Healthy Futures: Engaging the Oral Health Community in Childhood Obesity Prevention
 

Research Questions, Abstracts & Presentations


Keynote Presentation


Topic: Building Bridges: Actions to Promote Oral Health and Reduce Childhood Obesity

Speaker: Margo G. Wootan, D.Sc.

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Session I:
Provide an Overview of the Science


Research Question: What are the non-modifiable (socioeconomic, genetic, epigenetic, home environment, food preferences) and modifiable factors (physical activity, eating behaviors) related to childhood (under age 12) obesity? How can this knowledge be applied to oral health professionals' efforts to prevent or manage dental caries in children?



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Authors:

Donald Chi, D.D.S., Ph.D., Frances Chu, M.L.I.S., M.S.N., and Monique Luu, B.A.

Purpose: Studies have identified various risk factors for childhood obesity. These epidemiologic data from the literature have implications for future research and interventions in dentistry aimed at preventing obesity and dental caries in children. The purpose of the scoping review was to develop a conceptual model to identify non-modifiable and modifiable risk factors for childhood obesity, and to illustrate how these findings are relevant to preventing obesity and dental caries in children.

Methods: The authors searched Medline and Embase and limited their search to English-language publications. A total of 2,390 studies were identified. After, de-duplication, 2,354 studies remained and were downloaded into a citation-management tool. Two authors screened the titles and abstracts for relevance. Two-hundred-sixty-one studies remained and were retrieved for a full-text review and 76 studies were removed because of irrelevance, resulting in 185 studies that were included in the scoping review.

Results: The authors classified statistically significant risk factors for obesity as non-modifiable or modifiable. Non-modifiable obesity risk factors include biological (e.g., genetic markers, developmental disability, early onset puberty); developmental (e.g., disabilities, poor self-regulation); sociodemographic (e.g., minority race/ethnicity, lower levels of caregiver education, unemployment, low household income, caregiver incarceration, maternal age); and cultural characteristics (e.g., degree of acculturation). Modifiable risk factors include behavioral (e.g., poor diet, increased carbohydrate intake, inadequate physical activity, sedentary lifestyle); psychosocial (e.g., parenting practices, stress); and medical (e.g., caregiver obesity, maternal gestational diabetes and hypertension, post-partum weight gain, poor sleep, medication use). Understanding how these risk factors influence obesity in children has important implications for future oral health research aimed at reducing pediatric obesity and dental caries rates.

Conclusions: Epidemiologic knowledge gleaned from the literature can be used to develop more rigorous interventions and programs aimed at preventing obesity and dental caries in children and improving oral health outcomes for children





Research Question: What are the health-equity issues that relate to childhood (under age 12) obesity? How could oral health professionals and parents decrease the effect of health-equity issues on childhood obesity?

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Authors:

Clemencia Vargas, D.D.S., Ph.D., Elise Stines, D.N.P., C.R.N.P., and Herta Granado, B.S.

Purpose: The purpose of this scoping review was to identify the health-equity issues that are associated with childhood obesity and determine how to decrease the effects of health-equity issues to reduce childhood obesity.

Methods: The health equity issues related to childhood obesity were identified by analyzing the food environment, natural and built environment, and social environments, which are the factors that mediate the relationship between the macrosocial context and individual related to childhood obesity. The authors searched Medline, PubMed, and Web of Science using children and obesity as main keywords. For food environment elements, the authors conducted individual searches, adding the following terms to search strategies: food desert, advertising, insecurity, price, processing, trade, and school. For natural and built environment elements, the authors conducted individual searches, adding the following terms to search strategies: urban design, land use, transportation mode, public facilities, and market access. For social environment elements, the authors conducted individual searches, adding the following terms to search strategies: financial capacity/poverty, living conditions, transportation access, remoteness, social support, social cohesion, working practices, eating habits, time, and social norms. Inclusion criteria were studies or reports including children under age 12, conducted in the United States, written in English, and published in 2005 or later.

Results: The initial search based on titles and abstracts yielded 352 references; the final search yielded 39 references (16 for food environment, 11 for natural and built environment, and 12 for social environment). Most of the identified food environment elements were associated with childhood obesity; the exceptions were food insecurity and food deserts. A natural and built environment that hinders access to physical activity opportunities and access to healthy food increases the risk of childhood obesity. Similarly, a negative social environment was associated with childhood obesity. More research is needed on the effects of food production, living conditions, time for shopping, and physical activity on childhood obesity.

Conclusions: Most elements of food, natural and built, and social environments were associated with childhood obesity; the exceptions were food insecurity and food deserts. To reduce childhood obesity, health professionals, professional organizations, policymakers, and advocates should recognize and address health-equity issues in the community, in schools, and in the work place.






Research Question: In children (under age 12) does increased consumption of sugar-containing beverage result in excess weight gain?



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Authors:

Julie Frantsve-Hawley, R.D.H., Ph.D., Jim Bader, D.D.S., M.P.H., Jean Welsh, Ph.D., M.P.H., R.N., and Tim Wright, D.D.S., M.S.

Purpose: Multiple reviews, primarily of studies involving adolescents and adults, conclude that there is a positive association between consumption of sugar-containing beverages (SCBs) and obesity. SCBs includes sugar-sweetened beverages as well as beverages in which sugar is naturally present, such as 100% fruit juice. Whether this association holds true among children is not known. A systematic review was conducted to address this clinical question: Does increased consumption of (non-dairy) SCBs among children <12 years result in excess weight gain?

Methods: The authors searched the following databases for randomized controlled trials (RCTs) and cohort studies published in English through March 29, 2016: PubMed, EMBASE, Cochrane Database of Systematic Reviews, and CINAHL. The literature search yielded 2,886 unique citations. Initial screening (title and abstract) and full-text screening were performed independently and in duplicate by teams, with discrepancies screened by a member of the opposite team. Data abstraction and risk of bias assessment of included studies were also performed independently and in duplicate by teams. Risk of bias was assessed using the Cochrane protocol for RCTs, and a modified CASP protocol was used for cohort studies.

Results: Thirty-eight studies met the inclusion criteria for this systematic review. One of the included studies was an RCT (at high risk of bias), and 37 were cohort studies, including 4 studies designed initially as controlled clinical trials where the grouped data were collapsed for analysis as a cohort (risk of bias assessment: 4 high, 26 moderate, and 8 low). Substantial heterogeneity in populations, study designs, exposures, and covariates precluded planned meta-analyses. The evidence provided by the studies is mixed, but the majority found that SCB consumption in children <12 years at baseline is positively associated with total adiposity (19 out of 31 studies) and central adiposity (5 out of 6 studies). Conversely, the majority of studies that assessed 100% fruit juice consumption and either total adiposity (10 out of 15 studies) or central adiposity (2 out of 2 studies) do not support an association. Among young children only (<5 years at baseline), all studies examining SCB consumption (6 out of 6 studies) and a majority examining fruit juice consumption (4 out of 7 studies) demonstrated a positive association between consumption and total adiposity. No studies of this age group assessed the impact of consumption of SCBs on central adiposity.

Conclusions: Available low- to moderate-quality evidence is mixed but suggests that consumption of SCBs among children <12 years is associated with increased total adiposity and central adiposity. Consistently positive results with total adiposity indicate that children <5 years may be at greatest risk. Limited evidence on the association between the consumption of fruit juice and adiposity is inconclusive. Additional high-quality RCTs and/or well-designed long-term cohort studies are needed and could significantly alter these conclusions.





Session II:
Describe Actions Being Taken


Research Question: What can be learned from oral health professionals' efforts to address other systemic health issues (e.g., tobacco cessation, blood pressure management, diabetes management)? How can this knowledge be applied to their efforts to address childhood obesity?



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Authors:

Barbara L. Greenberg, M.Sc., Ph.D., Michael Glick, D.M.D., and Mary Tavares, D.M.D., M.P.H.

Purpose: The purpose of the scoping review was to focus on oral health professionals' (OHCPs') efforts to provide medical screenings and counseling that could guide the development of strategies to address childhood obesity in the dental setting.

Methods: The following databases were used (limited to English): PubMed, Embase, Cochrane, Grey Literature, and CINAHL; the following terms were used: oral health care professional or dental therapist or tobacco use cessation or diabetes or blood pressure or cardiovascular disease or oral-systemic disease or pediatric obesity or oral-systemic diseases or alcohol use or pediatric obesity or child obesity. Relevant articles were categorized according to the relationship to the question. Search results: four articles directly related to obesity screening by dentists, five articles on obesity and the role of the dentist, three articles on tobacco screening in a dental setting to help inform a potential model strategy, and fourteen articles providing background/support for medical screening in a dental setting.

Results: Four studies assessed OHCPs' current practices and attitudes related to obesity screening and counseling in a dental setting. The majority of dentists did not provide these services, but did recognize their value and would be willing to provide them. Major barriers to providing obesity screening and counseling were lack of trained personnel, fear of appearing judgmental, and fear of patient rejection. A majority of dentists (82%) would be more willing to offer counseling if obesity were directly related to oral disease. Among dental hygienists who implemented a healthy-weight intervention pilot, the majority felt that obesity screening and counseling in the dental office was important and did not require too much time. Almost all children and their parents or other caregivers reported that obesity screening and counseling were worthwhile and the dental office was a good place to get information on diet and exercise, and 32% felt that receiving obesity screening and counseling would make dental visits longer. Tobacco-screening studies reported that few OHCPs (<10%) received training on oral cancer screening and counseling, and few asked about tobacco use or provided counseling about nicotine-replacement therapy.Chairside medical screenings for diabetes and heart disease in dental settings can effectively identify patients who are at increased risk for these diseases but are unaware of their disease risk. Most OHCPs and patients have positive attitudes about medical screenings in dental settings.

Conclusions: Training is needed on the relationship of obesity and oral health and the role of oral health professionals in overall patient health and well-being. Studies need to be done that build on results from preliminary efficacy studies of childhood obesity screening by OCHPs.





Research Question: What are oral health professionals in practice and in public health settings currently doing to address childhood (under age 12) obesity (e.g., measuring heights and weights; plotting body mass index; providing nutritional counseling, including counseling to reduce consumption of sugar-sweetened beverages)?





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Research Survey: AAPD Survey on Childhood Obesity and Sugared Beverages

Authors:

Robin Wright, Ph.D., M.A., and Paul Casamissimo, D.D.S., M.S.

Purpose: Childhood obesity is a major health care concern in the United States, and oral health professionals have prime opportunities to be part of an interprofessional effort to intervene in the pediatric obesity problem due to their access to young patients and their abilities in addressing such obesity-related dietary habits as the consumption of sugar-sweetened beverages (SSBs). The purpose of the study is to determine the attitudes, current behaviors, future intentions, and perceived barriers of pediatric dentists regarding providing obesity-related information and other interventions to the parents of child patients, as well as providing information and other interventions about the consumption of SSBs.

Methods: The American Academy of Pediatric Dentistry, in conjunction with Nationwide Children's Hospital, conducted online electronic surveys with convenience samples of approximately 5,400 pediatric dentists and 1,000 pediatric dental residents during the spring and summer of 2016.

Results: Over 17 percent of pediatric dentists currently offer childhood obesity interventions. Of those not providing weight-related interventions, 67 percent were interested in offering the services. Nearly 94 percent of pediatric dentists offer information or other interventions on the consumption of SSBs. Statistically significant barriers to providing healthy weight interventions were fear of offending the parent, appearing judgmental, creating parent dissatisfaction, and a lack of parental acceptance of advice about weight management from a dentist. Barriers to the provision of SSB interventions were sufficient time in the clinical schedule and issues of provider and personnel education.

Conclusions: Although more pediatric dentists stated they offer childhood obesity interventions than in previous surveys, the low percentages suggest a child's weight is seen as a medical rather than a dental issue. The vast majority of pediatric dentists provide interventions related to the consumption of SSBs, perceiving the issue as integral to their practice and the care of children. Preferred intervention methods for obesity were chosen more for simplicity and speed (providing educational materials and noting signs of obesity in the patient chart) rather than proven effectiveness (offering motivational interviewing or behavior modification). The responses also suggest that pediatric dental interventions are propelled by market forces, particularly parent preferences and expectations. Provision of obesity and SSB interventions may be increased by more potential methods that add little or no time to a dental visit, more parents asking for information about healthy weight issues, increased education courses on both clinical content and communications skills, and clearer clinical guidelines on nutrition and obesity.





Research Question: What are examples of oral health professionals', community-based programs', oral health coalitions', and professional associations' and societies' efforts to influence health policy and advocacy efforts to reduce childhood (under age 12) obesity and reduce children's consumption of sugar-sweetened beverages? How could such efforts be leveraged, replicated, or expanded?






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Authors:

Ankit Sanghavi, B.D.S., M.P.H. and Nadia J. Siddiqui, M.P.H.

Purpose: While a large body of work documents the interconnections between oral health and obesity, much less is known about the role that oral health professionals and oral health professional organizations play to reduce childhood obesity, especially by influencing the consumption of sugar-sweetened beverages (SSBs). The purpose of this study was to (1) identify and describe efforts by oral health professionals and oral health professional organizations in influencing policy and advocacy efforts to reduce childhood obesity and consumption of SSBs and (2) inform future opportunities to leverage, replicate, or expand efforts to elevate the role of oral health professionals and oral health professional organizations in influencing childhood obesity reduction.

Methods: The authors conducted a two-phased scoping review to identify existing oral health studies, interventions, policy statements, and guidelines for reducing children's consumption of SSBs and preventing childhood obesity. Phase 1 involved a comprehensive review of peer-reviewed literature published between 2000 and 2016 utilizing key search terms such as oral health professionals, policy, child obesity, and SSBs. Phase 2 involved a web-based review of oral health organizations to identify obesity- and SSB-related programs, policy statements, and guidelines. Inclusion and exclusion criteria were applied. From these reviews, 36 unique citations were identified. After a full-text screening, 11 publications met the inclusion criteria. Both qualitative and quantitative data were extracted using a priori determined headings.

Results: A total of 6 peer-reviewed and 5 non-peer-reviewed publications were included in the review. Peer-reviewed literature included one descriptive study, two interventional studies, one causal study, and two policy statements or practice guidelines. These publications strongly suggest that oral health professionals can play a role in addressing childhood obesity, offering guidelines to support the effectiveness of interventions such as weight screening and nutrition counseling in pediatric dental office. The publications also cite barriers to fully embracing such interventions in oral health settings such as fear of offending the parent, appearing judgmental, and a lack of parental approval of information about weight management from a dentist. The non-peer-reviewed publications offer policy statements affirming the role of oral health professionals and oral health organizations in obesity prevention and resources for oral health professionals and the public on reducing children's consumption of SSBs (e.g., oral health curriculum for schools, Drink Pyramid).

Conclusions: This study affirms the growing recognition among oral health professionals and oral health organizations of their role in preventing childhood obesity and reducing consumption of SSBs. However, evidence of effectiveness of oral health professionals' actions, and the oral health professional organizations remains limited. This review offers new insights into how oral health professionals can be involved in influencing policy and advocacy efforts for obesity prevention and reducing children's consumption of SSBs. These include: increased and proactive engagement of oral health professionals and oral health organizations in practice and policy to reduce childhood obesity and consumption of SSBs; collaborating with other health professionals regarding patient care, dissemination of resources on healthy eating habits, and advocacy efforts; and pursing research to evaluate the effectiveness of existing practices, policies, and guidelines.





Research Question: What are dental schools and dental hygiene schools doing to promote knowledge and skills related to addressing childhood (under age 12) obesity and to reduce consumption of sugar-sweetened beverages? What else could these schools do to better equip future oral health professionals to address childhood obesity and to reduce consumption of sugar-sweetened beverages?







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Authors:

Kimon Divaris, D.D.S., Ph.D., Vaishnavi Bhaskar, B.D.S., M.P.H., and Kathleen McGraw, M.A., M.L.S.

Purpose: The purpose of the systematic review was to address the following questions: (1) What are dental and dental hygiene schools doing to promote knowledge and skills related to addressing childhood obesity and to reduce consumption of sugar-sweetened beverages? (2) What else could these schools do to better equip future oral health professionals to address childhood obesity and to reduce consumption of sugar-sweetened beverages?

Methods: The authors searched PubMed and Embase to identify peer-reviewed publications reporting on obesity or dietetic-related curricula in dental and dental hygiene education published within the last 20 years. Articles in languages other than English and continuing education papers for dental practitioners were excluded. Outcomes of the identified studies were abstracted and summarized independently by two investigators.

Results: Three studies met the inclusion and exclusion criteria. A 2009 survey of residents in 41 pediatric dentistry programs in the United States reported that approximately half of the respondents had a formal curriculum on managing obese pediatric patients but lacked other essential knowledge or skills (i.e., how to calculate body mass index). A 2013 study among Saudi Arabian dental students' knowledge about obesity described nutrition-related coursework given in the second year and supported expansion of education in this area. The third study reported on the development of an “oral health rotation” dietetic internship in the New York University pediatric dentistry clinic as an excellent opportunity for interprofessional education (IPE).

Conclusions: The importance of addressing childhood obesity and its nutritional correlates is frequently articulated by academic and professional agents, but evidence of curricular content and efforts specific to the pediatric population are scant in dental and dental hygiene education. Several opportunities exist to leverage existing resources and innovative, experiential approaches including IPE to formally and effectively address this important issue in predoctoral education in the oral health sciences.





Session III:
Explore What Is Needed to Support and Promote Involvement


Research Question: What are non-oral-health professionals (e.g., physicians, nurse practitioners, dietitians) in practice and in public health settings currently doing to effectively address childhood (under age 12) obesity and reduce consumption of sugar-sweetened beverages?





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Authors:

Diane Dooley, M.D., M.H.S., Nicolette M. Moultrie, R.D.H.A.P., M.S., Elsbeth Sites, B.S., and Patricia B. Crawford, Dr.P.H., R.D.

Purpose: This review examines recent evidence on effective primary care interventions to reduce pediatric obesity. Efforts to reduce sugar-sweetened beverage (SSB) consumption, a major contributor to childhood obesity and tooth decay, will be highlighted.

Methods: A multi-disciplinary team identified key search terms and reviewed 1,404 systematic reviews and primary source articles relevant to primary care treatment of obesity in children 0–11 years. Recent articles from PubMed, MEDLINE, major pediatric and obesity journals, the Cochrane Library, relevant websites, and reference lists from articles were included. After exclusion of 1,189 articles not meeting screening criteria, data were extracted from the remaining articles to assess effectiveness of individually based approaches and policy-oriented efforts.

Results: Effective interventions generally fell into four areas: family-based programs, motivational interviewing, use of electronic health systems and/or office tools for improved family communication, and interventions to change policy. The review showed that health professionals have few effective interventions to impact sugar-sweetened beverages consumption. Finally, evidence on industry influence on public health research and conferences is presented.

Conclusions:
The review demonstrates that primary care health professionals can play a crucial role in reducing pediatric obesity by linking effective clinical approaches targeting specific individuals and families with broader efforts to impact local and professional communities. The authors suggest that future research be conducted and pathways be identified for addressing barriers to full implementation of these effective practices. If widely adopted by both primary care professionals and oral health professionals, the identified effective practices have significant potential to synergistically impact pediatric obesity and dental caries, the two most common diseases of childhood.





Research Question: What skills (e.g., communication, counseling) and tools do oral health professionals need to effectively engage children (under age 12) and parents in implementing dietary changes that can prevent childhood obesity and consumption of sugar-sweetened beverages?





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Authors:

Lisa Mallonee, M.P.H., R.D.H., R.D., L.D., Linda Boyd, Ed.D., R.D.H., R.D., and Cynthia Stegeman, Ed.D., R.D.H., R.D., LD, CDE, FAND

Purpose: Increased consumption of sugar-sweetened beverages (SSBs) has been linked to obesity. The World Health Organization has issued guidelines advocating limiting intake of added sugars, which includes sugars in SSBs, to less than 10 percent of total caloric intake. The purpose of the scoping review was to examine studies that discuss skills and tools that oral health professionals can use with children and their parents to encourage dietary changes to aid in the preventing childhood obesity and reducing children's consumption of SSBs.

Methods: Key search terms were identified and used to examine selected databases via PubMed, EMBASE, CINAHL, and Cochrane Database of Systematic Reviews. Search terms included: dentist, dental hygienist, oral health professionals, counseling tools, advise and counsel, dentist healthy lifestyle, obesity, nutrition, behavior modification, communication skills, sugar sweetened beverages, and behavior change. Initially 582 citations were identified. A more focused search yielded 25 citations. A third search of peripheral studies identified an additional 25 citations. Of those, two were scoping reviews. After screening the combined 50 research and non-research materials, only 5 met the inclusion and exclusion criteria and were included in the review.

Results: Two studies presented a dental-office-based weight-intervention protocol. Patients responded favorably to education on healthy habits and weight maintenance in the dental setting, with 95.5 percent stating that they felt the dental office was a good place to get healthy eating and exercise information.Grey literature supports a role for oral health professional in sugar-cessation programs. A correlation was made between sugar-cessation programs and tobacco-cessation programs in dental settings, with the suggestion that sugar-cessation programs in dental settings could be as effective as tobacco-cessation programs have proven to be. Literature indicates that addressing SSB consumption would benefit not only oral health but also general health.It has been suggested that oral health professionals have an opportunity to expand their role in health care delivery by offering nutrition and physical activity recommendations to prevent and/or reduce chronic disease. Active listening and motivational interviewing were common tools and skills identified as techniques that can be used by oral health professionals to promote positive lifestyle changes.

Conclusions: Oral health professionals are uniquely positioned to address consumption of SSB and promote positive dietary habits for improved weight management. However, there is limited research on behavior-modification tools and skills that have been effectively implemented in the dental setting to address consumption of SSBs and weight management to decrease the risk of obesity. Future studies are needed to identify tools and skills that oral health professionals can integrate into preventive patient care.





Research Question: What is the role of insurers in oral health professionals' efforts to address childhood (under age 12) obesity and reduce consumption of sugar-sweetened beverages? What can be learned from insurers' other efforts to change behaviors?





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Authors:

Mary E. Foley, R.D.H., M.P.H. and Timothy S. Martinez, D.M.D.

Purpose: The purpose of the scoping review was to assess the role that health insurers play in promoting and ensuring the delivery of professional services aimed at preventing and managing childhood obesity.

Methods: Literature and resource searches were conducted via PubMed, CINAHL, and Google search. The primary endpoint was the impact of public and private health insurers on the delivery of professional pediatric obesity-prevention and weight-management services. Search terms included: childhood obesity, pediatric obesity, oral health, dental, dental insurance managed care, sweetened beverages, insurance, behavior modification, behavior change, prevention, health promotion, and patient education. The inclusion criteria included: articles written in English; published from 2000 to 2016; children and adolescents birth to age 20; and evidence of linkage between: obesity and health care, obesity and morbidity, obesity and health care insurance, obesity interventions, treatment for obesity, and provider practices/services. The exclusion criteria included: articles written in non-English languages, articles published in 1999 or earlier, adolescents aged 21 or over, and studies that lack focus on pediatric obesity.

Results: The search resulted in 3,629 studies with 73 articles meeting the inclusion and exclusion criteria. Review of the literature revealed that approximately 17% of U.S. children and adolescents are obese, with children and adolescents from low-income and ethnic minority groups experiencing disproportionate rates of the disease. Obesity-prevention interventions, treatment protocols, and health outcomes vary considerably across the states as benefits, coverage, reimbursement, and guidelines differ. Significant gaps exist in the health care system, which may inherently create barriers to care. Opportunities were identified that support the implementation of innovative models by insurers. The review found no evidence of existing models that demonstrated the role of insurers on oral health professionals' efforts to reduce consumption of sugar-sweetened beverages, however, opportunities for program modeling were identified under the Affordable Care Act (ACA) that prove promising.

Conclusions: Health insurers play a role in policy development, benefit design, service delivery, provider reimbursement, and potentially impacting health outcomes for children and adolescents at risk overweight and obese. Despite the fact that health insurers have not supported oral health professionals' efforts to reduce the consumption of sugar-sweetened beverages to date, opportunities exist under ACA to do so now. Under health care reform, insurers may broaden the health care workforce to include oral health professionals who are well prepared to fill the workforce gaps, and deliver stages 1 and 2 obesity screening, prevention, and counseling services. Insurers may also take the lead in promoting employer, health provider, and beneficiary engagement, as well as policy development that assures increased access to obesity treatment services for children and adolescents at risk for obesity.