December 1, 2022


Health & Fitness

Despite one big success, Missouri’s ambitious effort to stem childhood obesity fell short. Here’s why.

Despite one big success, Missouri’s ambitious effort to stem childhood obesity fell short. Here’s why.

ST. LOUIS — Sarah Woods, a dietitian at a public health clinic in north St. Louis County, gets called into the exam room whenever a physician becomes concerned about a child’s weight.

When Woods started the job five years ago, she diligently told families how much exercise children should be getting and what food they should be eating.

“But then I really sat back and started asking questions instead of giving information. And when I did that,” she said, “I learned a lot of things.”

Nearly 10 years ago, the state of Missouri launched an extensive effort to prevent and treat childhood obesity, taking on one of the most challenging health challenges facing its residents.

Nearly 10 years ago, Missouri launched an extensive effort to prevent and treat obesity in children, yet it remains an intractable problem with elusive solutions.

The hope was that Missouri could become a national leader in figuring out how to reduce childhood obesity and ward off a projected $12 billion a year in obesity-related costs for the state.

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Children who are obese have an 80% chance of remaining obese into adulthood, research shows, increasing the risk of multiple life-threatening diseases such as diabetes, hypertension, cancer and even dementia.

A report released this year detailing the results of Missouri’s effort showed that while major strides were made, only one of the five recommendations was completed.

However, that one action — Medicaid coverage for a six-month, family-based obesity treatment program — has set Missouri apart, say those involved in the effort.

The coverage began in July and enlists a team of providers that include dietitians like Woods, doctors, social workers or psychologists to work with families.

“We don’t know of any other state that has done this for pediatric obesity,” said Dr. Sarah Hampl, a pediatrician at Children’s Mercy Hospital in Kansas City who co-chaired the statewide strategy effort.

Asking questions

The accounting of Missouri’s failures and successes comes just as President Joe Biden’s administration is set this Wednesday to host the first White House Conference on Hunger, Nutrition and Health in over 50 years.

After months of collecting input from across the country, federal officials will roll out a list of actions they will take to increase healthy eating and physical activity by 2030.

Since the first White House conference on nutrition in 1969, Americans have seen countless campaigns and strategies to stop our expanding waistlines.

Just as numerous are studies on the causes — everything from sweet drinks and super-sized portions to metabolism-disrupting chemicals in plastics and time spent sitting.

Yet, in the United States, the percentage of children and adolescents affected by obesity has more than tripled since the 1970s. Rates are highest among those in low-income and minority groups.

In Missouri, nearly 20% of children ages 10 to 17 were obese, according to the 2019-20 National Survey of Children’s Health, the 11th highest rate in the country.

Woods, the dietitian, says she is learning she needs more time with families. She now asks questions like: What does physical activity look like for your family? What is your evening routine? What is a typical dinner? How do you cook it? How do you get to a grocery store?

That’s when Woods says she learns how a mom would rather have her son overweight than playing on their new basketball hoop amid increased gang activity. That unsupervised unruly kids are on the apartment complex playground.

Or how the parents are exhausted from working two or three jobs, and all they have nearby are fast food restaurants and convenience stores. That they don’t know how to apply for food assistance. That that’s how their grandparents taught them to cook.

Woods can brainstorm with families on ways to get rides, find a similar yoga class to the one they loved at school on YouTube or make enjoyable meals with less sugar and salt.

“We are going to have to sit down and make these very individualized targets and changes and talk to them on that level,” Woods said. “I don’t think we are succeeding with just these general blanket statements.”

Places like hospitals and food banks are learning their roles in the individualized strategy and also taking extra steps, such as discharging patients with two weeks of healthy meals or providing cooking classes.

Efforts by Operation Food Search in St. Louis include sending a mobile market full of fresh produce into neighborhoods, and studying the impacts of delivering meal kits, recipes and cookware to pregnant women and their families.

The STL Metro Market, a roving grocery store selling mostly fresh produce, makes a two-hour stop outside the Boys & Girls Club’s Teen Center for Excellence in Ferguson. Video by Christian Gooden, St. Louis Post-Dispatch

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Filling food pantry shelves helps, but it doesn’t overcome all the obstacles to eating healthy, said Kathy Mora, director of Food is Medicine initiatives at Operation Food Search.

“We can’t solve every problem in the community,” Mora said, “but we can find alternative ways, innovative ways that really help people become more independent, more sustainable in terms of their health care and their nutrition.”

Five recommendations

In 2013, Hampl and her colleagues in Kansas City had been offering comprehensive behavioral health treatment for families with obese children for several years. But families were paying out-of-pocket.

In the St. Louis area, Washington University psychiatry professor Denise Wilfley was also offering the treatment to study participants, thanks to research grants to fine-tune the best approaches.

Both had become among the nation’s leading experts on the model, but both knew their programs were not sustainable.

“We were concerned about kids getting sicker and sicker without getting access to care,” Hampl said, especially in rural Missouri.

They were able to make their plea for treatment coverage before the then Missouri Children’s Services Commission, made up of representatives from various government agencies and elected officials.

The commission wanted even more. It authorized the creation of a Subcommittee for Childhood Obesity to develop recommendations on how to prevent childhood obesity, not just treat it.

“We were like, ‘Whoa,’” Hampl said. “We’re not going to turn this opportunity down.”

Hampl and Wilfley led the subcommittee and acted quickly, enlisting stakeholders from across the state and holding public forums.

The subcommittee agreed the recommendations must be backed by evidence, able to be implemented within the next two years and impact children in the entire state.

The results were presented to the commission at the end of 2014 and promoted the following year at a statewide conference in Columbia.

In addition to reimbursing obesity treatment programs through Medicaid, the other four recommendations were:

• Pass child care licensing regulations that align with the best standards for feeding, nutrition, physical activity and screen time; and provide support to meet the standards.

• Create a dedicated staff within the Missouri Department of Elementary and Secondary Education to stay up-to-date on the latest grade-level expectations for health and physical education and train school staff. Include health and wellness in school accreditation scores.

• Establish a commission within the state health department to oversee implementation of the recommendations, track outcomes and look for ways to improve.

• Establish and fund three academic centers that would coordinate access to treatment, provide training and conduct research to improve prevention of childhood obesity.

Fortunately, an active group of more than 350 volunteers from local health, government and education sectors across the state had long studied and supported prevention efforts — the Missouri Council for Activity and Nutrition (MOCAN), housed under the University of Missouri Extension in Columbia.

The council was instrumental in helping develop the five recommendations and continue to support their implementation, even after efforts fell short.

MOCAN continues work

An oversight commission was never created within the state health department to coordinate and track efforts, so the council established its own Healthy Weight Advisory Committee in 2018 take on the job. Again, all volunteers.

When the system of academic centers never materialized, the committee in 2020 interviewed personnel from Missouri’s system of seven autism spectrum disorder centers to help learn how to closely replicate it for obesity.

After lawmakers did not change child care licensing rules, the council shifted focus to support efforts by the nonprofit Child Care Aware of Missouri and the state health department to train hundreds of child care providers to implement plans voluntarily and recognizing those who do so with awards.

Missouri’s child care licensing regulations in 2019 scored 51 out of 100 in obesity prevention standards. The national average was 64.

Missouri’s department of education also failed to establish a dedicated student wellness staff, but went from having zero employees to two directors overseeing curriculum improvements and training for schools — efforts that greatly expanded through a dizzying array of grants and partnerships with various organizations.

Still, between 2015 and 2019, the percentage of Missouri high school students who had obesity continued to rise, going from 13.1% to 18.4%.

Members of MOCAN are trying to determine why only about half of Missouri schools use the School Health Index to assess their physical education and nutrition programs.

The online tool created by the U.S. Centers for Disease Control and Prevention helps schools identify weaknesses, develop improvement plans and engage their communities.

Candace Rodman, a nutrition and health educator working in northeast Missouri for the University of Missouri Extension, serves as the coordinator for MOCAN.

Rodman said garnering political support for sweeping state mandates and costly programs is a heavy lift. Even those already underway, from the federal level on down, face challenges.

“It only goes so far,” she said. “It may not always be supported by your state, by your local commissioners, by your school district or by a teacher in the room. There are so many levels where everyone has to be on board, and just one cog in that wheel could stop the whole thing.”

While broad policies are important in moving the needle on childhood obesity, Rodman said, so is addressing challenges facing individual families.

“A lot of it is what they do at home,” she said, “and no mandate is going to be able to control that.”

The cutting edge

That is where the intensive obesity treatment program for families aims to help.

Family-based behavioral therapy has long been the gold standard for treatment for those with obesity, with research dating back to the 1980s, but it is mostly only available in specialty clinics because of the lack of provider time and training. Many children lack access.

Advocates praised leadership within the Missouri Department of Social Services for pursuing the long process of adding the treatment to coverage, particularly Dr. Samar Muzaffar, the chief medical officer for Missouri’s Medicaid program between 2011 and 2018 before becoming assistant secretary for California’s health department.

“They were seeing rising morbidity and rising costs and felt that they needed to do something more intensive,” Hampl said. “She (Muzaffar) and her colleagues had been looking at, ‘What are more intensive-types of treatments that go beyond regular, traditional clinic visits?’”

The treatment, highlighted in a Post-Dispatch story in January, includes at least 26 hours of child and parent sessions over six to 12 months as well as individual behavioral coaching to target each family’s goals and barriers.

Families not only learn what foods are healthy, but also consider everything inside and outside the home that makes it easier to make healthy choices.

They work on ways to plan nutritious meals, maintain regular eating times, get enough sleep, find activities in their neighborhood or school, limit screen time and do things with friends that doesn’t always involve food or sitting.

Lisa Nelson is co-chair of the Healthy Weight Advisory Committee and is responsible for community health improvement plans at the three-hospital Freeman Health System in Joplin.

Nelson said states like California and Massachusetts, usually at the forefront of health reforms are looking to learn from Missouri’s accomplishments in obesity treatment.

“You have a national leadership team right here that is at the cutting edge,” Nelson said. “They are definitely setting the bar for treatment and reimbursements.”

Nelson and her committee are now looking at ways to train more providers in the treatment, and convince families to make the time commitment. Advocates will also seek to have the treatment covered by private insurance.

Having the treatment reimbursed is not the end of the story, but the beginning, Nelson said.

“The active participation of providers in the treatment is going to really shift things,” she said, especially in rural areas. “We have not had any tools in the toolbox except to recommend eating healthier and exercise more.”

Hampl said the small victories made family by family will change the trajectory of the ever-growing obesity epidemic. But it’s going to take a mix of efforts.

“Not every family is going to participate. Some may not still buy the health options at the concession stands and may not want to eat the school meal that has been made healthier,” she said. “It’s an issue where there’s multi-level influences.”

Much more could be done, Hampl said, but those who care for children are not deterred.

“I think that good progress is being made,” she said, “and we need to be OK with celebrating the small successes as we continue to look for more population-level impactful interventions.”

Josh Renaud of the Post-Dispatch contributed to this report.

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