Little Big Kids We have the tools to combat childhood obesity, but lack the will of implementation

By the age of 12, Amber, who was an only child and lived with her mother, Veronica, had already struggled with obesity for several years. Amber was teased remorselessly by the kids at school. She felt down about herself and lonely much of the time and had a very negative body image. She avoided, at all costs, changing clothes in the school locker room or exposing her body in public. Despite participating on the basketball team at her school, Amber felt completely isolated. She would come home right after school or basketball practice and watch TV and eat sweets and other easily accessible junk food. Because of this pattern, Amber was often up late scrambling to finish homework.

Nearly everyone in Amber’s family struggled with obesity, including her mom. Amber’s mother was a single parent, juggling two jobs with raising her daughter. She felt overburdened, isolated, and alone. Pressured by her work schedule, Veronica, frequently sleep deprived, found herself picking up fast food for dinner and stocking the home with easy-to-grab snack foods. Veronica lacked the time, energy, or any sense of incentive, to plan and prepare home-cooked meals. When she did have a spare moment, she found herself watching TV and eating foods such as chips and cookies, to unwind from her hectic days. Given her own habits and feelings of guilt for not having enough time for Amber, it was hard for Veronica to say “no” to Amber when she requested fast food or to set limits with her about bedtime.

Despite the fact that Amber had struggled with her weight for many years, Veronica was first informed that her daughter was obese and at high risk for the development of type 2 diabetes at Amber’s 12-year-old check-up. Veronica was shocked to learn that the problem was so critical and was upset that her daughter’s pediatrician had not warned her sooner. Veronica had read some educational materials on childhood obesity; however, she was at sea, lacking any plan or strategy to help her daughter. She felt despair and anger that she had somehow failed as a parent.

Amber helps draw a stark portrait of many children and adolescents in the United States, along with their parents, struggling with obesity. Nationwide attention has turned to this growing public health crisis. Since 1970, rates of obesity have risen dramatically among youth and adults in the United States. Currently, one out of three youth and two out of three adults are overweight or obese. Overweight and obesity ranges are determined by using weight and height to calculate body mass index (BMI). For children, overweight and obesity are defined as a BMI at or above the 85th percentile or 95th percentile, respectively, for children of the same age and sex. For adults, overweight and obesity are defined as a BMI at or above 25 kg/m2 or 30 kg/m2, respectively. As recently highlighted in Time, obesity is now “more dangerous than ever.” Children and adolescents at the far end of the weight spectrum are getting heavier faster, and with this shift, a new weight status category, “severely obese,” has been created to describe the characteristics of this population. Not only are more youth obese now than in the past, but the severity of their obesity is also much greater. The United States has the 6th-highest obesity rate in the world. Of note, the rest of the countries in the top 10 are in Oceania and the Middle East and three are developing countries—almost two-thirds of the world’s obese people currently live in developing countries. Of the countries with the lowest obesity rates, the majority are in Asia. Our nation is in an obesity crisis, and the situation in St. Louis is no exception. One out of three children and two out of three adults in our own city are overweight or obese, with Missouri ranking 27th in overall prevalence of pediatric overweight and obesity.

Similar to the rest of the nation, socioeconomic disparities in obesity prevalence exist in Missouri. Prevalence of overweight and obesity is double in African American, non-Hispanic children compared to the number of White, non-Hispanic children in Missouri. Obesity prevalence is also much greater among children who are on Medicaid and among children who come from very low-income families. The Washington University For the Sake of All project provides information on factors that account for these disparities and suggests that where an individual lives in St. Louis has a powerful impact on health. Residents of zip codes separated by only a few miles have differences in life expectancy of up to 18 years. In addition, many areas in St. Louis with a high proportion of African-American residents also have high levels of poverty and poor health. Despite their greater need, these areas typically lack health-promoting resources such as supermarkets, safe places for recreation, and convenient health care access.


Tremendous Negative Impact

Obesity is associated with a tremendous number of negative health consequences, both in childhood and adulthood, afflictions that affect individuals from head to toe, impacting all bodily systems. These include hypertension, heart disease, sleep apnea, and type 2 diabetes. Before 1980, type 2 diabetes was rarely found in youth—now, it is an emerging epidemic. Type 2 diabetes now accounts for up to 50 percent of new-onset diabetes cases in youth, and its many complications, including nerve, kidney, and eye damage and heart disease, can be severe. These health problems are compounded over the lifespan, resulting in devastating health consequences and reduced life expectancy. The current generation of youth may be the first to live shorter lives than their parents. If current trends continue, it is projected that by 2030, 86 percent of American adults will be overweight or obese and a full 50 percent will be obese, 31 million people will have diabetes, and medical costs associated with treating preventable obesity-related diseases will increase by $66 billion per year. Indeed, healthcare costs for individuals with obesity are astounding—children treated for obesity are about three times more expensive for the health system than the average child at a healthy weight. By 2030, it is projected that healthcare costs related to obesity in Missouri alone will exceed $12 billion annually.

Sadly, obesity does not just affect physical health; it also significantly affects mental health. Obese children are often stigmatized and become targets of teasing, bullying, and experience rejection from peers. We have found that overweight youth are called many disparaging nicknames related to body fat (e.g., “fatso,” “chubbs”), body parts (e.g., “lard legs,” “blubber-butt”), overweight characters in popular culture (e.g., “Porky”), and large animals and objects (e.g., “whale”). Psychosocial problems can include depression, anxiety, disordered eating, poor body image, low self-esteem, and decreased quality of life. Indeed, obesity has a debilitating impact on a child’s quality of life. Youth who are obese report their quality of life to be as low as youth receiving chemotherapy for cancer, and in one population-based study, obese girls were 1.7 times more likely to report a suicide attempt in the previous year than were thinner peers. Stigmatization not only plays out in in-person social interactions at school and at home, but also online, often via social networking sites like Facebook and Twitter. Unfortunately, stigma is not just limited to peers. Individuals who are obese experience stigma from teachers, doctors, nurses, psychologists, and employers. Consequently, individuals who are obese perform less well in school, have higher rates of absenteeism, are less likely to be employed, experience lower career advancement, and are less likely to seek out or receive high-quality medical care. Clearly, childhood obesity is a problem that needs addressing.


Youth who are obese report their quality of life to be as low as youth receiving chemotherapy for cancer, and in one population-based study, obese girls were 1.7 times more likely to report a suicide attempt in the previous year than were thinner peers.


Obesity Starts Young

Efforts to address this epidemic must start early, because obesity itself starts young. As recently highlighted in The New York Times, for many obese, “the die was cast by the time they were five years old.” Since more than 80 percent of obese children become obese adults, early intervention is key. When obesity is treated early, even small weight losses can have a big impact and result in a child moving from the obese range to the healthy range. We have identified an algorithm that demonstrates the differences between weight loss needed when starting early vs. late. For instance, an 8-year-old girl at the 97th BMI percentile only needs to lose 4 pounds over one year to achieve a healthy weight, but a 12-year-old girl at the same BMI percentile needs to lose 17 pounds to reach that same goal.1 For children who are more modestly overweight, slowing the rate of their weight gain can lead to the attainment of a healthy weight, given height changes occurring at the same time. For an 8-year-old girl at the 90th BMI percentile, slowing the rate of her weight gain from 11 pounds to 7 pounds over the course of one year means the difference between remaining overweight and achieving non-overweight status. Thus, intervention is all about timing (getting in early) and treatment dose (matching the intensity to meaningfully improve the child’s life), but far too often are opportunities for prevention and intervention during this critical period missed.


Main Drivers of the Obesity Epidemic

But what causes obesity in children? Weight is determined by the balance between the number of calories eaten and the number of calories burned or expended. Obesity develops when energy intake regularly exceeds energy expenditure or when there is an “energy gap.” Weight, and thus obesity, are affected by an individual’s eating and activity behaviors, but the equation is more complicated than this, as these behaviors are influenced by a variety of environmental factors, individual factors, and their interaction.

First, there are environmental influences on obesity. During this time of dramatic increases in obesity, the environment in the United States and many other places has become increasingly “obesogenic.” In other words, the modern American environment encourages the consumption of calories and discourages caloric expenditure. Changes in food accessibility, food pricing, dietary patterns, and portion sizes have made high calorie, high-fat foods the default option for many individuals. Such foods, like chips and soda, are highly accessible and very inexpensive in comparison to lower calorie, lower fat foods, such as fruits and vegetables. Fast food and other calorie dense, nutritionally lacking foods are available just about everywhere—sporting events, malls, gas stations, and even on the drive to and from work or school. Furthermore, many low-income, urban areas and rural areas can be described as “food deserts”—areas without grocery stores or access to affordable, fresh food. Indeed, on the north side of St. Louis city, there are only five major, full-service grocery stores for nearly 100,000 residents—many without cars. In contrast, there are at least 15 major, full-service grocery stores in the southern portion of the city serving roughly 200,000 residents. Food deserts have increased in number in recent decades and stem from problems related to politics, public policy, and social institutions and also supply- and demand-related issues. For instance, low income levels and higher prices for some healthy food options may be associated with lower demand for healthier food and higher demand for fast food in low-income areas. A potentially small customer base and higher security risks are factors that may contribute to high costs for retailers and thus low healthy food supply. For individuals residing in food deserts, convenience food-type establishments may be the only option. Americans are also eating more and spending more money on meals and snacks outside of the home, which is problematic given that eating out is more unhealthy and caloric than cooking at home. The proportion of the national food budget spent on food consumption outside of the home has steadily increased from just 27 percent in 1970 to 42 percent in 2012, coinciding with a time period when more and more women were entering the workforce. There are now many dual-career and single, working parent families, which contribute to increased food consumption outside of the home. In addition, most portions offered at fast food chains and restaurants are at least double (and sometimes eight-fold) the recommended serving size—leading many individuals to overeat without even realizing it.

We have identified an algorithm that demonstrates the differences between weight loss needed when starting early vs. late.

Coupled with this easy availability of calorie dense foods, our environment encourages a sedentary lifestyle. Instead of walking, running, and biking, many individuals are spending their time in more sedentary activities, such as watching television, using a computer, and engaging in other “screen time” activities. On average, children spend about 6-8 hours per day participating in sedentary activities. Recent research indicates that one in four Americans admits to doing no voluntary exercise, and Missouri ranks as the 40th most sedentary state with more than one-quarter of residents reporting a lack of engagement in any physical activity. This is extremely problematic given recent research finding that a sedentary lifestyle, regardless of weight status, is associated with twice the risk of death as being obese. Thus, whether a person is overweight or not, going from inactive to active can reduce the risk of early mortality considerably. Physical activity is also reduced during the work and school day, as many jobs now require little physical activity, and schools now provide fewer opportunities for activity—for example, less recess time and fewer physical education classes – to make room an increased focus on test scores and improved academic performance, despite the fact that recess has been found to be associated with numerous cognitive, social, emotional, and physical benefits. Additionally, individuals in many communities are impeded by barriers to physical activity, such as lack of safety, lack of green space, and few sidewalks. We are thus barraged with environmental prompts that encourage calorie consumption and discourage caloric expenditure.

Although our genes have not changed at the same speed as these environmental changes, we do know that people who are genetically vulnerable are the ones at greatest risk. Genetics accounts for half or more of the variance in body weight from as early as five months of age. Not only do genes influence metabolic and physiological aspects of obesity, but they also play a role in eating behaviors and various traits that may promote increased food intake and obesity. For example, taste, which affects food preference, food intake, and thus eating behavior, is affected by genetics. Binge and loss of control eating, fullness and hunger cues, motivation to eat, and impulsivity have also been found to be highly heritable.

On the north side of St. Louis city, there are only five major, full-service grocery stores for nearly 100,000 residents … In contrast, there are at least 15 major, full-service grocery stores in the southern portion of the city serving roughly 200,000 residents.

While genes may affect susceptibility to an environment that promotes weight gain, social disparities also contribute to the obesity crisis. Although it was not always the case, low-income individuals are now the most vulnerable to obesity—a change that likely coincided with the rise of fast food and the increased accessibility of cheap, highly caloric food. Low-income individuals face additional challenges in combatting America’s obesogenic environment. They have little access to healthy and affordable food, fewer opportunities for physical activity (e.g., due to fewer green spaces and recreational facilities, unsafe neighborhoods, and being less likely to have physical education opportunities compared to students at higher income schools), greater exposure to advertising for obesity promoting products such as fast food and video games, and limited access to quality health care. In addition, low-income individuals are likely to face chronic stress and food insecurity (including cycles of food deprivation and overeating). All of these factors may contribute to elevated rates of obesity. Indeed, low-income children in the United States have more than two times the odds of being overweight or obese compared to children from higher income homes. Interestingly, research suggests that the poverty-obesity link is stronger for women than for men and that black women are more likely to be overweight than black men.


Early Intervention is Crucial

The good news is that childhood obesity, and the related health conditions and healthcare costs, are solvable problems, but early efforts are essential. It is important to remember that although obesity has a strong genetic component, genes do not act in isolation—they act in combination with the environment and individual factors. Childhood, prior to adolescence and the progression to more severe obesity, represents an ideal time for intervention. Intervening early allows for the establishment of more healthful eating and activity patterns before obesogenic behaviors become entrenched and resistant to change, and in addition, counterbalancing the energy gap at younger versus older ages takes a much smaller caloric net reduction.2 Moreover, childhood intervention usually precedes the onset of medical comorbidities that could complicate treatment. In addition, parental involvement can be harnessed to provide ongoing support for healthy behavior change—this is crucial given that children consume the largest proportion of their total daily intake and energy from low-nutrient, energy-dense foods at home. Alternatively, delaying intervention results in increased physical and psychosocial problems, more healthcare costs, and poorer treatment outcomes. Clinicians and parents are often hesitant to intervene due to stigma and the belief that children will “grow out of it.” But as research shows, children do not outgrow obesity and obese adults experience diminished possibilities for healthy and productive lives (e.g., less likely to be employed, lower career advancement).


Making Healthy the Easy Choice with Family-Based Behavioral Treatment

Our obesogenic environment is a key factor driving obesity, and as such, successful early interventions must target improvements in lifestyle behaviors and advocate for the creation of more health-promoting environments so that healthy eating behaviors and active lifestyles become the default choices for our families. Family-based behavioral treatment is considered to be the first-line treatment for pediatric overweight and obesity. This approach helps families engineer the environment and optimize their social support to make the healthy choice the easy choice. Not only do family-based treatment approaches aim to modify the eating and activity behaviors of the child, they also aim to modify parental behaviors, as parents have a powerful influence on child weight status. For children with obese parents, the odds of them being obese in adulthood are 2-3 times greater than the odds of a child without obese parents. While genetics may play a role in this association, so does the home environment, including parental behavior and modeling. And it does not stop at home—changes are made at the peer and community levels, too. By taking intervention steps at all levels, overweight children are exposed to healthy activities and behaviors as they move through the different aspects of their lives, which helps inculcate healthy habits and enable changes to endure. Healthy choices are practiced over and over, leading to durable change and sustained weight loss.

Family-based behavioral treatment promotes small, successive, and sustainable changes to eating and activity using behavioral science strategies. The traffic light system is used to help children easily grasp how to make healthy changes. GREEN foods are “go” foods or healthy foods, YELLOW foods are “sometimes” foods which require moderation and caution, and RED foods are ones to “stop and think,” foods that are largely to be avoided. The traffic light system can also be used to code activities, with RED for TV or other screen time activities, YELLOW for activities like walking the dog or playing catch, and GREEN for physical activities like running or playing soccer. Interventionists work with families to create a healthy home environment, so that the whole family is engaged in healthy eating and activity. By enhancing eating and activity options, as well as parenting practices around them, children’s nutrient quality, activity level, and overall functioning improve. In addition, as parents eat healthfully and exercise regularly, their children benefit from their modeling and the shifting of the home environment to one that is very supportive of healthy lifestyles. For example, when a family switches their routine from watching TV to walking after dinner, they not only reduce screen time and increase exercise but they also increase the quality of their time together. In this approach, families are encouraged to get grandparents, aunts, uncles, and cousins on board and involved in healthy behaviors as well, thus expanding the network of support. Interventionists also work with families to not stigmatize or single out an overweight child. For example, families are counseled not to serve vegetables just to the child in the treatment program and give chips and candy to the rest of the family. Rather, the focus is on creating healthy lifestyles for everyone.

Who an individual spends time with has a major impact on one’s food choices and activities, and for children, peers are particularly important. Families are encouraged to set up healthy get-togethers with their child’s friends. For example, they may arrange to take a friend ice skating or to a playground instead of playing video games. Such interactions with peers can have a positive impact on both healthy behaviors and self-esteem. Children are also taught how to respond to teasing and to advocate for healthy options for all of their friends.

Families are taught to engineer their environments to support health rather than undermine it.

Interventionists work with families to build on skills that have been developed for the home to planning for health outside of the home as well. Families are encouraged to identify community resources, such as local grocery stores, parks, and community events like fun runs or field days at school, that promote health. Families are also encouraged to advocate for healthy options, such as removing school vending machines and switching classroom party rewards from desserts to fun physical activities like relay races. In this way, families are taught to engineer their environments to support health rather than undermine it. As families improve their planning, decision-making, and social skills, they establish a network that promotes sustainable health behaviors and emotional well-being. This comprehensive approach helps families create a structure that supports health across all the areas in which their child lives, learns, and plays.

Although it was not easy to make changes, for Amber and Veronica, family-based behavioral treatment ultimately helped them to reduce more unhealthy habits and increase sustainable, health-promoting skills and behaviors. First, their provider worked with them to understand the problem, including when it started, when Amber was most likely to overeat, and other factors that maintained unhealthy habits. The family’s provider learned that Amber had always been a heavy child but that she had likely moved into the obese range about three years ago—a time that coincided with her parents’ divorce. Amber was most likely to overeat after school when she was home alone, and other factors that were identified as contributing to the problem included: lack of time, social isolation, keeping lots of junk food in the home, lack of scheduled eating times, and lack of easy access to a grocery store.

After gaining a thorough understanding of contributors to the problem, the provider brainstormed with the family to create intervention points and gradual ways to make durable changes. For example, one of the first things the family worked on was implementing more planned, regular eating—three meals and 1-2 snacks each day. Given Veronica’s extremely busy work schedule and the lack of a grocery store nearby, this was not easy but the family got creative to make it work. They learned that there were lots of healthy, affordable staples that would last and that could be cooked quickly, like oatmeal, eggs, beans, and frozen fruits and vegetables. When they were able to get to the grocery store on the weekend, they stocked up on these items. They were able to eat breakfast together and pack affordable, healthful lunches and snacks for school/work. Dinner and the time period after Amber got home from school were challenging though, as Veronica sometimes had to work late. Veronica was able arrange for Amber to go to her sister’s house several days per week, which also afforded Amber the opportunity to spend some time with her two younger cousins. However, Veronica’s sister did not always serve the most nutritious foods—Veronica urged her sister to get her on board, helping her understand the importance of healthy eating not only for Amber but also for her own family. On days when Amber was home alone, Veronica made sure there were quick, healthful dinners available, and she minimized the amount of junk food kept in the home. She made sure that there were plenty of enriching activities for Amber at home too, like books and puzzles. It also took practice for Veronica to make healthy eating a priority for herself—it was not always easy to resist fast food, and she sometimes slipped, but she was ultimately able to break this habit by reminding herself that getting healthy meant that she would be there for her daughter in the long-term. The family learned that while they didn’t need to cut out favorite foods like chips and cookies completely, it was important to treat these as “sometimes” rather than “always” foods.

As they were working on improving their eating, Amber and Veronica also worked to implement other lifestyle changes—for example, making it a priority to do something really active together on the weekend, like swimming or playing soccer, and go walking together in the evening whenever possible. Veronica learned that a few of her neighbors were also trying to lose weight and was able to organize a group devoted to a physical activity, like playing basketball or tag, one night per week. With practice, both Amber and Veronica were ultimately able to get their sleep on track, too—Amber learned to do her homework right after school, and once she became more active and developed more supports, Veronica no longer felt the need to stay up late watching TV each evening. By implementing these changes, Amber was able to achieve and maintain a weight healthy for her height. Amber saw that it became easier for her play basketball and be active, and her body image and confidence improved making it easier for her to reach out to other kids at school and in the neighborhood about playing together. Amber and Veronica realized how good they felt when they made these healthful choices and even became advocates for healthy living at Amber’s school—for example, by advocating that more healthy foods be easily accessible in the cafeteria.


Having an Efficacious Intervention is Just the Beginning

Unfortunately, having an efficacious intervention is only an initial step in solving the problem of childhood obesity in St. Louis and beyond. Multi-sector approaches, including the healthcare system, schools, community organizations, and policy, must be developed to support obesity prevention and intervention services that can be tailored to individual needs and delivered across the lifespan.

First, screening for and early identification of weight-related problems is essential. Policy could be implemented to enact mandatory BMI screening at each well-child visit with a pediatrician (starting at birth), in the schools, or in both. In one study of parents of obese children, nearly half failed to recognize that their child was overweight. Screening provides parents with accurate information about their child’s weight status, information that may motivate families to work on making healthy lifestyle changes themselves and/or seek out additional services or support for doing so if indicated. Mandatory BMI screening at each well-child visit also ensures that pediatricians are paying attention to this information and providing psycho-education, recommendations, and referrals as needed. Even small changes can yield effective outcomes, and pediatricians and other medical providers can play an important role in identifying and addressing problems early. Of course, to minimize potential harm and maximize benefits, schools should not implement BMI screenings until they have established a safe and supportive environment for students of all body sizes. Such a program might include anti-bullying prevention measures, curricula fostering body acceptance and denouncement of societal pressures for thinness, and staff trained in responding to students’ weight- and body-related concerns.

One in four 2-5 year-olds in the United States is overweight or obese, with even higher rates of overweight/obesity among low-income children. Clearly, prevention measures need to reach children in this early-age bracket. These prevention efforts should focus on nutrition and appropriate portion sizes, physical activity, screen time limitations, using food for hunger only, and the importance of a regular sleep schedule, as poor sleep highly correlates with obesity. One of the best places to reach these young children is the early childcare setting—in Missouri alone, more than 115,000 children under the age of six are in licensed childcare facilities, which often become a “home away from home.” In Missouri, licensing rules and regulations for childcare centers could be updated to include evidence-based nutrition, feeding, physical activity, and screen time practices. The licensing rules for nutrition and physical activity standards in Missouri childcare centers have not been updated since the early 1990s and do not align with recommended practices. Updating these rules would not only improve standards of care but also promote healthy lifestyles and help prevent obesity.

Such primary prevention for obesity should be a top priority and should take a life-course perspective. Early efforts, like the ones mentioned above, are necessary but so too are strategies across the lifespan. Other evidence-based public health strategies for preventing obesity could be implemented in school, workplace, and community settings and via legislation. For example, schools could be required to maintain up-to-date standards for nutrition and physical education curriculum and allot additional time for physical activity during the school day. In the workplace, stairs could be made more accessible and easy access to healthy and affordable foods could be provided. Employers could also offer comprehensive weight management services to their employees, a benefit that would ultimately reduce costs and make their employees more effective. In St. Louis, BJC HealthCare, in collaboration with our group, is doing just that with the MyWay to Health program, which helps participants and their families create healthy lifestyles by maximizing prompts for healthy behaviors and minimizing prompts for unhealthy ones. One participant described that his entire family has gotten on board, “We all think about food choices and eating out choices differently. … We shop differently, so the cupboards and pantry don’t have the same choices as before.”3 It is our vision that the success of this program will serve as a model for the rest of the country. Communities could design new neighborhoods that are pedestrian friendly and offer easy access to green spaces, and legislation limiting advertisement of less healthy foods and beverages and subsidizing the sale of fresh fruits and vegetables could also be passed. The aforementioned practices have been implemented in some settings and have been found to have benefits but their use needs to be much more widespread. Imagine the impact that could be had if schools, workplaces, communities, and governments worked together to create environments that support healthy eating and active lifestyles. The Caloric Calculator, located at, could even be used by policymakers, administrators, community leaders, and parents to explore and compare various evidence-based strategies that could be used to reduce the energy gap and combat the obesity epidemic for various target populations.

Prevention for those at greatest risk is another key component in addressing this crisis. Such targeted prevention efforts also must start early in life—as early as pregnancy and infancy. Overweight women are more likely to have large babies, who often go on to be overweight or obese children and adults. In St. Louis, the Raising St. Louis initiative is responding to these populations, working to impact the health and development of children and young families from low-income, under-resourced areas from pregnancy to when the child is 8-years-old. This unique program targets parenting and uses home-based intervention from multidisciplinary providers, such as nurses, parent educators, and social workers, to promote children’s healthy weight and adherence to a vaccination schedule as well as their literacy. Such a program provides a prime example of integrating a system of care to help at-risk families modify weight gain trajectories and establish healthy patterns for life.

Family-based behavioral intervention is the first line of treatment for pediatric overweight and obesity and is associated with large treatment effects for both children and parents—the average child shows reductions in percent overweight of 20 percent and the average parent loses around 20 pounds. However, access to this type of specialized care is seriously lacking. In addition to the aforementioned barriers of the under-recognition of obesity and lack of knowledge regarding care needed, other major barriers include lack of reimbursement for treatment and lack of specialty clinics and providers offering this treatment. Despite United States Preventive Services Task Force (USPSTF) recommendations that this treatment be covered by insurance, there is currently no insurance coverage for specialty treatment for childhood obesity. However, the state legislature in Missouri could pass a law to require obesity treatment as a covered service. Indeed, steps are currently being taken by the Missouri Children’s Services Commission Subcommittee on Childhood Obesity to advocate for just that.


Vision for Centers of Excellence

Children are suffering, and each day that we wait to take action, intensifies the problem. In order to bridge gaps in care for youth and change practice patterns from a focus on illness to a focus on promoting a culture of health, one recommendation is to create regional centers of excellence to create synergy in research, clinical care, community outreach, and policy for family wellness and weight management. By establishing centers of excellence, teams could be built that provide leadership and best practices across levels of care for healthy lifestyles. This approach has been effectively used for autism to leverage the resources necessary to support impactful research and top-notch clinical care. Obesity centers of excellence would serve as catalysts for increasing access to high-quality, evidence-based care and outreach for the many children and families struggling with weight-related problems. These centers would also promote continuity of care across prevention, early intervention, and treatment, so that individuals would receive care tailored to their level of need. In addition, such centers would serve as hubs of resources, knowledge, and activity for community organizations and families. They could also take advantage of resources in the region to support the collaboration and partnerships necessary to address this complex, public health issue.

It is clear that obesity is a pressing problem in St. Louis and beyond, but it is also a solvable problem. Obesity is a multi-sector problem, and as such, we need to change practice patterns and establish networks, resources, and policies that support healthy behaviors in settings such as homes, schools, worksites, healthcare organizations, and communities. Through strategic partnerships, we can change policies, train providers, reduce stigma, and guide coordinated care delivery that tailors intervention to children’s and families’ needs. By coordinating a collaborative effort, everyone gets value back, we maximize impact, and we work to ensure that every child and family engages in healthy eating and weight management practices.

Editor’s Note: Amber and Veronica are pseudonyms used to protect the privacy of patients, drawn from composite case studies of childhood and adolescent obesity.


Authors’ Note: Correspondence concerning this article should be addressed to Denise Wilfley, Scott Rudolph University Professor of Psychiatry, Medicine, Pediatrics, and Psychology, Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8134, St. Louis, MO 63110.



Works Cited: 

1. A.B. Goldschmidt, D.E. Wilfley, R. A. Paluch, J.N. Roemmich, & L.H. Epstein, L. H. (2015). “Indicated prevention of adult obesity: How much weight change is necessary for normalization of weight status in children?” JAMA Pediatrics, 167 (2015)21-26.

2. Y.C. Wang, A. Hsiao, T. Orleans, & S.L. Gortmaker, S. L. “The caloric calculator: Average caloric impact of childhood obesity interventions,” American Journal of Preventive Medicine, 45, (2013) e3-313.

3. P. Johnson, “Program helps employees find ‘their way’ to health,” BJC Today, (December 2014)Retrieved from‘their-way’-to-health.aspx