Pandemic Impacts on Mental, Physical and Educational Outcomes for American Children: Session Three

KRISTEN BROADY: All righty. Welcome again.

[CHATTER]

All right, so I feel like we gained some people, and I know that one or two people transitioned to online. So welcome again. I am so excited about this paper, and I told him this. I feel like I've said this to each one of you all, why I'm excited that you're here.

But we wanted to talk about health and specifically obesity. And so there was talk with Dan and Kristen and Kelly and I about when various data sets came out, we said we can't write about obesity until whenever, I don't know, December. See, Kristen knows. But I said, what if we find someone who is actually doing the work right now? Like, their work will be cited in whatever data set Kristen just said.

And so Dr. Brian Jenssen is here, and he is creating this data. So he's going to talk to us about COVID-19 and changes in childhood obesity. And as he comes, I'll just say that I kind of started out writing about obesity, so this is really exciting to me. So thank you so much for coming.

BRIAN JENSSEN: And thank you for having me. Can you hear me in the back? Yes, OK.

So I'm Brian Jenssen. I'm a physician scientist, so I'm a primary care pediatrician in Philadelphia. I work primarily in West Philadelphia. I'm also part of a large primary care network, which is where this data is pulled from, which I'll speak to.

And I'm a researcher. I'm a health services researcher. I actually do a lot of work around tobacco control, as I was mentioning over lunch. And I got pulled into this from a lot of our innovation work, which I'll speak to.

And one little note, too, before I start. We mentioned here obesity, and we'll talk about obesity. When I'm actually in my clinical role as a physician, I tend not to use that term with families. There's emerging evidence that it's more motivational for parents to hear the term unhealthy versus healthy weight. So I tend to use that term when I'm kind of motivating behavior change.

Again, it's important to use this term in the point of diagnosis, and then we can guide treatment decisions. But again, when I'm actually in my role as a physician, I tend not to use that term.

I don't have any conflicts of interest to disclose.

A little note about this great team I work with. I'm happy to collaborate with anyone here, if they're interested, in our data, in our large care network. So at heart, I'm actually an interventionalist. We're going to talk about a lot of secondary data analysis that we've done. But I'm part of this innovation team that's embedded in this large primary care network, which I'll show a little bit more about in a second.

And the goal is to reimagine primary care delivery, to improve health outcomes, enhance the experience for patients and families, and really meet the future needs of children. And it's a lot. The team consists of people like myself. I'm also a clinical informaticist, meaning I build things in the electronic health record-- health services researchers, programmers, and data analysts. And we have a range of different efforts that we're focused on, and then we use those efforts to guide our intervention development. And so that's what you're going to see some of this data.

And we do a whole bunch of it. I won't bore you with these details, these rapid learning cycles in innovation, iteration, development. So again, happy to talk more about that. If you have data and want to test interventions, we're kind of in a pediatric setting. We're that group, if you'd like to work with us.

So briefly, I'm going to go over some of our early data, then I'll talk about a second study that we did analyzing the persistent disparities in child obesity. I'll put this in context of what we're seeing nationally and internationally, and then I'll close with some clinical and policy recommendations.

So as I mentioned, I work within a large primary care network. I'm actually one of our medical directors, one of our leaders in our large primary care network. I focus on value-based care, which is cost relative to quality. And we have practices across Pennsylvania and New Jersey, more than 320,000 patients, this integrated electronic health record that we've been using for more than 20 years.

And the demography of our patient population is very similar to national array. We have about 53% of children identify as white, 25% identify as African-American, 61%, about 2/3, have commercial insurance, and about a third have Medicaid. And just showing a little bit of a map of where we are across southeastern Pennsylvania and southern New Jersey.

So why don't we do this first study? So at this time, back in the end of 2020, there were all these reports about increased obesity that we're seeing. And we were learning about this and saying, well, that's a somewhat objective measure to look at in terms of what's happening with the pandemic. Not to say anything we've heard about subjective, but measuring someone's weight and height, there are more objective things we can look at.

And so we're actually analyzing this data for a separate effort. So full disclosure, this is not what we were originally doing, but what we found was so striking, we had to report on it and get it out quickly.

And what we did was very simply-- and we have a more complicated analysis that I'll show next-- was we looked at body mass index, which is that measure of your weight for height at a visit level for children aged 2 to 18. 0 to 2, BMI is not validated, so it's for children aged 2 and older.

And we looked at the data from January 2019, so a pre-pandemic period, through, at this point, December 2020. Now, at 10 months into-- the eight months into the pandemic. And we looked at obesity rates by age, race, ethnicity, insurance. And then we used insurance as a proxy measure for socioeconomic status. And then we also looked at median household income.

And we compared these very simply pre-pandemic through the pandemic. And the high level, what we found was pretty striking. Overall, the obesity rates-- so obesity defined by BMI greater than the 95th percentile, so essentially, a comparison of weight for height, factoring in the dynamic nature of growing of a child-- we found the rates almost went up by 2% in a relatively short period of time.

And I'm going to show you the figures, but I'm giving you the words right here. It went up more for children aged 5 to 9, more for children who identify as Hispanic or Latino, also for non-Hispanic Black children, children with Medicaid insurance, and then children from those lower household income quartiles.

Now, to the visuals, if you don't believe the statement. So what we did was we found these rates went up for everyone, but especially children aged 5 to 9. Again, how we define obesity is that BMI greater than the 95th percentile. And when I'm showing you with these figures, the different color coding aligns with the different ages.

And everyone really went up. That hash line is when the pandemic started and when the national emergency was declared. We had kind of a wash-in period.

Remember what was happening, if we go back to that time in March. Everything shut down, but we also stopped seeing patients. We were kind of sheltering in place. And then we needed to open up quickly to get kids back in. And that's what that yellow boxed area is showing. That's what we define as our pandemic period.

Rates went up for all children, but especially that blue line, which is children aged 5 to 9. And we can talk about why that is, why we conjecture that is. But nonetheless, really for all children, it was going up.

When you look at race, ethnicity, I think the striking thing about this figure is, first off, preexisting disparities. Children who identify as Hispanic, Latino, those who identify as non-Hispanic, Black, baseline had much higher rates of obesity. And then everyone went up in the pandemic, but especially for those children who were already underserved.

Same figure with different data, or same kind of visual. This is now broken down by insurance. The orange line represents commercial insurance. The blue line represents our public, what we refer to as Medicaid or children with CHIP, the Children's Health Insurance Program, insurance. That went up as well.

And then finally, when you break it down by median household income, again, everyone went up. But it was most striking for children from that lower quartile of household income.

And so I'm going to come back to these recommendations. But essentially, that early study has remained true, what we recommended in that paper.

So what we found was that the pandemic was associated with worsening pre-existing disparities. If you model this data out, this 2% increase in obesity meant 6,000 additional children in our care network, of our 350,000 patients, were now obese who wouldn't have been obese. If you get-- this is a lot of hand waving. If you model this across the United States, that means an additional 1 to 2 million children would have been obese during this time period.

And what we focused on is that our underlying genetics didn't dramatically change in a matter of six to 12 months. So there was big social forces here that kind of threw things off. And what we focused on was trying to educate patients and families about what was happening. That's why we were recommending-- in the clinical context, we really emphasized getting back to in-person schooling.

There was a lot of factors going on, but we said with those factors plus this, this is a strong reason to open up and get children back in. Also improving school lunches, addressing agricultural policies that distort market forces, and then really promoting physical activity. I'm going to come back to these. But these recommendations remain the same of what we were seeing early on.

So then we looked at this data again. Why? Well, we needed to understand the disparities and what was really happening to specific pediatric populations to then guide our obesity prevention and management efforts.

So this analysis was a little more robust and complicated. We did a retrospective cohort design modeled after an interrupted time series analysis. And what we were doing was analyzing electronic health record data and then actually using match period and children. This time we were controlling for children who had multiple visits, so we had multiple measurements for the same child.

The previous study that I mentioned is really repeated cross-sectional assessments. And what we defined was we looked kind of a further, longer pre-pandemic period and then defined a through pandemic period. And again, we excluded data from March to May when we really had low visit volume because we were still recommending children not to come in for routine preventive care visits.

So we created a cohort of children 5 to 17. We went on an increased age, because we needed more visits, so we couldn't do two-year-olds, because they really only had one visit at that point, but at least had one preventive visit during the two analytic periods, so at least really two visits with a height and weight.

And we looked at the monthly prevalence of obesity. I'm going to show you the visuals, because they're easier to review, so we're not just looking at data tables. But then we also fit a whole bunch of logistic regression models. Trust me, when I show you the visuals, they align with the regression models, and I can share those with anyone else that's interested.

And this is what we put into those models. The change in obesity levels and the trajectories between the pre- pandemic and the pandemic periods. And we looked at the covariates that I list here-- a binary pandemic indicator, a continuous time variable, and then a pandemic time interaction.

And we also adjusted for primary care clinic site. Even though we are an integrated health system that has 32 clinics that act similarly, in many ways they don't. They have different patient populations. I work in an extremely underserved clinic population that has 85% Medicaid in West Philadelphia. We have clinics in much more affluent areas that have 1% children with Medicaid insurance. So we have a lot of variance among the clinics. And then we also looked at calendar month to account for the potential seasonality.

And what we found was, again, striking, actually even more striking and then with an interesting kind of result. So we created this cohort of 150,000 children with roughly 600,000 visits. And what we found, which the visual will show you, this trend, all the way back to 2017, of increasing obesity, which then dramatically went up in the early part of the pandemic and then returned to its pre-pandemic-- and I tend to use quotation marks here-- trends, because the trend is still bad. Nonetheless, though, it got back to that trend level.

And again, not to bore you too much with the underlying data, the regression results essentially show this as well

- an increased odds ratio of about 1.2 and then followed by a decreased odds ratio. That's what you're seeing here in the visual. And so that was overall.

And then we also, again, looked by race, ethnicity, and found these similar same trends-- dramatic increase, especially for children who identify as Hispanic or Latino or non-Hispanic, Black. And then back to this kind of pre-pandemic trend.

OK, bear with me. Again, similar sort of representation in terms of the visual for different sort of variables at this point now. So blue represents Medicaid or CHIP, the Children's Health Insurance Program, and orange represents commercial. Same dramatic increase back to the pre-pandemic trend.

Same-- we looked at different age cohorts. We see this big increase both for 5 to 9 and 10 to 12. The more significant ones actually get 5 to 9, but overall increase across ages and then back to the pre-pandemic trend.

Now, let me show you that what we were finding was also consistent with national and international trends as well. So we were kind of early reporters of this, and then others picked this up and appropriately ran with it. We were just trying to get this out, because, again, this is not our main thing that we were focused on, but we were so concerned about it.

So when you look at national data, the CDC analyzed a larger sample using connected electronic health records. Their cohort was larger than our initial cohort of more than 400,000-- 430,000 children aged 2 to 9. And what they found was the rate of the BMI increase really doubled.

So again, to orient you a little bit, what I'm showing you here are the different boxes represent different ages, and the different blue lines represent the degree of obesity. The highest line is actually severe obesity. That hash line below it is moderate, and then the dotted line above or below that is overweight. And so you see this inflection point at the pandemic, where weight went up pretty much across the board, so concerning at a national level.

And then internationally, there was this nice systematic review and meta analysis that came out last year, which incorporated our data and others, where they took pooled estimates of the mean difference in outcomes. They also did a nice job of assessing risk of bias and certainty of evidence. And they essentially looked at 33 different studies across a range of countries, including our data in the USA, but also China, India, Italy, South Korea-- diverse sort of countries.

And what they found was a small but real difference in BMI z-scores is essentially a measure that's similar to the BMI percentile, so the same thing we were seeing that we're reporting on, increase in weight. And then again, this came up, this increase in obesity prevalence of about 2%, so remarkably consistent in what we were seeing, what the national data was telling, and the international data.

They also did-- I always like forest plots, sorry. But they also show-- all these pooled studies, what this is showing you is there is an increase in BMI that really, again, backed up by their statistic, showing you have a diamond all the way at the bottom, that there was a small but real difference when you look across all the different studies that they included.

So the conclusion here before we go into the clinical policy is that we really need to continue our work to improve obesity rates. Because what the pandemic really did was expose all the risk factors for weight gain, and they really exacerbated. Food insecurity-- if you remember back to that time, those early pandemic months, food insecurity got worse. For children, there was reduced access to "healthier"-- in quotation marks-- free school lunches.

So as I've mentioned over lunch time, it's a little counter-intuitive. But for a large cohort of children in the United States, they actually gain weight during the summer months, because they don't have access to the "healthier"-- again, in quotation marks-- than what they actually get at home during the school year. So the school is offering them healthier lunches than they would get at home.

We saw in the pandemic all of this consumption of highly-processed, calorie dense foods. It was more shelf stable. That was a big thing, especially during those first 6 to 12 months-- more screen time, which was understandable, but something we have to now push back against, and sedentary activities.

And what I worry about as a physician, and what I'm seeing in patients, not just the researcher, is an acculturation that happens. Everyone got used to these things, and now that's the norm. Like, kids tend to respond to all of these extrinsic factors on them, and that's what's influencing them and their parents to continue these behaviors.

There are some limitations in this data, that maybe the reporting-- maybe kids who had more unhealthy weight were more likely to go to a physician. I'm not sure if that's really true, because that's not-- we see that in adult populations, not for children as much. And the obesity rates have gotten better, but they're back to the bad trend in which obesity rates continue to rise.

And I'll close this section. This is a nice figure.The Economist just had this great article focused on why the war on childhood obesity is failing. And what they're highlighting, this is a problem that we're not just facing in the US. This is across the world now. What they're showing you in this figure is the great victory is the rates of underweight for children has gone down over the last 30 years, 40 years. But the rates of obesity, regardless of the country you're in, continue to climb.

So I'll close-- I think I'm well within time-- just with some clinical and policy recommendations and giving some educational points for those people and doing more research in this space. So there are clinical guidelines from my professional group, the American Academy of Pediatrics, where they recommend evaluation and treatment for children with unhealthy weight. And there's a lot-- it's a lot of focus on intensive health, behavioral, lifestyle treatments, motivational interviewing. I'll speak over the silverware.

And I'm going to highlight two things that are mentioned. But we are really conflicted as pediatricians to really actually offer these next two things-- metabolic and bariatric surgery and pharmacotherapy. They're part of our clinical guidelines, but we're not really at this point using them, I think, for understandable reasons, as I'll speak to.

So we've all heard about these new pharmacotherapy treatments for adults, and they are now approved for children. The two ones are semaglutide and liraglutide. Don't worry about the pronunciations of those trade names there. It's Wegovy is the biggest one. Ozempic is the one that's approved for type 2 diabetes. They're approved for children down to age 12. Wegovy is a once-weekly injected. It's preferred because it's once weekly versus daily, but it also has a larger treatment effect size. It works better when you look at the randomized controlled trials.

What they do-- and this is important, because I'll come back to this in the further recommendation-- they really work by targeting your brain, the central nervous system, to decrease your appetite and increase satiety by slowing the gastric emptying, by slowing the food leaving your stomach. So they actually help you feel full more quickly, which is a good thing. It helps people eat less. There are other ones that are approved for treatment for type 2 diabetes, but not in children and not for obesity. So those are the big medications.

And I just wanted to highlight them. These do work. When you look at the randomized controlled trial that prompted FDA approval for semaglutide-- this was published back in the New England Journal back in 2022-- what I'm showing you is just two of the many figures that I had in this randomized control trial. They randomized 12-year-olds and older to either semaglutide or placebo, and they found in this essentially a year-and-a-quarter, year-and-a-half study, a dramatic decrease in BMI for semaglutide use and then a dramatic decrease in body weight. They work. They do work, and that's what led to the approval.

But are surgery and pharmacotherapy really the answer? So first, on a surgical note, and I'll close by kind of reading and speaking to the pharmacotherapy. Bariatric surgery has been an effective way of treating adolescent obesity for the last 30 years. The problem is we don't tend to use it, because it's hard to make-- to think about as pediatricians, as parents, as families do we really want to have something a child undergo something that's going to alter their life for the rest of their lives?

And what ends up happening is we delay the referrals to those surgeries, and by the time they actually get the surgery, they're unlikely to get the maximum treatment benefit. What I mean by that is that usually there will be a decrease in BMI by about 10%-- 10 points when you have in adults bariatric surgery. So typically, adults get referred to bariatric surgery when they have a BMI of 35 or over. If they have the procedure, they get down to a healthy weight. Great, and that's been backed up in randomized controlled trials.

For adolescents, we tend not to refer them or they're not ready or the parents are not ready-- complicated factors-- until they get to a BMI of 45. And so they have a procedure, and the procedure may not actually maximally benefit them, but nonetheless, they have this life-altering procedure. So bear that in mind when we think about these new medications.

So the glucagon-like peptide agonists, there's issues with adherence and cost. So it's a potential lifetime commitment to treatment. In the adult studies-- this hasn't been looked at yet in pediatrics-- only one out of three adults continue to use them at one-year follow up. And when you stop using them, you pretty much gain the weight back.

Maybe there's a future state when these are combined with behavioral modification and that helps keep the weight off. But that hasn't been proven yet.

And they cost a lot of money, about $1,400 a month. If all adolescents in the US with obesity were to use these medications, that's $100 million a year. If 40% of Americans with obesity were to use these medications, that's

$1 trillion a year, which I'm an economist, but that's 4% of the US GDP. That's a lot of money, a lot of effort, which may not be worth the impact.

So are there more effective approaches? And so especially for children, as pediatricians, as a researcher, we just have to emphasize that diet, lifestyle needs to be central. The problem is we need better research here, more studies looking at this.

As I was mentioning over lunch, I'm a possibilist. I'm an optimist. Good things are always possible. The heartening thing about these medications is that we can mimic their effects by better dietary modification. So things like low glycemic index foods, having nuts for snack, for example, fills you up and then you're less likely to eat the less healthy foods. So if we focus on that, maybe that's a way to help not just that, but more behavioral modification around that and healthier eating. Maybe that's the way to help get us out of this problem. So I close by saying that we need more funding, more research around dietary and behavioral interventions.

And what the pandemic really exposed was just the need for larger policy changes. We have to address the complex environmental determinants of dietary habits and physical activity.

When I train my med students who come and I'm teaching them in the office, I'll ask them, what are our approaches to help children who are struggling with obesity? And they'll often say about individual choices.

And the interesting thing that's not really borne out by the evidence, when you look at individuals, when they're young adults and obese, when they became obese, it wasn't when they were teenagers. It wasn't when they were school age. The inflection point for this trajectory of obesity and childhood is really around age 2 to 4.

And that's not a judgment. I'm not placing a judgment, but that points out that's not a child, a 2 to 4-year-old making individual choices. It's the complex environment in which they're living. So me and my pediatrician will probably play some role in this, but it's not really driven by health care. We're not going to be the solution to this problem. We really need to think about population level efforts, school-based efforts. Because this all happened-- this dramatic increase and then decrease was likely independent of anything we were doing clinically in any sort of change in our clinical underlying biology.

And I'll just close this section by saying this was a study that one of my colleagues did, where we looked at-- the intensity of the green on this slide represents the degree of green space, vegetation index. And so when you look at in our data set, children who had more vegetation, more green space around them, doing our best to control for socioeconomic status, they gained less weight during the pandemic compared to children who didn't have access to that. Now, there's a complicated overlay of socioeconomic status with that, but nonetheless, there's something about the built environment as well.

And so I'll close with this, is that we need to think about norms and nudges, access to healthier school lunches. There's a lot of politics there, but we really need to focus on that. For a large cohort of children, that's the only time they're getting a healthy lunch, a healthy meal. Interestingly, in the United States, food insecurity is so strongly tied to obesity.

Another thing that's outside my scope of expertise but we have to speak to is we have these weird market forces at play here. We subsidize. For those unaware, we subsidize a lot, especially around corn and sugar that leads to altering the market to artificially decrease the price and the expense of that through the form of agricultural subsidies.

I do a lot of policy research, and it's very fascinating to me that we have those forces at play. We subsidize, and now we're doing soda taxes to go after something we created with the subsidy in the first place. It strikes me we should probably go after the subsidy.

We need to think about physical activity, and we need to do these studies, because right now, there aren't great research that these actually work. But we need to expand work in this space and really need to think in novel approaches.

And then I'll close by saying that we really need to be-- I think one of the biggest lessons, maybe the only lesson from the pandemic, is that we can't let policy get ahead of evidence. And I'll close with-- we were, again, talking about this over lunch. There was a lot of energy expended on doing calorie labeling as this big intervention that was going to help on menus. So menu calorie labeling that was going to help people make healthier choices.

It turns out when you evaluate that, it does not work. It does not help people make healthier choices. In fact, it actually is counterproductive in a very rational way. If you're coming from an underserved population, you might look at a menu and say, I can get more calories for my buck if I choose that than if I choose that. So talk about now that's a national policy based on the number of restaurants that you potentially have, and that's been implemented, and a lot of money has gone into implementing that. There are better things that we can do if we stay aligned with the evidence. OK with that, I'll close.

Do you want me to pull up the other slides, or are you--

KRISTEN BROADY: Yes.

BRIAN JENSSEN: OK.

KRISTEN BROADY: Don't go far.

BRIAN JENSSEN: Yes.

KRISTEN BROADY: Thank you so much, Dr. Jenssen. I have a million thoughts, and I'm sure you all do, too. But first, we are going to hear thoughts from Dr. Harris.

BRIAN JENSSEN: You're not going to go back to slides? OK. All right.

PATRICE HARRIS: So we're going to get to those million thoughts rather quickly. Good to be up here again to reflect. But I think it's going to be a very rich conversation, so I won't be long.

But I just wanted to widen the aperture on a couple of things. By the way, let me say two points. It's Dr. Jacqueline Fincher. I couldn't remember my colleague's name this morning, who was president of AAFP, along with Dr. Sally Goza at AAP and me at AMA. So I wanted to make sure I did that so that Jackie would not be mad at me.

And the second thing, again for a whole other seminar, is long COVID. I mean, when you think about the neuropsychiatric consequences and the other health consequences-- so again, that could be one to two days of discussion. But let's just not forget that. As you know, I'm pretty rabid about context setting. And so as we continue to think about solutions in all of these issues, let's not forget about that.

And I say that in the service of clearly at the very beginning of the pandemic, the folks who were most significantly impacted when it came to morbidity and mortality were our seniors, and particularly our seniors with co-morbid health conditions and, of course, communities of color with co-morbid health conditions.

And I recall this fantasy where we don't have to worry about the kids, right? They'll be fine. I'm probably being a little bit hyperbolic here and mischaracterizing perhaps some opinion, but we don't-- the kids won't die. So let's let kids get COVID, get infected with COVID. Of course, that, again, certainly does not appreciate the fact that kids in school would go home, and those who were living with other family members who were immunocompromised or seniors. But again, those are the nuances of conversations. But now we're seeing these consequences for children. And so we always have to keep in mind long COVID.

So glad we are talking about obesity, and I hadn't seen that data with obesity related to the pandemic. Obesity has been an interest of mine, as Kristen knows, for a long time. In fact, I had the wonderful opportunity when I was public health director in Fulton County to reimagine one of our facilities.

So we had this huge complex, several acres, several buildings. And we saw-- again, and this was around 2013 or so-- childhood obesity was increasing in Fulton County, Georgia. And we thought, all right, what can we do at the county level with the resources we had to address this issue? And we had the opportunity to, again, reimagine this facility.

And so we thought, all right, we believe in integrated care and collaborative care. So we were able to redesign a facility where we had our behavioral health services in one wing. We had a pediatric services in another wing.

And we even sort of made sure the physical plant was designed with people who are overweight and obese. And thank you for the language-- and so making sure that the exam tables were electric. Because people who may weigh more may have more difficulty getting onto our exam tables.

And so we designed that in mind. And then there was a gymnasium on site, and we fantasized that it would be great if you come in see your pediatrician, your pediatrician says, hey, we want you to increase your physical activity. And here's a physical therapist or an occupational therapist that can take you right over to the gymnasium for physical activity. And there was a walking trail. So as we think about policy, and designing systems, and health campuses, I think that's something that we should consider.

You also mentioned issues around language and stigma, and I think that's very important. We also have to wrap that around cultural humility and make sure as we are coaching and educating folks about foods and healthier choices-- I'm going to come back to that term, choices, in a second-- that we appreciate their culture.

So also on this campus, we built a teaching kitchen. Because we said-- and so I'm a doctor, I raised my hand. I think we're very good at saying, here, do this, and here's a pamphlet, or here's a one-pager. But we really thought we need to take some time educating and teaching and allowing our families to practice.

And so, again, I'm a good Southern girl and raised in a family where we ate lots of fried foods, and was so good-- still so good. But everything in moderation. But just saying, well, stop frying foods, that is not going to work.

And so we brought in some nutritionists, and they thought-- and I'll never forget one little kid. Now I can't remember what it was, but he-- and his mom said, I'm not sure I can make it healthier. And so we said, let's teach you. And he ate a vegetable he had never had. And he said, I didn't know this could taste so good. And the family, too.

So those are the things that we can think about when we are redesigning, again, health systems, and, again, maybe even hospitals are coming on board, bringing in teaching kitchens and some of these other issues that can be on our campuses. If we are really, truly about the business of health, it's about health and wellness and incorporating that. Clearly, we need to take care of tertiary care needs and acute needs, but we also need to, I think about from a policy and a practice standpoint, how can we incorporate wellness into this overall idea of health?

Many people have heard this, say we are a sick care system, not a health care system, and we need-- what did I say earlier today? Not either-or. We need sick care, if you will. Don't love that term, but we also need prevention and wellness and health care. So those are some things to think about.

Choices-- I will just say this. The choices people make are based on the choices that they have. And as we think about the determinants of health, I was on a panel, I think during the pandemic, with a colleague from Tulsa, Oklahoma.

And we all know the data around zip codes. And you can be two miles away, 10 miles away. We've done some work. Actually, the AMA did some work here in Chicago, and the health outcomes are so very different.

And so if it takes-- and I remember a colleague said, OK, it takes someone living in this zip code two hours to get to a grocery store where they can have healthy, fresh fruits and vegetables-- two buses and two hours. That's just not going to happen when you take care of your family, you work, then you have to come home and other-- if you work outside the home, other obligations. And so policies and practices around zoning and being creative about--

And clearly, listen. So the huge, huge big box stores might not be able to come into a neighborhood. We know that they have to keep the lights on and pay the bills. But how can we think creatively about smaller stores and opportunities, or bodegas even, again, depending on where you live, but just making sure that the option, the choices.

See, I can talk to you about choices once you have equitable opportunities to make healthy choices. Then we can have conversations about choices. But I believe until then, we have to be really circumspect about our conversations around choices.

Certainly access to health care-- so they can see great pediatricians and child psychiatrists and nurses and physical therapists. And certainly, making sure that folks have Medicaid, and CHIP, and they are using these. And then what is paid for is a policy issue.

On the opioid issue, related, we should think about if the only option that someone has to treat their pain is a pill, if that's paid for, or if the co-pay is $2 for the medication but $50 for a physical therapy visit, what do we think is going to happen? What are we incentivizing there? So we have to look across the system to see what we are incentivizing in our policies.

We already talked about stigma, cultural humility, planning, and development, the built environment. We can say-- I can say as a physician, any health care professional, you don't have to join a gym. Just go outside and walk around your neighborhood. But if there are no sidewalks, and if they're not well lit, those are other issues.

And so it's not just so easy to say. Well, it's quite easy to say just go outside and walk around, but certainly not so easy to do, so lots of issues.

Thank you. You must be a quiet psychiatrist, because you put out some elephants in the room. And we always need to talk about the elephants in the room, really. And sometimes we have to talk about those in smaller groups and hash out some things. But we have to look at our greater food policy in this country if we really want to address this issue.

Thank you for bringing up the GLP-1s and the surgery. We're going to have to talk about that and the costs. But we certainly need to make sure that, again, when we are thinking about policy issues, we make sure that there's equitable access and that we are thinking about many communities. And so those are just some thoughts, and I guess I'll be up here on a panel with you to continue the discussion.

[CHATTER]

KRISTEN BROADY: All right, so let's get started. I have more questions than there's time, because we could have a conference on this topic. So I first want to ask, is the measurement of obesity the same for children as it is for adults?

BRIAN JENSSEN: Yes and no. So you have to factor in-- so we use BMI as the gold standard, but you have to use a measurement that accounts for the shift in children, the fact that they grow. And then we use that as a comparison to the mean. So that's why I was mentioning, we use the BMI percentile or a BMI Z-score. Does that answer your question?

KRISTEN BROADY: Yes. OK, so I wanted to get that one out of the way. The next one-- and some of this as a researcher, I want to know, but some of this because I have these two doctors. So there is this thought that people are shaped differently, mature differently based on race. Like, is that genetic or not? Like, I'm thinking there's this statement that we shouldn't use the same BMI for Black people as other people because-- I can't even explain why, but we shouldn't. Is that a stereotype or is that real?

And then can you, too, talk about the age at which children mature and how that impacts the BMI? So basically, should the same rating be used for kids of different races or is that not a thing.

BRIAN JENSSEN: Well, so I think the-- well, first, the BMI is not perfect, but it kind of works well as a general screening tool. There is no one perfect approach. There's emerging evidence around maybe using essentially waist circumference that better effects for better risk factor. If you have a lot of central adiposity, central weight gain, that's actually more of a risk factor than if it's more evenly distributed, which is great. I mean, if we have better tools to help identify, the problem is that even if we have better tools to identify more specifically, we still don't have great treatments.

Now, to your other point, I think what's fraught around-- race, ethnicity are social constructs, so it's hard to really get into that. When I talk to my families, the vast majority are, again, children in West Philly. When this topic comes up, I say, right. And we're not using any sort of-- we're going to focus on healthy versus unhealthy weight and trying to make sure that we're kind of living healthy and focusing on wellness.

So in many ways, I think the best approach is bypassing that, because I think we're all in this together regardless of race, ethnicity. Does that makes sense?

PATRICE HARRIS: Yeah, I would agree. And I am not speaking from the data that's right in front of me, but I know there have been some conversations in the African-American community about BMI. And I would say I think what you said is critically important, that as long as folks realize that, realize that it is just one tool and one piece of data, and there are so many other pieces of data that should be factored in, we'll be OK.

And the other thing is just talk about that. And I know you do this. And I talk a lot about the street committee. People have heard on the street that BMI might be based on racist policies or whatever the word is. And so the key is we can say, listen, we have this tool, BMI. It's not a perfect tool. Just as you said, you've probably heard that there may be some differences. We don't know that yet, but here's one thing we're going to look at. We're going to look at all these other tools. I think just telling people and having that humility to just talk about this and know that they are hearing things on the street or on the internet that at least need to be addressed.

BRIAN JENSSEN: And one more thing to speak to, just for the data-minded folks. So the standards are based-- it's a population- based assessment and standard. So it's not an absolute number. It's based off a median and distribution. And there's two different cohorts, too. So sorry to get into the weeds, but I think this is helpful in this discussion.

The CDC is a US-based assessment of BMI, and it actually over-assesses from the Midwest population. So you can make that interpretation about what that means in terms of race, ethnicity.

Now, the WHO also has one, which is much more of an international cohort, which has disproportionate population of children who are breastfed. Now, those are different sort of ages. But the point is, it depends upon the sample that you're using to make your population estimate.

Now, sorry if that gets too far into the weeds. So I don't go into that complicated discussion when I'm doing my patient-level counseling. But usually what I try to do is motivational interviewing, just get back to what are you most worried about, and how can I best help? And I try to really guide.

Maybe one thing to remember from my talk today is one of the biggest issues is consuming sugar through beverages. And so there's well-done research in adult and pediatric populations, that if you consume one to two cans of soda a day, you gain 10 pounds a year. And that's what I try to educate families on because, hey, look, you save money by just not drinking the soda, and you'll feel better. And that's kind of nudging in that direction.

But I think when we get-- there's such a complicated and so much historic racism that's part of health care that we don't want to go down that direction. And so we want to advocate for families and recognize that they're getting targeted by all these different things, forcing them, pushing them towards unhealthy eating. So trying to empower them and educating around that I think bypasses some of those conversations. Oh, this may not necessarily apply to me, and it does, because we're dealing with so many children, especially underserved children, who are really struggling with extreme weight issues.

I'm sure I didn't make this clear, so 15% to 20% of the US pediatric population is obese. 40% is either unhealthy weight, so overweight or obese. In our adult population, 70% of Americans are either overweight or obese. This is a big thing that we need to really focus on together.

KRISTEN BROADY: As one of those people-- so, I guess, I want to talk next about the stigma. And you talked about changing the language, but I think about how much I work out and the shape that I'm in when I go to the doctor. My doctor says that I'm obese based on these numbers. So thinking about parents hearing that, how do we change the language so that people aren't afraid to go to the doctor or want to avoid the topic or say, I'm not going to get on the scale? How do we change the stigma, one?

And two, you're putting down a code, I'm guessing, that insurance companies are going to look at. So it's like if you're labeled at 5 or 50 as being obese, do you know-- how does that track long term? How does that impact the ability to get insurance, to keep it, and insurance costs? So that's a broad topic, but--

BRIAN JENSSEN: And a great one. I'll have three responses, and you have several questions within that. I think the first thing, again, when I'm at my best as a physician, but I think all of us, behavior change happens in a place of non- judgment. Most of my research is helping people quit smoking. It's incredibly hard. No judgment. That's what we say. And the 1,000 step journey starts with the first step. That's what we so emphasize.

If we could solve obesity through judgment, we'd all be perfect, because there's a lot of judgment that gets thrown around. So I think starting there first. And then the second thing, which I'm glad to see this is really being driven by the pediatric community, but I think others, and I think raising more awareness of, it's not an absolute number. It's about wellness and health. Let's help you be healthier. And again, unhealthy versus healthy weight, shifting that sort of messaging.

But the final thing is that you mentioned around advocacy around the labeling. We don't want people walking away feeling labeled. You're still a person. I don't like-- I always struggle with this in health care, when someone refers to someone as a diabetic, an asthmatic, a smoker, an obese person. No, you're a person who's struggling with weight. You're still a person.

And so we do a lot of-- my other role as medical editor for value-based care, a lot of advocacy with insurance companies to stop using certain labels and use more objective measurement. We don't need to use obesity in the diagnosis code. You can say BMI of x, right? Simple things like that could go a long way.

But we still have to spend a lot of time counseling. You might see this. That's not what I'm talking about today. I just have to use that label to get the things that we need to do to help you.

KRISTEN BROADY: The last piece, though, is thinking about how does that translate for insurance. And I guess I think about it as there are all of these things that doctors put in these codes. Any thoughts about how that translates to are you going to be able to get insurance coverage to be able to come back and see you again?

BRIAN JENSSEN: Well, you mean in the sense of what you have to use in terms of labeling?

KRISTEN BROADY: Yes.

BRIAN JENSSEN: [INAUDIBLE]

KRISTEN BROADY: So basically, I'm saying, like, the insurance company looks at that and says I have this person as a risk. Even if they can't change your coverage now based on policies, if and when they can, might you be afraid of getting labeled as obese, a smoker?

BRIAN JENSSEN: Oh,I'm sorry.

KRISTEN BROADY: You see what I'm saying? Like, a lot of people wouldn't say I smoke, because the doctor's going to put that down. The doctor needs to know it, but now I'm labeled as a smoker forever, or I'm labeled as obese. So how do you--

BRIAN JENSSEN: I think that's advocacy.

KRISTEN BROADY: Yeah, for policy, how do we do that?

BRIAN JENSSEN: Yeah, I mean, colleagues do this great research, part of this behavior economics team at UPenn, where they found that paying individuals to quit smoking worked, a small amount of money, $450-- $450 across a year can help people quit smoking. And what was fascinating is to watch the policy implications of that, what several employers and insurance companies did.

I struggle with the idea of paying someone to quit smoking. That felt so weird. There was an ick factor. People who don't smoke say, why are you-- I mean, you're not paying me to continue my health. Why are you paying them to quit smoking?

So what companies did in quitting-- both of my companies I worked for, both UPenn and Children's Hospital of Philadelphia, they turned the carrot into a stick. And so you're penalized. You have to pay more for your insurance if you continue to smoke, which is un-evidence based, right? That doesn't work to help people quit smoking.

And so I think we need to, as a culture, say, look, we're all in this together. People are struggling with weight, not just because of individual choices. It's large social forces. People struggle with smoking. I grew up on Long Island, where I had a lot of protections against ever becoming a smoker. If I was the same me who grew up in West Philly, I'd have a lot of forces pushing me towards smoking, independent of me.

And so I think you bring up such a great point. And I think this is us. It's not just physicians advocating around this. I think it's us as a culture, as a force saying, no, we're all in this together.

KRISTEN BROADY: So in our-- I want to--

BRIAN JENSSEN: I'll get off my soapbox.

KRISTEN BROADY: We're out of time. I'm still going to ask this question, and we are going to get to solutions and the 3 o'clock panel. So I don't want you to think that I'm ignoring solutions. Stacey is going to ask about solutions.

But I have one more. Can you talk about side effects of Wegovy? So it's a new drug. We're hearing a lot about it, stuff like, yes, it causes you to empty your stomach slower. But is that really a good thing? Because, I mean, there are these thoughts that your stomach may shut down, like gastroparesis, gastro--

BRIAN JENSSEN: Yeah, there's been-- I can speak to it for the-- yeah, we have to continue to evaluate this. Right now, they seem to be safe and effective. There's been case reports of gastroparesis. But nonetheless, when you look at the large randomized controlled trials-- and I'm not pushing this. Like I said, I actually don't prescribe it for children right now, because we struggle with the idea of prescribing it.

The biggest one is nausea and just people talk about then having to take it and delay the time they take it. I'm not if anyone's taken it themselves, but some people have to take it-- wake up in the middle of the night to take it, and then go back to bed.

KRISTEN BROADY: I won't admit to taking it, but--

BRIAN JENSSEN: Yeah, so I think that-- but it is working. When you look, again, for a large cohort-- I'm not pushing this-- but I think this is something to continued to study is the point. We always have-- after drugs are approved, we continue to have the post-marketing evaluation of them.

PATRICE HARRIS: What we don't want to do, and this is tough, is stigmatize the medication.

BRIAN JENSSEN: Correct.

PATRICE HARRIS: Because we know some famous people that are on these meds, but they were afraid to come out and say. And I think that gets to our whole, I guess, paradigm around weight loss. Heretofore, it's been about choices. Oh, just push back from the table.

BRIAN JENSSEN: Right.

PATRICE HARRIS: And so now we are finally appreciating-- those in this room probably already appreciated, but we are now appreciating that it's much more complex than that. So that's the good news. So we have to figure out-- and we are early on. We have to figure out our way through this. It won't be for everyone.

But just as we don't want to stigmatize those who have unhealthy weights, we also don't want to stigmatize evidence-based treatments and therapies if they can work and reduce the risk of diabetes, and hypertension, and stroke, and joint replacement later on. So huge question for not just the health profession, but for society in general.

And I'll just only say, certainly the plural of anecdote is not data. But I will say I've not heard anyone being discriminated against for having a diagnosis of obese, but I don't have any data, just not heard. So that's just one person.

But we do know that that's a real-- the point you raise is real. And sometimes you might not be able to get life insurance or even other sorts of insurances based on genetic profiles. So we all have to just be careful.

KRISTEN BROADY: Yeah, I think I asked that question. I recently got, a couple of years ago, long-term care insurance. And so I don't know about the earlier insurances, but the cost of long-term care insurance is directly related to a bunch of different medical things-- whether or not you can get it, whether you get it for seven years or a lifetime, and how much it costs. Again, conference for another day.

We are going to have a break. There may be questions, but I feel like they're related to the policy. And I feel like anything more that we would say would get into Stacy's portion. So we will take a break and come back and hear from Dr. Diane Whitmore Schanzenbach, who will introduce shortly.