The purpose of this study is to review the current data regarding implementing pediatric obesity treatment recommendations in rural areas. Data considering barriers to care, challenges as well as opportunities, including leveraging telemedicine, provider training, e-consults to improve pediatric obesity care are provided. Given the pediatric obesity prevalence, particularly in rural settings, a multipronged approach is needed to provide equitable access to vital care. This requires continued advocacy to address barriers, including coverage of treatments, improving broadband in rural areas, and educating patients and providers to decrease bias and stigma.
Key points
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Barriers to effective obesity care for pediatric patients living in rural settings include lack of access to treatment, limited insurance coverage, limited obesity medicine providers, weight bias and stigma as well as the lack of extensive pediatric-focused clinical obesity research.
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Ways to overcome these barriers have been implemented but challenges remain.
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Telehealth-based programs can be successful in treating pediatric obesity in rural settings.
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Further research into effective treatment of pediatric obesity in rural settings is needed.
Introduction
According to the World Health Organization, over 300 million children and adolescents globally have the disease of obesity, with 14.7 million in the United States. While new and effective options have been developed as adjuncts to standard obesity treatment practices, the number of children and adolescents who suffer from obesity has not declined. Numerous factors contribute, ranging from the availability of affordable nutrient-dense foods to third-party payor reimbursement for treatment. One such factor is ineffective delivery of care to those who live in areas where the disease is highly prevalent, such as areas of lower socioeconomic status and rural settings. An understanding of these factors allows us to identify barriers and develop strategies to overcome them. In doing so, the prevalence of pediatric obesity will decrease can reduce pediatric obesity prevalence, which will hopefully lead to a reduction in adult obesity prevalence and the pediatric and adult-onset comorbidities that come with the disease. This document highlights the current data on implementing pediatric obesity treatment in rural settings, barriers to effective care, and potential ways to overcome them.
Data from 2011 to 2012 compared to 2017 to 2020 outline that there has been an increase in obesity for children aged 2 to 5 years and for adolescents aged 12 to 19 years. The trend of higher incidence of obesity, with more severe classification of obesity at younger ages compared to 12 years ago, highlights the added negative health risk for these patients. The prevalence of obesity, and particularly for severe obesity (class 2 and 3), is higher for those living in rural and underserved areas, lower socioeconomic settings, and those with high-risk social determinants of health screens. Flattum and colleagues compared family-based preventive intervention in urban versus rural settings, finding 20% to 25% higher odds of obesity for those living in a rural setting. McDaniel and colleagues reviewed current trends in the barriers of travel needed to provide care even for common pediatric medical diagnoses and found that overall, children living in rural areas traveled 4 times further for hospitalization in 2017 compared to 2002. Thirty-four million Americans live in rural communities and providing care to children living in these rural settings has unique challenges.
A full spectrum of care is required to optimally manage obesity across the lifespan. Growing research and evidence-based guidelines support that these therapies should be delivered in an empathetic and compassionate patient-centric approach. Access to care in these areas continues to be diminished and challenges for implementation and sustainability of intensive health and lifestyle behavior therapy and specialty obesity care persist.
In January of 2023, the American Academy of Pediatrics released a clinical practice guideline (CPG) for the evaluation and treatment of childhood and adolescent obesity. This guideline, a massive undertaking that started with a review of 16,000 abstracts and ultimately included almost 350 articles, was a dramatic shift in the Academy’s recommendations, incorporating new, effective therapies for obesity treatment and highlighting the need to choose therapies that treat obesity and its comorbidities concurrently. The recommendations consider the multifactorial causes of obesity, including the socioeconomic and racial disparities that have contributed to disease risk. They review challenges in the communication of body mass index (BMI) status in the clinical setting, some of the limitations of use of BMI, the need for improved access to medications and surgery, and the deficit of available intensive health, behavior, and lifestyle therapy (IHBLT) programs, which are intended to be the first line of care for obesity treatment in children who are at the age of 6 years or older. Authors included recommendations on evaluation of comorbid illness that align with those from other pediatric specialty societies, with some nuanced changes to optimize care in the setting of obesity.
Implementation of new CPG has historically been found to take over a decade , and can be complicated by multiple factors, including, but not limited to, guideline complexity, guideline dissemination, education, and training and clinical decision support systems. Optimizing implementation of the American Academy of Pediatrics CPG recommendations for obesity evaluation and treatment in a rural setting needs to utilize a multifaceted approach, keeping evidence for how to promote practice guideline adherence in mind.
Studies have been conducted on strategies to implement obesity care to children and adolescents who live in rural settings, with many focusing on the use of telehealth following the coronavirus disease of 2019 (COVID-19) pandemic. Janicke and colleagues randomized children with obesity who reside in a rural setting to one of 3 interventions: lifestyle and behavior modification for the family; lifestyle and behavior modification for the parents only; and lifestyle modification alone for the family. The attendance during the treatment sessions peaked at 69%, while attendance during the maintenance sessions decreased to 42%. The main barrier noted for all 3 groups regarding attendance was scheduling conflicts. There was no significant improvement in weight or BMI z-score in any of the groups. Hosseini and Yilmaz conducted a feasibility study examining a telehealth intervention for families in rural Pennsylvania. They found that there was a mix between families who prefer in-person visits and those who prefer telehealth visits, but no differences in BMI change were noted between groups. A study using a program called IAmHealthy found family satisfaction with the telehealth aspect of this 6 month intensive behavioral obesity intervention. The program is composed of 15 hours of didactic family group sessions and 11 hours of health coaching for the family. There had been a high dropout rate and follow-up interviews suggested that logistical/scheduling issues played a large part in dropout rates, as did concern about the stigma of being part of an obesity treatment program. A feasibility trial including an intervention group using a mobile health support system as an addition to standard care and a control group receiving standard care alone found that overall satisfaction, compliance, and dropout rate as well as BMI reductions were better in the intervention group. Enhanced PREVENT is a study that tested 3 family-based telehealth interventions that were developed with input from a patient advisory council and pediatricians to target family concerns and encourage healthy lifestyle behavior. Three arms were created based on the feedback they received: healthy eating, physical activity, and a hybrid dyad. The hybrid dyad had the best compliance, but all telehealth interventions were well received with positive BMI outcomes.
Overall, telehealth-based programs can be successful in treating pediatric obesity in rural settings. Dropout rates and compliance, however, continue to be barriers to effective treatment, which is the case in most pediatric obesity treatment centers, irrespective of whether the visits are in person or via telehealth. Little to no data exist to guide providers on which of the many programs available would be most efficacious for a particular environment. This decision needs to be made by the treating provider, considering the patient population, its needs, and area-specific treatment barriers, until more research is conducted and published.
Despite the expansion of more effective therapeutic options to treat obesity in children over the last 5 years, and positive outcomes for adolescent metabolic and bariatric surgery (MBS) as well as anti-obesity medications (AOM), there remain many barriers for patients and health care providers in being able to deliver these treatments equitably. The barriers can be considered across multiple sectors, from health care policy, attitudes, and bias to pediatric inclusion in research trials to best inform care ( Table 1 ). Key barriers include access to treatment centers for those living in rural areas due to a lack of pediatric obesity medicine providers within reasonable driving distance from the patient’s residence or due to a lack of transportation to get to the provider’s office. Telehealth visits with pediatric obesity medicine specialists are an effective way to overcome this barrier, but challenges still exist, including a lack of access to adequate broadband to be able to successfully have a telehealth visit, as well as lack of insurance reimbursement for telehealth visits. The Federal Communications Commission 2018 outlines that more than 35% of US rural households were without broadband, and roughly 30 million had limited access. Other potential solutions involve using community properties, such as the town school or community hall, to conduct both in-person and telehealth visits.
