 All right, and we are going to close the day with the pediatric weight clinic. Oh, yeah, the Center for Healthy Weight Just a clinical program Well after After this we're going to have more of a discussion going on so if you want to come up towards the front anyway, it looks like Sort of this desert out there I'd like you to move forward if you want also because you stand up Mary will be happy if you stand up because it's that post-prandial You know nap time okay, so for This discussion of clinical programs. I was Gonna talk about the clinical programs we have in pediatrics with the main purpose being for this group to Identify patient populations that we have available to do research Because some of you may want to work in pediatric populations and we're already doing some Collaborations with some of the participants different trials in some of our studies so that the Center for Healthy Weight was developed To try and bring together all of the resources around campus devoted to childhood obesity prevention and treatment and we have six areas within the the Center that we focus on the research patient care Community programs were not the mainly through the Lucille Packard Children's Hospital actually has community outreach and community programs that are Directly implemented in the community professional education courses like the CME course that were involved with coming up as well as resident and fellow education of course Advocacy for public policy change and through the hospital's Public policy office or government affairs office Working with advocating for legislation and other changes at the local regional national international levels and building a healthy Hospital as well and we put a lot of effort into trying to make the hospital a healthier place for patients parents and Visitors as well as the employees And believe it or not, it's it's almost tougher to change the hospital culture than it is to go change other institutions in the community But there are a lot of people trying to work on that. So we think of our What I think is the clinical programs as a is the we put our pyramid upside down here for this And we start with the the things the top or those with the highest volume Programs or where we reach the the highest number of people down to the lowest number of people affected Patients and on the opposite side it goes sort of the other direction from the lowest cost or from the highest cost at the bottom And intensity of treatment to the lowest cost the top so like BMI and WASER conference cost and intensity seem to be very highly correlated the Start with community programs generally are we're involved in in coalitions There are a number of them partnerships with individual community organizations and then diffusion of our research projects through the the SPRC Health Promotion Resource Center as well as a project we have going to try and do technical assistance in the community To to promote evidence-based Activities in with community organizations, but that's the the broadest reach we have in terms of these Clinical programs then our pediatric weight clinic, which is the closest to a traditional clinic setting Is where we do mainly as what you expect diagnosis referral management follow-up We meet actually one physicians are there one half day a week in addition We have a second half day per week in which there's diet Counseling from dietitians as well as nurse practitioner social work and psychologists And so overall we see patients two half days per week. It's all a referral patient population We get about a hundred. We see about a hundred to a hundred and fifty new patients per year And have about seven hundred eight hundred and visits eight hundred fifty visits per year That's over the last three years. It's range from seven hundred eight hundred and fifty So it's averaging about four to five visits per patient per year They get an initial comprehensive assessment diagnostic testing for causes and comorbidities Many of them get additional subspecialty referrals the one thing I often say is if you come to our clinic We you leave with more diagnoses than you come in with Because in fact we do find quite a bit of for example a fatty liver disease and other complications even in young children Behavioral counseling occurs through our clinic through the dietitians and the physicians as well as all the evaluations for bariatric surgery At this point. We're really overwhelmed with the demand in the community. So even with two half days a week And at least one half day for new patients We're saying the the wait list currently is a hundred and seventy five patients as of this month Who are waiting to get in an offense spans about six months to get in the clinic So we're working with different models for how to try and reduce that weight Because we actually don't have the resources to be able to increase the volume necessarily much more than that Behavioral treatment programs Primarily the main behavioral treatment program is the Packard pediatric weight control program And that's been going on for probably almost 15 years now. We started it as part of a research project It became a clinical program. It's modified from Len Epstein's traffic light Family-based group behavioral program So we see families in groups We have groups for eight to 12 year old and 13 to 15 year old English speaking families as well as eight to 12 year old Spanish speaking families they have to have a BMI over the 95th percentile or 85th percentile with co-morbidities associated with it both the child and the parent must want to attend and agree to attend the sessions it is They put on here. It's 25 sessions over six months. So it's weekly sessions for six months So fairly intensive And oh, yeah, it is six months of weekly meetings mean percent overweight at the start is 71 percent Ranging from about 27 percent to a hundred and 42 percent So that means the average patient coming into this program starts out with a BMI that is 70 percent 70 percent Greater than what we expect them to be for their age and sex and in kids As you probably know BMI changes with age So we can't just draw a cutoff of 25 or 30 or 35 So it changes with age normally and so we base it upon There the relationship to what we expect their BMI to be the the median BMI at the age for their age and sex according to national standards The the financing for at this point is is either self-pay or financial assistance or scholarships or through research studies up to now in terms of the Excluding research studies about 80 percent of the families get some type of financial assistance and that's through the hospital Mainly we don't have any payers that have been willing to pay for this We had a trial at one point with Santa Clara family health plan, but that it ended It's basically Something that no one agrees to pay for none of the third-party payers, which is a major problem The our results. This is just a about 200 patients I think it's about 200 patients shown as like Christopher did and sort of the whole range of weight Changes over time here. This is not weight but change in percent over weight. And so we see it ranges from close to 40 percent reduction, so that'd be from say double the expected weight to only 60 percent over the expected weight type of thing so 40 percent reduction up to Minority of kids who continue to gain weight even through the program, which is not unusual of course and the The the the the lighter gray bars or the Spanish speaking Patients in this cohort to show you that they're really we get similar effects in both Spanish and English speaking groups 85 percent which is really amazing for 85 percent complete the entire six-month program or complete the six-month program in the literature Most programs have about a 50 percent dropout within the first month or with by the second visit usually 85 percent of completers decrease their weight The mean change in percent over weight has been minus eight although now I think it's more like around minus ten and And in more than 75 percent of the overweight parents lose weight an average of about five pounds with a maximum has been 45 pounds and that's been a real bonus even though we don't concentrate at the parents at all on treatment It's all focused on the kids. Also. We've seen a significant reduction in depressive symptoms Drug and behavioral clinical trials we had a Metformin trial for adolescents that is now completed. That was one study that's done We also these are two ongoing trials that we're recruiting for now if you happen to know any families Who want to participate and here one is involves the family-based group behavioral treatment in addition to half the families are randomized to home coaching to change their eating and screen time environments in the home And they're followed for a total of 18 months with six months of sort active treatment And then the new Stanford goals trial of which we're just now recruiting for a pilot project with 40 new participants Over the 85th percentile and this is moving treatment from the clinical setting to the community setting in which They will be involved in after-school team sports home visits the same type of home coaching visits and a primary care physician intervention which they will receive as well and that is Contrasted with a group randomized to health education More standard health education and that is going to be a three-year intervention and follow-up Which is pretty unprecedented as well and that's going to be 240 families when we get that up and rolling totally Intensive medical treatment is something we haven't done much of but that would be for example hospitalizing patients with on The protein modified fast for example or doing outpatient protein modified fast Our neurologist use those quite a bit for for seizures We have not been using them a lot people usually regain the weight on those They're very difficult to stick with for them, but it's something that we would use in in situations where there are Complications and and patients are not either severe enough or not candidates for surgery and finally Bariatric surgery and it's too bad John's not here because he John Morton as well as Craig Albany's the head of Pediatric surgery do the bariatric surgery? Program we were the first children's hospital to offer a gastric bypass surgery to adolescents first in in California with the idea being Not only did we have a skill set for that? But we wanted to make sure it was pediatric specialists doing the care of patients if they were going to get bariatric surgery This is only children. We really have life-threatening complications of their of of their obesity and To date we have done about 40 operations I think since 2004 So it's not like we're we're doing as many as or anywhere near that the number that you're doing in adults Or even any where near some of the bigger centers are doing like Cincinnati Children's does the most And in actually the most popular operation now Is the gastric sleeve about I think about half the patients are doing gastric bypass after doing the sleeve operations now Which is different where they don't I think get as much weight loss, but we'll see John's really the expert on that Do but it's also it's an easier operation to perform I believe for them and luckily we've yet to have any severe complications in any of these kids because that's something that we're Very concerned about as well So those are the clinical programs that really make up the the Center for Healthy Way And so hopefully there are there are adolescent and childhood populations out there patient populations who are All very interested in participating or many of them very interested in participating in clinical trials or other research as well And we have a number of of other projects that have gone on So if you have interest in in using these populations for research As participants in research Please let us know because it's a good resource and they certainly need the the services and the and the help So that's it. 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