. The I.D.E.A.L. Clinic currently brings together a network of largely volunteer pediatricians, psychologists, dietitians, physical therapists, and practitioners of multiple medical sub-specialties to cooperate in each child's care. As the capacity of this clinic grows, we will add a social worker to assist families as they negotiate their lifestyle changes. We will also add a new component, possibly shared among all our prevention, behavior modification and intervention programs: a post-

Monitoring and Evaluation

An effective weight-management protocol consists of the following five stages:

n recruitment and referral n comprehensive health assessment n goal-setting n selection and implementation of an appropriate

management scheme

n monitoring and evaluation, both of the children

and of the program's effectiveness Our clinic's expansion will make it possible for us to track a significant number of patients for a comprehensive data-based study of the efficacy of this intervention both immediately and over time. We will use validated evidence of our success to

argue for a reimbursement structure that will lead to financial sustainability for the clinic, allowing us to reach a larger percentage of children who need this type of intervention.

WHat Is MetabolIc synDRoMe?

Metabolic syndrome is characterized by

Creating an Ideal Environment

Our first priority will be to provide dedicated space for the clinic to create an environment that is more appropriate for addressing the special needs of obese patients, including exam rooms with bariatric furnishings for interventions, a classroom for group sessions, and an exercise facility with bariatric equipment. The new space, located conveniently on the first floor of the hospital near both the Children's and Adolescent Health Centers, will allow us to expand clinical services from one to five sessions a week and to reduce the waiting time for participation to one month or less. With improved capacity, we will be able to add a special health needs clinic to accommodate obese children with physical, behavioral, and mental disabilities such as autism, cerebral palsy, and spina bifida.

a cluster of risk factors associated with obesity. They include:

n Abdominal obesity (excessive fat tissue in and

around the abdomen)

n Elevated triglycerides (Low Density Lipoprotein

or LDL cholesterol)

n Decreased "good" cholesterol (High Density

Lipoprotein or HDL cholesterol)

n High blood pressure n Insulin resistance or glucose intolerance (the

body can't properly use insulin or blood sugar) People with metabolic syndrome are at increased risk of cardiovascular disease and type 2 diabetes.

Intervention Program

The profile of patients who are being referred to Children's National for treatment has changed considerably over the past few years, often requiring that clinicians design complex interventions. For example, the most common group of children who present with abnormal lipids are no longer those with familial high cholesterol, but rather those with mild elevation in LDL and total cholesterol and significant elevation in triglycerides and a low HDL. These are possible indicators of metabolic syndrome when combined with large waist measurement, hypertension, and/or impaired glucose tolerance. At their first visit to the I.D.E.A.L. Clinic, children see a pediatrician who conducts a complete medical exam, assessing each child for co-morbidities and health risks. Dieticians, health educators, physical therapists and psychologists also conduct evaluations, and during the 12 weeks of Phase 1 of our program, they lead individual and group

fIGuRe 6 Percent of obesity at age 25 according to age and obesity status as children

ages 1­2 ages 3­5 ages 6­9 ages 10­14 83% 69% 52% 36% 26% 15% 19% 12% 11% 10% 9% 55% 75% 67% 77% ages 15­17

n BMI < 85th Percentile n BMI

85th Percentile n BMI

95th Percentile

SOURCE Whitaker et al. NEJM: 1997; 337 (13):869­873

educational and training sessions for children and their parents. During Phases 2 and 3, they return to the Clinic once a month and once every two months respectively, for a total of two years.

Specialized Clinics

the I.D.e.a.l. tertiary care sub-clinic Efficiencies in treatment are best addressed when clinicians and researchers collaborate. The first meeting with new patients and their families is critical: it determines the overall state of health and referrals needed. The I.D.E.A.L. multi-disciplinary tertiary care sub-clinic will accommodate the 20% of children who present with co-morbidities requiring regular follow-up appointments with a gastroenterologist, a cardiologist, an endocrinologist or other sub-specialist. Referrals to other sub-specialists and departments such as radiology, orthopedics, sleep medicine, and psychiatry may also result from these clinics.

100 80 60 40 20 0

Post-Intervention Support Program

As children and their families continue to need motivation and support to maintain weight loss and lifestyle change, we intend to add a postintervention support program to our current prevention and intervention programs. We will use a variety of promising techniques, including the following: motivational interviewing, taking a "mindful" approach to eating, interactive webbased activities, support groups and mentoring. Mentors may also be recruited from among program graduates to help motivate current participants.

special Health needs clinic Children's National will establish what may be the first weight management clinic for obese children with special health needs in the nation. Dedicated sessions of the I.D.E.A.L. Clinic will accommodate those children who have chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally. The Clinic will develop and implement comprehensive, culturally competent, coordinated systems of care for these children, helping them and their families create a healthy, active lifestyle for effective weight management. These skills are that much more crucial and relevant as medical advances have made it possible for children with some severe conditions to live much longer than in the past. The I.D.E.A.L. Clinic is the only comprehensive treatment program in the Washington metropolitan area for obese children and those overweight children who are suffering from co-morbidities.

toDay at cHIlDRen's natIonal

At the Improved Diet, Exercise, and Activity for Life (I.D.E.A.L.) Clinic, over 100 children have undergone assessments for obesity-associated medical complications such as hyperlipidemia, hypertension, fatty liver disease, obstructive sleep problems and orthopedic problems. They and their families participate in a two-year multidisciplinary program that meets their physical, behavioral and psychosocial needs. The Clinic's medical director is Dr. Nazrat Mirza.

Extreme Interventions

Pharmacotherapy While the I.D.E.A.L. Clinic's comprehensive approach will help most children lose weight and improve their health through customized lifestyle management, a small number of children may need additional treatment. Researchers have found certain medications to be effective in treating eating disorders; noradrenergic and serotonergic drugs can work by increasing the availability of norepinephrine, serotonin and/or dopamine in the body, facilitating satiety and/or inhibiting feeding; and orlistat can help by affecting fat-soluble vitamin absorption in adolescents. These and other medications, currently undergoing clinical studies throughout the country for effectiveness and safety, may be considered on a case-by-case basis.

Most obesity is caused by energy imbalance--consuming more calories than the body expends.

adolescent bariatric surgery In order to offer a full complement of obesity treatment options, Children's National is currently considering developing a bariatric surgery program using minimally invasive LAP-BAND technology to

®

Impact Projections

Care Delivery

The clinical intervention initiative will dramatically increase the capacity of Children's National to treat obese and overweight children who are at risk for or suffering from co-morbidities in D.C.'s greater metropolitan region. This initiative will also improve the ability of our clinicians to discover, adopt and deliver the safest and most effective interventions. We anticipate the following outcomes:

n Comprehensive assessments will help patients

treat a group of carefully selected patients. Surgery is an extreme intervention for those morbidly obese children most at risk or suffering from very severe complications due to obesity and who are unable to lose weight. Performed as a last resort, the aim of this surgery is to achieve durable and significant weight loss and avoid the complications of obesity. Patients to be considered for this intervention would be adolescents who have a BMI greater than 40, or a BMI greater than 35 and suffer from at least one co-morbid disease. The process to determine patient candidacy typically takes months and involves an extensive health screening, a complete psychological evaluation for the patient and his or her family, and thorough counseling on the procedure and its risks. Finally, long-term follow-up care is imperative for children who have had bariatric surgery.

and their families change their lifestyles as needed to live long, healthy and productive lives.

n The multidisciplinary tertiary care sub-clinic

will generate new avenues for research while implementing the latest in clinically proven protocols.

n The special health needs clinic will allow those

children to become as healthy and as active as their conditions allow.

n Life-saving bariatric surgical intervention may

be available as an option for those extremely obese adolescents who are most at risk and who have had no success with weight-loss programs.

n The expansion of the clinic will bring us a

critical mass of data so that we may provide proof of concept to managed care organizations and Medicaid for long-term financial sustainability.

n The clinic will be the place where Children's

National will train the next generation of practitioners through internships, externships, residencies and fellowships.

fIGuRe 7 obesity-related Health expenditures for children: 1979 and 1999

$35 million

$127 million

1979

1999 SOURCE U.S. Government Accountability Office

Financial

Effective clinical treatment can have a significant long-term positive impact, especially in terms of health care dollars. The U.S. Government Accountability Office estimates that:

It is therefore in everyone's interest, especially managed care organizations, that at-risk obese and overweight children be treated and avoid even greater health problems later in life. Due to inadequate reimbursement, Children's

n Costs more than tripled for children from

National will need philanthropic assistance to expand and maintain the I.D.E.A.L. Clinic for the first years. Following extensive study of the effectiveness and real costs of this program, we will have the necessary data to advocate for new structures and policies with managed care organizations and the District's Medicaid program.

1979 to 1999, from $35 million to $127 million. (See Figure 7.)

n Obesity-related health expenditures account

for more than 25% of the growth in health care spending between 1987 and 2001.

n In 2000, an estimated $117 billion was spent for

health-related expenditures due to obesity, with direct costs accounting for an estimated $61 billion.

Operational Plan

Year one

n Appoint a Director for the Prevention and

Behavior Modification, and Clinical Intervention programs

n Renovate first floor office space for new

I.D.E.A.L. Clinic; establish Tertiary Care Sub-Specialty Clinic

n Create multidisciplinary hospital-wide network

of clinicians and researchers to support the clinical intervention program

Year Two

n Expand services from one session to five;

reduce waiting list

n Design and implement post-intervention

support program

Years Three­Four

n Evaluate all aspects of I.D.E.A.L.; identify gaps

in services, challenges and opportunities

n Establish I.D.E.A.L. Special Health Needs Clinic

Year Five

n Establish program sustainability

0

research

Children ate out at

fast food

and other restaurants nearly

three times

more

in 1996

than they did in 1977.

F as in Fat (2007)

ReseaRcH

Context: An Institution Uniquely Poised

Children's National Medical Center is ready to attack the childhood obesity problem head-on with the following assets:

n Government funding as a national health

tHe obesIty InstItute

disparities center for childhood obesity research, and a focus on the minority populations at greatest risk

n Cutting-edge initiatives in "systems

Research

cal clini tion ven Inter

biomedicine"­the integration of lifestyle, genetics, activity, diet

n Ability to transition new compelling findings to

innovative health policy and build a compelling

n Integration into the public school system (with

Pu and blic P ad olicy voc acy

case to District of Columbia lawmakers our Comprehensive School Health Program), and regional Catholic schools

d an tion ion ifica t d en ev Mo Pr ior v ha be

Translating Findings from Basic Research into Effective Interventions

A unique strength of Children's National is the integration of a focus on service to the children of the Washington metropolitan area with cuttingedge science and the rapid translation to improved health care through community-based research and public policy. Scientific discovery can propel new efforts toward further understanding the forces contributing to childhood obesity, and toward developing strategies for its treatment and prevention. The increase in obesity has been fueled by a complex interplay of environmental, social, economic, and behavioral factors, acting on a background of genetic susceptibility. Thus, the Obesity Institute will encourage and support a broad spectrum of obesity-related research, including

an edu d ca tr ti ai on ni ng

molecular, genetic, behavioral, environmental, clinical, epidemiologic and translational studies. The challenges of today's obesity epidemic are daunting, yet the discoveries emanating from previous investments in basic and clinical research offer unprecedented opportunities for translational research to help meet these challenges.

Integrative Systems Biology: the 21st Century Science

The human body, in both health and disease, is enormously complex. However, the stunning advances in "high tech" science, with the new ability to generate millions of data points on the

DNA, RNA, protein, and physiology of a single patient, and the integration of all of these data into emerging computer models of health and disease, are transforming how we view complex problems. In short, the technical ability of science is now able to tackle this complexity. The study of children is becoming increasingly important in this exciting research direction. Why children? Because they are purer, less complex than the body of an 80 year old with a lifetime of biological events behind him or her. We will understand obesity--and even type 2 diabetes--in a child long before we will fully understand it in adults. Yet the knowledge gained from studying children is entirely relevant to understanding the adult condition of type 2 diabetes and how to prevent it. Across the biological sciences--genomics, proteomics, molecular and cellular biology-- Children's National researchers are leading efforts to further understand the complex interactions among the many levels of biological activity important for the development of obesity: from genetic processes of DNA and RNA transcription, to protein development, to cell and tissue function, to organ structure and function. At the same time, Children's National has made the investment in public access databases and computational sciences--significant advances that are enabling scientists to begin modeling complex biomedical processes. Here, multidisciplinary teams, including mathematicians, physicists and engineers, can represent and computer-simulate a physiological system at multiple levels of biological activity, showing an organism's functions at a level of complexity unimaginable only a decade ago.

National Institutes of Health (NIH) and foundationfunded studies underway at Children's National include:

n Policy research on the effectiveness of

government programs focused on childhood obesity

n Latino community-based research on preventing

obesity in the highest-risk populations

n School-based studies of activity and diet in D.C.

Catholic and Michigan public schools

n The AIMMY program (Assessing Inherited

Metabolic Markers in the Young)--a network of universities looking at the role of ethnicity, sex, and genetics in the "freshman 15" gain of 15 lbs. in the first year of school; the network currently includes Howard University, the University of Massachusetts, and Eastern Carolina University, and has enrolled hundreds of college students into health screens and obesity prevention By integrating community health research, Integrative Systems Biomedicine research, and public policy research, Children's National is able to provide unparalleled focus on obesity and related conditions, greatly enhancing our ability to predict and prevent obesity, and to personalize interventions.

Environmental Scan

While there are several strong research programs across the nation, to our knowledge we are the only research facility that is integrating community-based programs and interventions, cutting-edge integrative systems biomedicine research, and public policy reform, thus truly spanning the translational spectrum. Furthermore, we are collaborating with national policy experts at our academic institution, George Washington University's School of Public Health and Health Services. To our knowledge, we are the only institution to combine our clinical research efforts with legal and health policy experts to undertake the problem of childhood obesity locally and nationally. [See Appendix 6: Environmental Scan for details.]

Opportunity Assessment

An Established Research Infrastructure

Children's National has an established infrastructure for conducting obesity-related basic research and supporting clinical research within the Children's Research Institute:

n The Research Center for Genetic Medicine is

toDay at cHIlDRen's natIonal

The following studies represent some of the innovative research currently underway at the Children's Research Institute:

n School­based studies of activity and diet in D.C.

a global leader in the application of emerging genomics technologies to problems of child health. Recently initiated is a new Washington metropolitan area program called Integrative Systems Biomedicine in collaboration with George Washington University and other regional academic institutions.

n The Center for Clinical and Community Research

Catholic Schools and Michigan Public Schools--Eric Hoffman, Ph.D. and Chiatogu Onyewu, M.D., Ph.D.

n Design of early intervention and prevention

programs for overweight and obese toddlers for primary care providers--Irene Chatoor, M.D.

n Study of girls' weight control behaviors and

their effect on weight gain/loss--Eleanor Mackey, Ph.D.

n Examination of the role of elevated myostatin

provides epidemiological, biostatistics and informatics support, and performs communitybased research in many areas of public health including obesity, nutrition, health delivery, health disparities, and health policy. The center includes the General Clinical Research Center and the Biostatistics and Informatics services program.

levels in obese children with special health needs-- Sally Evans, M.D.

n Analysis of the vitamin D deficiency associated

with the orthopedic condition known as slipped capital femoral epiphysis--Laura Tosi, M.D.

n Investigation of how excess fat tissue may be

associated with early kidney inflammation and

A Network of Active Researchers

Children's National has over 325 full-time faculty members, spanning the spectrum of pediatric medical, surgical, behavioral, and laboratory medicine subspecialties. Of the 198 faculty members with primary appointments in the Department of Pediatrics at George Washington University, 25% devote more than 50% of their effort to research while an additional 18% contribute between 5% and 50%. Our many areas of expertise provide a tremendous resource as well as flexibility for engaging in a broad range of projects within basic laboratory, clinical and public health research.

leakage of protein into urine--Mona Khurana, M.D.

n Development of a "standard of care" protocol

for the treatment of obese Latino children-- Nazrat Mirza, M.D., Sc.D.

n Measurement of the obesity­promoting

environment, including assessment of stigma against obese children and their parents-- Anjali Jain, M.D.

An Innovative Research Program

Research concerning neural, hormonal and genetic influences on obesity and related co-morbidities has relevance for the design of weight control interventions, yet little research is being done to translate these findings into weight loss programs or approaches. Our national genomics research

We are the only research facility that is integrating communitybased interventions with cutting-edge genomics research.

focuses on a broad range of ages, from 6th graders in Michigan, to the families of Washington, D.C. to

tHe consequences of obesIty

Overweight children and adolescents often experience immediate health-related consequences--and may be at risk for additional weight-related problems as adults. Psychosocial risks: Overweight children and adolescents are targets of early and systematic social discrimination. The psychological stress of social stigmatization can cause low self-esteem, which, in turn, can hinder academic and social functioning and persist into adulthood. cardiovascular disease risks: Overweight children and teens have been found to have risk factors for cardiovascular disease, including high cholesterol levels, high blood pressure, and abnormal glucose tolerance. In a population-based sample of 5- to 17-year-olds, almost 60% of overweight children had at least one cardiovascular disease risk factor. additional health risks: Less common health conditions associated with increased weight include asthma, hepatic steatosis, sleep apnea and Type 2 diabetes.

n Type 2 diabetes is increasingly being reported

college students in a network of universities. Our personalized clinical trials for type 2 diabetes will provide a comprehensive and scientifically sound approach to the disease.

Program Attributes

Our scientists and clinicians from diverse disciplines will engage in the potentially highimpact research needed to develop innovative new strategies for reducing obesity and improving obesity-related behaviors. Central to the Director's duties will be fostering a culture of innovation to facilitate and expedite new research endeavors to solve the fundamental questions of obesity, both to understand its complex genetic and environmental origins and to develop effective clinical interventions and prevention strategies. An Innovation Fund will allow the Director to promote interdisciplinary approaches by providing seed money for novel, but promising, new research.

Translating Discovery to the Community

Basic, translational, clinical and public health research at Children's National includes experimental laboratory studies, formative research, early phase trials and pilot/feasibility studies. Our goal is to accelerate the translation of discoveries in basic biological, behavioral and social science research to programs that facilitate the prevention and treatment of obesity. We will therefore focus on developing, characterizing, refining and evaluating new, innovative obesity-reducing strategies rather than on validating the effectiveness of already welldefined or proven strategies. In partnership with the Center for Genetic Medicine Research, we will implement a community-based prevention program using adaptive designs and pre-specified decision rules based on participant characteristics and responses to treatment. Our aim will be to customize intervention strategies to the individual, adapting them over time in order to maximize their effects. In addition, we will conduct

among children and adolescents who are overweight. While diabetes is a common health effect of adult obesity, only in recent years has type 2 diabetes begun to emerge as a healthrelated problem among children and adolescents. n Asthma is a disease of the lungs in which the airways become blocked or narrowed causing breathing difficulty. Studies have identified an association between overweight children and asthma. n Hepatic steatosis is the fatty degeneration of the liver caused by a high concentration of liver enzymes. Weight reduction causes liver enzymes to normalize. n Sleep apnea is a less common complication for overweight children. Sleep apnea is a sleepassociated disorder defined as the cessation of breathing during sleep that lasts for at least 10 seconds. One study estimated that sleep apnea occurs in about 7% of overweight children. SOURCE Centers for Disease Control and Prevention

studies using modeling techniques and integrative systems biology approaches (e.g., network analyses and systems dynamics) to develop interventions and suggest how, when and where they should be targeted within a social group, family, health care system or other system to achieve maximum benefit.

Proving the Effectiveness of Clinical Interventions

The Institute will offer many opportunities to build on existing synergies and encourage new ones among a broad range of experts in fields as diverse as endocrinology, anesthesiology, orthopedics, radiology and public policy. The Improved Diet, Exercise, and Activity for Life (I.D.E.A.L.) Clinic will provide a place where clinicians and researchers can work together to identify, assess and manage conditions arising from obesity in a verifiable way. Metabolic syndrome, for example, is extremely complex, requiring the combined expertise of individuals trained in many disciplines to treat effectively. We will monitor, test and evaluate the effectiveness of our intervention at the expanded I.D.E.A.L. Clinic and calculate the real costs associated with obesity among our children. The results will contribute to our public policy and advocacy program. But until obesity is successfully eliminated from the community, we will also need to know how to effectively treat obese children for its consequences--conditions as varied as chronic pain, injured joints, gum disease and depression. Our clinical research program will also address the complex physical and psychosocial needs of patients with obesity.

Augmenting Our Research Capability and Responsiveness

The Institute's research program has an overarching objective: to better understand the causes and consequences of childhood obesity and how to combat them through effective policy and treatment. Essential to an effective research program is the encouragement of

PuBlic Policy and advocacy

Approximately

60 percent

of obese children

aged 5­10 years

had at least one

cardiovascular disease risk factor

and

25 percent

two or more

had

risk factors.

F as in Fat (2008)

PublIc PolIcy anD aDvocacy

Context: Making a Difference in the Nation's Capital

A Growing World-Wide Concern

There is an increasing awareness and concern about the increase of overweight and obesity among adults and children both nationally and internationally, and in both developed and developing nations. Nowhere is this concern more

a Rese

tHe obesIty InstItute

comprehensively addressed than in the World Health Organization's 2000 report, Obesity: Preventing and Managing the Global Epidemic. It calls obesity one of the greatest public health challenges of the 21st century, taking the position that the problem is linked not just to individual economic development and policies such as those governing agriculture, transport, urban planning, the environment, food processing, distribution and marketing, and education. While "epidemic" is a word that has traditionally been used to describe contagious infectious diseases, there seems to be no better word to describe the rapid rise of obesity--a complex multifactorial condition that spreads by our common exposure to an environment that encourages eating and inactivity. The World Health Organization's plan for addressing the challenges posed by our environment includes public health measures such as restricting food advertising aimed at children, increasing the price of junk food through taxes and changes in farm subsidies, limiting unhealthy foods in schools, and encouraging manufacturers to reduce sodium, fats, and sugars in certain foods. behavior but also, increasingly, to social and

Public Policy and advocacy

rch

l ca ion ini cl vent er Int

ed and ucati tra on inin g

be

P ha rev vi en or t M ion od a ifi nd ca tio

n

Taking a Public Health Approach

Here in the United States, experts agree that obesity should be viewed as the consequence of a "toxic environment" rather than the result of the population failing to take enough "personal responsibility." To reduce the prevalence of obesity, we must therefore shift our view away from an exclusively medical model (which focuses on the individual) to a public health model (which focuses on the population). At the same time, we must be sensitive to the problem of weight bias towards overweight and obesity, as it can affect the ability of adults to find jobs and receive equal access to health care, and can take the form of lower expectations for students on behalf of their teachers.

fIGuRe 8 obesity trends* among u.s. adults: 1991 and 2005­2007

1991

WA MT OR ID WY NE UT CA IA IL CO KS MO KY NC AZ NM OK TN AR MS TX LA AL GA SC OH IN WV VA SD ND MN WI MI PA NJ NY MA RI CT DE MD DC VT ME

NH

NV

AK

FL

HI

2005­2007 Combined Data

WA MT OR ID WY NE UT CA IA IL CO KS MO KY NC AZ NM OK TN AR MS TX LA AL GA SC OH IN WV VA SD ND MN WI MI PA NJ NY MA RI CT DE MD DC VT ME

NH

NV

AK

FL

HI

No Data

Fewer than 10%

10%­14%

15%­19%

20%­24%

25%­29%

30% or more

SOURCES Behavioral Risk Factor Surveillance System, CDC and F as in Fat: How Obesity Policies are Failing in America (2008) *BMI greater than 30, or about 30 pounds overweight for 5' 4" adult

This public health approach is reinforced by Trust for America's 2007 report, F as in Fat: How Obesity Policies are Failing in America, which states that, "the strategy of focusing on personal responsibility alone is failing. People do not make decisions in a vacuum. They are influenced by their relationships with family, friends, neighbors, and colleagues; their home, workplace, neighborhood, and school environments; their economic limitations; and their genetics, physiology, psychology, and life stages." While schools may seem to be the ideal place for reaching the majority of our children, a recent report on the most well-known state-wide largely school-based initiative, the Arkansas Act 1220 of 2003 to Combat Childhood Obesity, indicates that this intervention may be having a limited impact. The Year Three Evaluation of this initiative suggests that school-based interventions alone are not enough to effect broad-scale changes in eating behaviors and physical activity. The authors found that at the end of three years of receiving annual BMI reports for their children and related information, parents reported a heightened awareness of the health risks associated with childhood obesity yet did not report significant changes in family nutrition patterns. Public policy research indicates that the country needs to develop a plan for combating obesity that is in proportion to the scope and depth of the problem. This requires focusing on strategies that will work on a wide scale. The Rudd Center for Food Policy and Obesity at Yale University has found that effective public policy--making positive changes in the environment rather than focusing on changing people's behavior one person at a time-- is an efficient way to help the greatest number of people make positive changes in their lives. When this is done well, according to the Rudd Center, "practicing more healthful behavior becomes the `optimal default'--that is, choosing a more healthful behavior becomes easier, if not automatic."

Environmental Scan

Just as local, state and federal legislation and nonprofit initiatives addressing childhood obesity have grown in recent years, so has the involvement of children's hospitals in finding and supporting solutions in the built environment, school settings, and public policy. However, few institutions, like Yale University's Rudd Center, Lucile Packard Children's Hospital, and the Children's Memorial Hospital of Chicago, have a well-defined public policy and advocacy agenda in the area of childhood obesity, and only the latter two, like Children's National, situate that agenda within a comprehensive, community-oriented approach to the crisis. [See Appendix 6: Environmental Scan for details.]

Opportunity Assessment

Children's National: A Trusted Advocate for Children

Children's National is ready to lead the advocacy effort in the Washington, D.C. metropolitan area and the region. We have a long-standing history of advocating for children. More than 30 years ago, Children's National established the nation's first hospital-based office focused exclusively on child health advocacy, and has continued to make advocacy a priority by incorporating it into the institution's mission. In an effort to advance our advocacy efforts, Children's National established the Child Health Advocacy Institute (CHAI), the newest of Children's Centers of Excellence, in 2007. CHAI identifies and studies threats facing children and develops and implements interventions to improve pediatric health outcomes. Our established relationships with community leaders, local and national organizations, and District of Columbia officials combined with our expertise researching and advocating for proven public policies make us respected and effective leaders on health issues.

Special Expertise

Children's National has been closely involved in setting child-oriented public policy and planning advocacy strategies related to childhood obesity for the past several years. Leadership and physicians from the Diana L. and Stephen A. Goldberg Center for Community Pediatric Health, CHAI, and the Committee on Advocacy & Public Policy within CHAI are actively engaged in many local and regional initiatives. Recently, our faculty successfully testified before the Maryland House of delegates in support of House Bill 1176, "Public Health--Task Force on Childhood Obesity," a bill that was also drafted by Children's National, and the new committee will include a Children's National representative as one of its members. We also adopted a Policy Statement on Childhood Obesity in April 2008.

"What is needed is for the childhood obesity epidemic to reach a `tipping point,' where small collective changes within and across all sectors will produce a substantial effect so that the obesity epidemic will be acknowledged, environmental changes will take hold, communities will be mobilized, and individuals and families will aspire to pursue healthy behaviors and active lifestyle as the norm."

Institute of Medicine

Established Partnerships

Children's National collaborated with several academic, and public and private organizations to establish D.C.'s Partnership to Improve Children's Healthcare Quality in 2005. The benefits of this partnership include providing a unified message and a coordinated action plan, aligning resources, and producing measurable outcomes in the fight against childhood obesity. Through this partnership we support social marketing, policy and legislation, and coordinate and collaborate with the D.C. government, managed care organizations and community leaders to find the resources that will improve the quality of health care services for our children.

Program Attributes

The Institute will continue to take a leadership role in the community through public health research that yields policies designed to prevent overweight and obesity among our children. We will ensure that the policies engaged in by the District and the greater community are data-driven to the extent possible. We will also track their effectiveness through objective measures, documenting both successes and failures in a community "report card."

0

Finally, we will continue to develop our public and private partnerships within the community and advocate for the scaling and spread of interventions known to be effective.

toDay at cHIlDRen's natIonal

Faculty from the Diana L. and Stephen A. Goldberg

"Practicing What We Preach"

The Institute will lead the effort to prevent overweight and obesity by modeling healthy practices. This is an essential first step to educating patients, families, and staff about the importance of obesity prevention. We are currently conducting an internal review to assess existing policies and practices that may contribute to obesity in the hospital environment, and review our cafeteria's menus to provide healthy food choices for patients, families, visitors, and employees at the hospital.

Center for Community Pediatric Health and the Child Health Advocacy Institute are actively engaged in many local and regional initiatives to improve children's health. One such initiative is leading Washington, D.C.'s Partnership to Improve Children's Healthcare Quality, or DC-PICHQ--a collaboration among several academic, public, and private organizations. The benefits of this partnership include aligning resources, providing a unified message and a coordinated action plan, and producing measurable outcomes in the fight against childhood obesity.

Public Policy Research

Children's National will seek to partner with institutions such as Yale University's Rudd Center for Food Policy and Obesity to identify and apply cutting-edge public policy and advocacy research to the District of Columbia. In addition, we will coordinate research by epidemiologists, political scientists and economists to identify those areas where changes in public policy will most likely make a difference, and then establish protocols for implementing them and measuring their success using outcome-based models. Potential barriers identified by research include: One overarching goal and critical area of study will be to calculate the real costs of treating overweight and obese children in multidisciplinary clinics and as a complicating factor when they present with other conditions (e.g., asthma). We are also interested in calculating the anticipated costs of both broad-scale action (prevention and behavior modification) and non-action within the District. Isolated treatment of the comorbidities of obesity is ineffective without preventing and treating obesity as an underlying cause. With as many as half of our children suffering from overweight and obesity, answers to these questions will contribute an important piece to our policy recommendations.

n The built environment n The (upwardly) changing norm for what is

Children's National is also currently conducting an internal review to assess existing policies and practices that may contribute to obesity in the hospital environment.

envIRonMental baRRIeRs to lIfestyle cHanGe

considered to be "normal weight," negatively affecting motivation

n Inexpensive fast food n Easy availability of energy-dense foods (high fat,

sugar) and sugary beverages

n Ubiquity of advertising for these foods and

beverages

n Lack of ready availability of affordable fresh

fruits and vegetables

n Falling real income for middle and lower classes

A "Report Card" for Our Community

Children's National will design and maintain a "report card" to track actions and outcomes within our community, as recommended by the Institute of Medicine: "A validated community self-assessment tool, such as a community health index [or report card], will help communities identify their strengths and gaps in designing and evaluating childhood obesity-prevention efforts, ranging from local programs and evaluation capacity to the local physical and built environments, and the extent of community involvement." This mechanism will allow both public officials and the health care community to measure and evaluate the longterm effectiveness of new policies and initiatives implemented in the District of Columbia, and provide a measure of accountability.

"By constructing two types of performance measures (i.e., a community profile and indicators for a specific disorder or problem), it is possible to understand the health of a community and where it might focus and how it might set priorities on health improvement strategies."

Institute of Medicine

Institutional Responsiveness

Our location in the nation's capital positions us to be closely involved in public policy debates taking place in the District, Maryland, Virginia and on Capitol Hill. The Institute will track new childhood obesity-related initiatives and legislation proposed at the local, regional and federal levels and respond quickly and effectively through public policy statements and written and oral testimony on their value and potential impact on our community. We will also make recommendations to the District and community leaders based on research published by associations, nonprofit organizations, international bodies, academic and mainstream journals, and newspapers.

D.c. coMMunIty RePoRt caRD (saMPle)

BASELINE DATA DATA YEAR 1 GOALS YEAR 1

DATA

n BMI measurements n Communities with programs needed n Communities with programs available n Number of programs initiated/expanded n Number of children enrolled in programs n Community policies proposed/implemented n Educational events n School policies proposed/implemented:

GRADE

Body mass index measurements School nutrition standards School vending machine usage restriction School recess and physical education School-based obesity programs and education

n Obesity treatment/health insurance reimbursements n Obesity commissions and task forces

oveRall GRaDe yeaR 1 A = Excellent Progress B = Good C = Satisfactory D = Poor F = Unsatisfactory

SUMMARY AND RECOMMENDATIONS Demographic information Data trends compared to peers and benchmarks Opportunities for action

Key InDIcatoRs of cHIlD Well-beInG

Of the 120,000 children who live in the District:

n 1 in 4 live in poverty: 23% (vs. 18% in the U.S.) n 1 in 10 live in extreme poverty: 12% (vs. 8% in the U.S.) n 1 in 2 live in low income families (< 200% poverty level): 46% (vs. 39% in the U.S.) n 2 in 3 live in single parent households: 62% (vs. 31% in the U.S.) n 1 in 15 have no health insurance: 6.4% (vs. 11.2% in the U.S.) n 2 in 5 are enrolled in Medicaid: 40.7% (vs. 28.2% in the U.S.)

SOURCES Poverty and family status indicators: 2008 KIDS COUNT Data Book, Annie E. Casey Foundation. Insurance and Medicaid indicators: American Academy of Pediatrics, Children's Health Insurance Status and Medicaid/SCHIP Eligibility and Enrollment 2007 (September 2008).

"No Child Left Inside": Working with the Schools

Children's National's Comprehensive School Health Program provides nursing and health services to all of the 177 public and public charter schools in the District of Columbia. Our school-based nurses will be an important medical resource for the D.C. Department of Health as it develops plans for partnering with the schools to halt and reverse childhood obesity rates in the District. However, measuring BMI, teaching nutrition, and providing healthy meals in schools will not be enough. With its partners in the District, the Institute will encourage innovative thinking about how to support our schools' academic mission while increasing our children's physical activity during the day. We will explore the feasibility of creative programs such as the "outdoor classrooms" of the Boston Schoolyard Initiative, which was funded by the Robert Wood Johnson Foundation.

Sharing an Agenda with Washington, D.C.'s Department of Health

The District of Columbia's 2008 Childhood Obesity Action Plan, developed in collaboration with Children's National, represents a public-private partnership between the Department of Health and multiple collaborating organizations. This action plan, one of only three in the nation, promises to lead to the improvement of the health and well-being of the District's children within three to five years. The first of the action plan's three strategies is to improve the nutritional options available to children and families in school settings and through the Healthy Corner Stores Network, including farmers' markets, and to increase the physical activity of children both at school and through the Department of Parks and Recreation.

n Children's National will support these efforts

through its Committee on Advocacy & Public Policy and the Child Health Advocacy Institute.

The second strategy of this action plan is to increase the number of prevention and treatment programs available in the D.C. health care delivery system and reduce fragmentation in programs and services.

n Children's National's Primary Care Learning

PublIc PolIcy InItIatIves

These are some examples of initiatives implemented across the nation:

n Educate the public on the importance of

Collaborative will increase providers' capacity to participate in the prevention, identification and treatment of obesity;

n The Institute will advocate for expanding the

avoiding energy-dense foods (high fat, sugar), processed foods, and fast foods

n Limit advertising of unhealthy and high calorie

foods, especially to children

n Eliminate transfats in restaurants n Eliminate sugary drinks in schools n Serve balanced meals in school cafeterias n Ensure that children have periods of intense

availability of comprehensive treatment programs for obese children and their families;

n The Institute will advocate for developing new

payment structures for delivery of multidisciplinary treatment programs; and

n The Institute will establish a program to track

physical activity every day in schools

n Ensure availability of affordable fresh fruits

BMI in multiple settings with linkage of data to the D.C. HealthCheck database as part of Medicaid's Early and Periodic Screening, Diagnostic, and Treatment registry. The third strategy of this action plan is to engage government and community in city-wide childfamily obesity intervention planning. An obesity work group will initiate long-term planning processes, engage community dialogue, and expand childhood obesity public awareness.

n The Institute will anchor these efforts by

and vegetables in every neighborhood

n Impose a moratorium on the opening of new

fast food restaurants, and convenience stores that do not provide healthy food options

n Provide calories on restaurant menus n Support safe neighborhood parks, playgrounds

and community centers

reporting on results of basic, translational and clinical research, and by organizing obesity summits, symposia, conferences and other formal and informal educational opportunities.

"If we don't act to reverse this alarming trend, we're in danger of raising the first generation of American children who will live sicker and die younger than the generation before them. Preventing obesity during childhood is critical, because habits that last into adulthood frequently are formed during youth."

Robert Wood Johnson foundation

Impact Projections

Care Delivery

The long-term impact of public policy and environmental changes on reducing childhood obesity rates has not yet been demonstrated. Experts have looked at the changes that have taken place in our society over the past 30 years to try to gauge obesity's environmental causes with an eye to reversing them, but most findings have been speculative. However, making our parks safer, reducing the time children spend watching TV or playing video games, controlling better what children eat in school and ensuring that they have ample time to play and be physically active--all of these changes will more than likely contribute positively to preventing overweight and obesity. As suggested by the Institute of Medicine, "What is needed is for the childhood obesity epidemic to reach a `tipping point,' where small collective changes within and across all sectors will produce a substantial effect so that the obesity epidemic will be acknowledged, environmental changes will take hold, communities will be mobilized, and individuals and families will aspire to pursue healthy behaviors and active lifestyle as the norm." Through the Institute, Children's National will bring all of its intellectual resources to bear on this crisis to assist the District in its mission to slow, stop and reduce the incidence of childhood obesity.

Operational Plan

Year one

Advocacy

n Set public policy and advocacy agenda and n Appoint a Director of Public Policy and

goals for the Institute in collaboration with the Child Health Advocacy Institute, the Committee on Advocacy & Public Policy, other relevant Children's National groups and partner organizations

n Conduct an internal study of Children's National n Continue leadership within D.C.'s Partnership

to Improve Children's Healthcare Quality to make D.C.'s Childhood Obesity Action Plan a reality

n Plan Obesity Summit and other outreach

activities

n Establish community "report card" for

the District of Columbia and guidelines for implementation

Year Two

n Create a mechanism for timely response to

proposed city, regional and federal legislation

n Publish first community report card for the

District of Columbia

n Continue outreach activities n Explore ways to involve schools in addressing

the childhood obesity crisis

Years Three To Five

n Continue to publish community "report card" n Evaluate public policy successes and establish

strategy for future initiatives

education and training

Experts estimate that if

we keep on the

current course

75 percent

of Americans will be

overweight or obese

by 2015.

F as in Fat (2008)

eDucatIon anD tRaInInG

Context: Creating a Network of Professionals

Providers face a number of important barriers when they seek to treat and care for obese and overweight children effectively. These barriers include lack of awareness of the importance of the problem among patients and their families, their own lack of knowledge about and experience with effective treatments, and a lack of training for communicating sensitively with patients and families about weight problems. Moreover, the lack of reimbursement for overweight and obesity services on the part of managed care organizations effort needed to treat the child holistically. Physicians in particular need to know how to account for the influence of overweight as a co-morbidity when their patients present with symptoms or an illness that may not be directly or obviously related to obesity. They also need tools and resources to address obesity effectively and efficiently using best practices. In short, providers need to be able to rely on a network of health care professionals and community leaders in order to participate in the solution to the obesity epidemic.

be Preve hav n ior tion Mo and difi cat ion

tHe obesIty InstItute

licy ic Po Publ dvocacy a and

education and training

does not allow a clinician to expend the time and

s Re

ea

rch

In cl te in rv ic en al tio n

Environmental Scan

Most if not all children's hospitals offer continuing medical education programs, such as grand rounds, to their faculty and staff, but few, like Stanford University and Children's Memorial Hospital of Chicago, seem to take a comprehensive view of the invaluable service they can provide to the community in the area of childhood obesity. Children's National is uniquely positioned to offer education to providers in the District of Columbia by virtue of being the only institution with expertise

Providers face a number of important barriers when they seek to treat and care for obese and overweight children effectively.

in comprehensive prevention and treatment programs. [See Appendix 6: Environmental Scan for details.]

Opportunity Assessment

Providing Leadership within the Community

Childhood obesity has been a growing problem for over 30 years, and it is not going to disappear overnight. As the only children's hospital in the Washington, D.C. metropolitan area, Children's National can, however, have a significant impact on the lives of our children today and in the future by educating not only our own faculty but also the primary care providers in the community to use appropriate tools for assessing, preventing and treating overweight and obesity. In its mission as a research institution, Children's National will also train the new generation of health care professionals in the treatment and prevention of childhood overweight and obesity. Our combined program of seminars, grand rounds, training, summits and conferences will further stimulate interest and help the health care community gain confidence in practicing approaches that work.

Program Attributes

An integral part of the Obesity Institute's mission is to develop innovative, effective and compassionate solutions to a local and national crisis. Our proposed Obesity Professional Education Network (O.P.E.N.) will consist of a multi-level comprehensive education and training program with both theoretical and practical components. The National Initiative for Children's Healthcare Quality's expert recommendations on the assessment, prevention and treatment of childhood overweight and obesity--developed by the American Medical Association, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration--will serve as the basis for the programming offered by the Institute.

Primary Care Learning Collaborative

Contracting with Washington, D.C.'s managed care organizations, D.C.'s Partnership to Improve Children's Healthcare Quality (DC-PICHQ) is launching the District of Columbia Childhood Obesity Learning Collaborative, an evidence-based quality improvement methodology that has been well documented as a successful strategy for driving improvements in healthcare. The goal of this initiative is to improve health and health outcomes for children who are obese or overweight by making improvements to the quality of healthcare. To achieve this goal, team members work collaboratively to identify improvement areas and objective evaluative measures, and then rapidly diffuse knowledge using an "all teach, all learn" philosophy. The learning collaborative is scheduled to run for 14­16 months and will involve approximately 80% of pediatric primary care providers in the District of Columbia. Materials will include a newly developed Childhood Obesity Toolkit. Services will include development of a city-wide data registry and facilitation of electronic data exchange to help providers manage the care of overweight and obese children, monitor their patients' progress, and generate practiceand city-level data. In addition to instruction and materials, DC-PICHQ will provide an up-to-date list of prevention, behavior modification and treatment programs in the area to which clinicians can refer their patients. As these programs are still limited both in the number of locations and the number of children they can accommodate, input from participants in this Learning Collaborative will also contribute invaluably to Children's National's ability to map real need throughout the community and plan for program expansion.

toDay at cHIlDRen's natIonal

With our leadership, D.C.'s Partnership to Improve Children's Healthcare Quality is launching the District of Columbia Childhood Obesity Learning Collaborative, an evidence-based quality improvement methodology. The goal of this initiative is to improve health outcomes for children who are obese or overweight by making improvements to the quality of health care that they receive. To achieve this goal, team members will work collaboratively to identify improvement areas and objective evaluative measures, and then rapidly diffuse knowledge using an "all teach, all learn" philosophy. The Collaborative will involve approximately 80% of pediatric primary care providers in the District of Columbia.

Training the New Generation of Practitioners

To actively engage the interest of future professionals for mentor-based training in the issues involved in the treatment and prevention of childhood obesity, we will work with our academic partners, such as George Washington and Howard Universities, to attract the best and brightest pediatric residents, fellows in community health, and health professions students.

Opening Our Doors to the Community

In its mission as a research institution, Children's National will also train the new generation of health care professionals in the treatment and prevention of childhood overweight and obesity. Our combined program of seminars, grand rounds, training, summits and conferences will further stimulate interest and help the health care community gain confidence in practicing approaches that work.

Due to its multi-disciplinary nature, the Institute will serve as a state-of-the-art think tank for best practice childhood obesity-related clinical interventions, preventive care, city-wide advocacy and public policy activities, and comprehensive basic, clinical and community-based research. The Institute will organize and sponsor new formal and informal educational programs for providers, researchers and community members, such as the following:

n an interdisciplinary seminar series led by a

researcher/clinician on current, relevant issues concerning the assessment, management and prevention of childhood overweight and obesity;

n a published research discussion group, where

participants will discuss current, relevant research articles on issues concerning childhood overweight and obesity; and

n a public policy seminar series, which will

welcome speakers from different disciplines to present and discuss their work and its implications for the study of childhood obesity and public policy. Working with colleagues at regional academic health centers, National Institutes of Health, and other institutions, O.P.E.N. will also organize and host scientific conferences and symposia focused on childhood overweight and obesity.

0

The primary objective of these programs will be twofold: to engage participants in efforts to identify best practices and new evidence-based research strategies for treating overweight and obese children; and to identify factors contributing to childhood overweight and the mechanics of those contributions.

Operational Plan

Year one

n Appoint a Director for the Obesity Professional

Education Network (O.P.E.N.)

n Identify education and training needs in the

community and within the hospital; develop strategy for addressing them

n Establish programming for O.P.E.N. n Create the District of Columbia Childhood

Impact Projections

Care Delivery

O.P.E.N. has the potential of making an immediate and lasting impact on how obesity-related health care is delivered here in Washington, D.C. It will create a community of focused professionals, and disseminate knowledge of both successes and failures as we ourselves discover them. Only through concerted and coordinated effort can we as a society hope to bring this epidemic to a halt and reverse its progress. Children's National's Institute is poised to provide the leadership for that effort.

Obesity Learning Collaborative

Year Two

n Create a city-wide electronic data-sharing

system

n Evaluate success of Learning Collaborative;

revise and offer to area providers over the next three years

n Explore the possibility of establishing a

fellowship program

n Plan for scientific conferences and symposia

over the next three years

Financial

After initial start-up costs to establish our program have been incurred, most of the activities of the proposed O.P.E.N. will be sustained through contracts and continuing medical education and conference registrations.

Years Three To Five

n Evaluate effectiveness of O.P.E.N. programming n Evaluate effectiveness of electronic data-

sharing system

n Set educational agenda and goals for next

three years

Organizational Chart

Goldberg Center for Community Pediatric Health

Community Partners Child Health Advocacy Institute Children's Research Institute Clinical Centers of Excellence

The Obesity Institute

Community Partnerships Fellowship Program in Community Health (COPC) Financial Administration Web-Based Services Innovation Initiatives Data Analysis Services

Prevention and Behavioral Modification

Pilot Programs COOL Kids Start Early Start Right Fit Family STARS FamFIT

Clinical Intervention

IDEAL Clinic Special Health Needs Clinic Physical Medicine Rehabilitation Services Tertiary Care Clinic

Research

Basic Science Genetic Medicine Translational Integrative Systems Biology Clinical and Community Radiology Orthopedics Cardiology Bionutrition Physical Medicine Endocrinology Emergency Medicine Hepatology/ Gastroenterology Psychology/ Human Behavior Anesthesiology

Public Policy and Advocacy

Internal Policies Public Policy Research Community Report Card Institutional Responsiveness School-Based Initiatives MCO Reimbursement Structures

Education and Training

Primary Care Learning Collaborative Obesity Toolkit Affinity Groups CME Programming

Core Services Pediatricians Nursing Services Social Work Psychology Nutrition Health Education Physical Therapy Administrative Billing Post-Intervention Support Programs

Bariatric Surgery

under consideration

Appendix

By stepping outside the traditional view of obesity as a medical problem, we may more fundamentally focus on the

many

institutions, organizations, and groups in a

community

that have significant roles to play in making the

local environment

more conducive to

healthful eating

and

physical activity.

Institute of Medicine

Children's Hospital Foundation 111 Michigan Avenue, NW Washington, DC 20010-2970 301 565-8500 www.dcchildrensfoundation.com

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