Keeping the ‘Yum’ While Fighting Obesity in Pediatrics

In the early days of the pandemic, Becca Saul, MSN, ACNP, remembers the alarm she felt as obesity rates among children were climbing.

“Everybody’s stuck at home, and the obesity numbers are just climbing, climbing, climbing because kids were so sedentary,” Saul, a primary care adolescent medicine specialist at health system Prisma Health in Greenville, South Carolina, said.

She began digging around websites with resources for clinicians treating children with obesity and came across doctoryum.org. With recipes, videos on nutrition basics, and a menu planner, Saul started using the resources to educate her patients and their caregivers about healthy eating during visits.

“I think it should be less expensive to be healthy than it is to be unhealthy, and it doesn’t cost my patients anything to use her product,” Saul said. “It’s also very user-friendly from the kids’ perspective.”

Today, approximately 1 in 5 children and teens in the United States have obesity. Rates of obesity in this population have increased over a decade alone, from 17.7% in the early years of the 2010s to 21.5% by 2020, according to a study published in JAMA Pediatrics.

With a growing recognition that clinicians needed help figuring out how to best treat these children, the American Academy of Pediatrics (AAP) in 2023 released updated clinical practice guidelines for treating children with obesity. The body recommends intensive health behavior and lifestyle treatment involving ≥ 26 hours of lessons on nutrition, physical activity, and behavior change over 3-12 months.

For many pediatricians, the guidance was welcome but also presented a challenge: How were they going to implement these lessons?

Later into 2023, the creator of doctoryum.org decided to help fill that gap.

Implementing the AAP guidelines

Pediatrician Nimali Fernando, MD, MPH, spent most of the 2010s in private practice in Virginia, where she noticed the challenges her patients and caregivers had in eating healthfully. She eventually created a teaching kitchen and garden in her practice, Yum Pediatrics, where developed tools, ideas, and lessons for helping families.

During the pandemic, she realized her website, doctoryum.org could be turned into something bigger. She retired from her practice in 2023 and launched Touchpoints, a multimedia, module-based program to help her colleagues implement the AAP recommendations.

She spent several months repackaging her material and writing scripts for pediatricians to guide them step-by-step through conversations with families. Modules include mindful meals, picky eating, food insecurity, and eating disorders.

“Pediatricians were very overwhelmed with that guideline,” Fernando said. Ideally, doctors would refer families to centers with multidisciplinary teams, “but in the real world, those clinics are largely overwhelmed and there are large areas of the country where they don’t have access to those kinds of programs, so the onus really falls on the pediatrician.”

Sarah Hampl, MD, an author of the guidelines and a professor of pediatrics at University of Missouri-Kansas City School of Medicine, said reception of the guidelines was overall positive. But in addition to figuring out how to implement an intensive lifestyle and behavior program into a busy practice, they needed to ensure reimbursement for this treatment, she said.

“Traditionally, there hasn’t been great insurance coverage of these because they’ve been perceived to be more educational programs when they’re really more health behavior change programs,” Hampl said.

That was the challenge that made Fernando realize what she could offer.

If insurers do not reimburse for intensive lifestyle and behavior programs, Saul said clinicians can bill an office visit for other comorbid conditions related to obesity. For example, many patients have foot pain, constipation, sleep issues, high cholesterol, or prediabetes.

“It allows a personal touch for a clinician who’s not had a lot of nutrition training and doesn’t feel comfortable giving the advice a dietitian would give,” Saul said. “There’s a scripted, formulaic way it can be delivered that you can expand on, or you can just stick to the script.”

Santhi Nair, MD, a pediatrician at ALL Pediatrics in Lorton, Virginia, and a founding board member of the Dr. Yum Project, said she conducts the program entirely over telehealth, often during evening hours from her home, which aligns better with most families’ schedules.

“Then you connect back for the next module and every month, you’re meeting with the family and building a relationship with the family,” said Nair.

Fernando said the program encourages telehealth visits, so the focus remains on the whole family instead of individual children.

“Coming out of the pandemic, there’s been a real uptick in eating disorders,” she said, “so we want to be as food-neutral and weight-neutral as possible.”

More than two dozen clinicians regularly use the annual subscription-based program, which costs $49 per month for a practice.

Fernando is also working with a researcher from UTHealth Houston to start a randomized control trial of body mass index changes among patients cared for by 35 pediatricians who use the program.

Those not using the program can access the original Dr. Yum website for free, including the Meal-o-Matic, a tool that helps families create basic recipes like soups or stir-fries using ingredients they have on hand. Saul said this is her favorite Touchpoints tool, one she uses with about one third of the patients she sees each day.

“The fact that they are the ones in charge of what’s being put in the food, their faces just light up,” Saul said. “Even kids who are reluctant to touch a vegetable are excited because they get to pick what goes into this recipe and then they see this recipe that they made.”

Saul supplements her use of the program with the HIPAA-compliant app Nourishly, a nutrition management app that allows secure provider-patient messaging and meal tracking.

“My patients respond with pictures of their food or how they’re feeling about what they’re eating or if they’re struggling with something,” she said.

One of her earliest patients, a 12-year-old named Gavin, first “came in feeling sad and dejected” because a specialist had told him “all of his problems were because he was too fat,” Saul said.

After going through the Touchpoints program, he is doing much better, she said.

Getting started

Pediatricians who are interested in deepening their care of children with obesity can start with the AAP, which can help pediatricians assess what they need, such as ensuring their staff has access to weight bias and stigma training and creating a private space for weighing patients.

“I think sometimes PCPs [primary care providers] have felt pretty helpless about the issue, like there’s no good resources in the community,” Hampl said. “But there are programs that can support PCPs who want their families to have access to more intensive options.”

The US Centers for Disease Control and Prevention also has a list of evidence-based weight programs for families that are prepackaged and ready to use.

For pediatricians just starting out in providing weight management, taking on two or three patients first is a good way to begin, Nair said. She also vets which families will benefit most from it.

“I only offer it to people that I think are motivated, who will work with me and commit to do the work,” Nair said. She gives families an intake form, which includes a 5-day food journal. Caregivers that do complete the materials likely do not have time for the program, Nair said.

Hampl said other providers in a clinic can also deliver an obesity management program. These might include nutritionists, nurses, dietitians, or lactation consultants.

“You cannot force people to want to change,” Saul said, “but if you make something easy for them and bring it to them, it’s much more likely that they’re going to adopt something that could be healthy.” 

Fernando is founder of the Dr. Yum Project and Touchpoints, and Nair is a founding board member of the Dr. Yum Project. Saul and Hampl reported no disclosures.

Tara Haelle is a health and science journalist based in Dallas.