key: cord-0923248-6me6k8th
authors: Woo Baidal, Jennifer A.; Chang, Jane; Hulse, Emma; Turetsky, Robyn; Parkinson, Kristina; Rausch, John C.
title: Zooming Towards a Telehealth Solution for Vulnerable Children with Obesity During COVID‐19
date: 2020-04-30
journal: Obesity (Silver Spring)
DOI: 10.1002/oby.22860
sha: e385ace4e2b4442a7dffd78b522210a0ce81256d
doc_id: 923248
cord_uid: 6me6k8th

Health inequities exist throughout the life course, resulting in racial/ethnic and socioeconomic disparities in obesity and obesity‐related health complications. Obesity and its co‐morbidities appear linked to COVID‐19 mortality. Approaches to reduce obesity in the time of COVID‐19 closures are urgently needed and should start early in life. In New York City, we developed a telehealth pediatric weight management collaborative spanning NewYork‐Presbyterian, Columbia University Vagelos College of Physicians and Surgeons, and Weill Cornell Medicine during COVID‐19 with show rates 76‐89%. To stave off the impending exacerbation of health disparities related to obesity risk factors in the aftermath of the COVID‐19 pandemic, effective interventions that can be delivered remotely are urgently needed among vulnerable children with obesity. Challenges in digital technology access, social and linguistic differences, privacy security, and reimbursement must be overcome to realize the full potential of telehealth for pediatric weight management among low‐income and racial/ethnic minority children.

This article is protected by copyright. All rights reserved As COVID-19 rages on throughout the world, data unmasks profound racial/ethnic disparities in COVID-19 mortality among adults in the United States. 1 Obesity, hypertension, and diabetes are emerging as risk factors for COVID-19-related morbidity and mortality, 2 and likely in part mediate the racial/ethnic disparities in COVID-19 mortality. The origins of disparities in the acute COVID-19 pandemic mirror those in the chronic obesity pandemic and are rooted in early life.

Racial/ethnic and socioeconomic disparities in obesity are already apparent by early childhood, and are rooted in multiple social, economic, and environmental factors that impact health and health behaviors. Among children age 2-5 years, 16.5% of Hispanic/Latino and 11.6% of Black, non-Hispanic children have obesity, compared to 9.9% of White, non-Hispanic children. 3 In comparison to healthy weight counterparts, children with overweight or obesity by age 5 years carry higher obesity risk into adolescence. 4 As a result, 20.6% of adolescents age 12-19 years have obesity, with Hispanic/Latino and Black, non-Hispanic adolescents disproportionately burdened by obesity, severe obesity, and health complications of obesity. 3 The necessary closures imposed on educational, health care, and community settings to mitigate the spread of COVID-19 could very well exacerbate prevalence of obesity and its health complications.

As pointed out by Rundle and colleagues, 5 widespread closures of schools and afterschool programs are likely to perpetuate increases in childhood obesity. Unhealthy diet, inadequate physical activity, excess screen time, and curtailed sleep are established behavioral risk factors for obesity.

Longitudinal cohort studies support racial/ethnic differences in these risk factors mediate racial/ethnic disparities in childhood obesity. Lack of access to healthy food, insufficient physical activity spaces and classes, disrupted sleep routines, and excessive screen use are likely accompanying widespread closures, thus potentially amplifying disparities.

Reports of established non-behavioral obesity risk factors, such as poverty, food insecurity, and stress, are also beginning to surface as downstream consequences of the COVID-19 pandemic and will likely exacerbate health disparities. Given the record high unemployment applications filed in the United States in early April 2020, 6 more families are likely facing poverty. At a population-level, public

This article is protected by copyright. All rights reserved health approaches to address food insecurity and equitable access to healthy food and physical activity options are required to prevent childhood obesity. However, children already afflicted by overweight or obesity require more intensive obesity treatment interventions.

Given the high prevalence of childhood obesity and persistent racial/ethnic and socioeconomic disparities in obesity, there is an urgent need to find telehealth solutions to provide intensive, familybased pediatric weight management during the time of COVID-19 closures. Without such interventions, the chronic pandemic of obesity will be exacerbated, particularly among disproportionately burdened populations, thus propagating a continual cycle of widening disparities.

Intensive behavioral interventions that provide at least 26 contact hours over 6 months are the most effective medically based weight management intervention for children age 6 years and older. 7 Therefore, children with obesity require intensive lifestyle modification and medical management that may include pharmacotherapy without in-person contact during COVID-19.

Some evidence supports the use of telehealth or mobile health interventions as an adjunct to pediatric weight management as feasible and cost-effective, 8, 9 but little data exists on the efficacy or effectiveness of exclusive telehealth for pediatric weight management. In the time of COVID-19 closures and physical distancing, telehealth has become a necessary default. In New York City, the current epicenter of the COVID-19 pandemic, we, the pediatric weight management programs at NewYork-Presbyterian, Columbia, and Weill Cornell, fully transitioned to telehealth weight management in March 2020. We primarily serve children who are racial/ethnic minorities or in lowincome households. Together, we created a cross-campus partnership to develop and implement virtual group and individual nutrition, physical activity, and mental health support in response to the COVID-19 outbreak.

Several advancements allowed for this rapid transition to telehealth weight management in our setting. First, use of a common electronic health record and ability of multiple providers to access telehealth visits simultaneously across multiple hospital campuses and universities allowed us to centralize resources to streamline remote health care and group session delivery. Second, changes to

This article is protected by copyright. All rights reserved telehealth billing rules allowed for care of patients across state lines and new patient care visits. This made it feasible for us to accommodate patients already scheduled who we may otherwise have needed to turn away. Third, the widespread use of mobile technology across all demographic groups makes telehealth possible for almost all of our patients. Finally, obstacles to participation in weight management programs, such as long-distance travel and childcare, are common in vulnerable populations. These barriers appear to be alleviated through use of telehealth in our urban setting. Prior to COVID-19, our benchmark show rate was 55-65% across our pediatric weight management programs. Between March 31, 2020 and April 16, 2020, the show rate for telehealth visits has been 76-89% across our pediatric weight management programs. These numbers should be interpreted with great caution, as the availability of patients and their parents will dramatically change when work and school resume. However, they do support the potential promise of telehealth in an urban pediatric weight management setting that serves predominantly racial/ethnic minority and low-income families.

Despite its promise, several challenges must be addressed to realize the potential effectiveness of telehealth weight management for vulnerable children.

1. Strategies to reduce the potential for digital technology disparities: Although smartphone ownership is similar across racial/ethnic groups, 61% of Hispanic/Latino and 66% of Black, non-Hispanic adults have high speed internet at home, contrasted with 79% of White, non-Hispanic counterparts. 10 The use of smartphone apps for patient portal and telehealth visits can help bridge the digital divide. However, lower income households may not have smartphones, and if they do, data storage and use limitations could pose obstacles. Health literacy and linguistic barriers can make it difficult for disproportionately burdened populations to navigate patient portals and electronic medical records. We call families at least a week in advance of their initial telehealth visit for approximately 30 minutes to discuss the telehealth visit, assist with installing and testing software, and explain the privacy risks and billing obligations.

2. Virtual approaches to address social needs and linguistic barriers are needed: During telehealth visits, we verbally screen for food insecurity using a 2-item screening tool and make

This article is protected by copyright. All rights reserved referrals to local food resources. 11 Some literature suggests that self-administered screening for food insecurity could improve validity of responses 12 Seamless integration of electronic self-administered screening tools in multiple languages could facilitate this process.

Simplifying access to interpreter services through telehealth platforms is also still needed.

3. Privacy and internet security concerns: Through continual discussions with legal teams and IT offices, we have identified platforms that safeguard security and meet regulations for patient privacy. To facilitate virtual group visits, institutions can identify a group visit platform that can be used for medical visits and disseminate instructions to providers on how to safely use those platforms.

visits with dietitians, physical activity specialists, and social work staff is still insufficient.

Phone visits provide limited reimbursement and there is no reimbursement for texting interventions, despite evidence of their effectiveness as adjuncts. 9 5. Effectiveness of primarily virtual pediatric weight management: Rigorous trials are needed to identify effective ways to deliver fully virtual, or mostly virtual, interventions that promote retention, adherence, and healthy weight. Valid and reliable methods to objectively monitor cardiometabolic health and weight outcomes in children remotely are needed.

Structural inequities have perpetuated health disparities for generations. The acute COVID-19 pandemic highlights these long-standing inequities. While telehealth will not eliminate all health disparities, it has the potential to play a crucial role in multi-pronged approaches to address childhood obesity in disproportionately burdened populations. Effective interventions via telehealth are needed to provide care during widespread closures for COVID-19 and -in the long-term -to overcome obstacles, such as transportation challenges, which hinder health care access among vulnerable populations. 13 Without effective interventions that can reach all children, the inter-generational cycle of obesity disparities will continue to widen, leaving children in disproportionately burdened

High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation. Obes Silver Spring Md

Differences in Obesity Prevalence by Demographics and Urbanization in US Children and Adolescents

Incidence of Childhood Obesity in the United States

COVID-19 Related School Closings and Risk of Weight Gain Among Children

The Unemployment Rate Is Probably Around 13 Percent. The New York Times

Screening for Obesity in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

An addiction model-based mobile health weight loss intervention in adolescents with obesity

Comparative Effectiveness of Clinical-Community Childhood Obesity Interventions: A Randomized Clinical Trial

Hispanics bridge some -but not all -digital gaps with whites

Development and validity of a 2-item screen to identify families at risk for food insecurity

Successes, Challenges, and Considerations for Integrating Referral into Food Insecurity Screening in Pediatric Settings

Transportation Barriers to Health Care in the United States: Findings From the National Health Interview Survey

populations at continued higher risk for morbidity and mortality throughout the current COVID-19 pandemic, and in future public health crises. This article is protected by copyright. All rights reserved