Building Effective Partnerships to End Childhood Obesity

Stephen Cook, MD, MPH,

Golisano Children’s Hospital at URMC

Disclosures

Grant funding: • NYS Dept of Health,

• Children’s Institute,

• NIH CBPR project

Boards: ABOM, AAP IHCW

..…and I used to work at a TJ’s Big Boy

Host a Community Screening

Declining childhood obesity rates — where are we seeing the most progress?

4

DISPARITIES PERSIST

To date, only Philadelphia has reported major progress in closing the disparities gap.

Stigma of Childhood Obesity

“The lot of fat children is a sad one. They are bashful and

ashamed of their shapeless figures, yet unable to conceal

them. Wherever they go they attract attention…..Obesity is

a serious handicap in the social life of a child, even more so

of a teenager. Obesity does not have the dignity of other

diseases…”

5Bruch H. Pediatric Annals: 1975

Adolescents’ Perceptions of Peers Being Teased or Bullied: The Reason Why

6

Perceptions of weight-based victimization among N=1555 high school students in Connecticut

Percentage of teen girls who report frequent weight teasing

7

Neumark-Sztainer. J Adolesc Health.

2009;44:206-213.

ObesityAlgorithm

1) Example – medical risk or behavioral risk

2) 10 years and older every 2 years

3) Progress to next stage if no improvement in BMI/weight after 3-6

months and family willing

4) Age 6-11yr = 1 lb/month, Age 12-18yr = 2 lbs/week average

5) Age 2-5yr = 1 lb/month, Age 6-18yr = 2 lbs/week average

Healthy Weight

BMI 5-84%ile

Overweight

BMI 85-94%ile

Obese

BMI 95-98%ileBMI >=99%ile

Assess Behaviors & Attitudes - Eating, Physical Activity, Sedentary Time, Motivation

Assess Medical Risks - Family History, Review of Systems, Physical Examination (BMI, BP)

Assess Fasting Lipid Profile

YesNo

Assess ALT, AST, Fasting Glucose(2)

Other Tests as Indicated by Health Risks

Prevention Counseling - Empathize/Elicit - Provide - Elicit

Stage 1 Prevention Plus(3)

Stage 2 Structured Weight Management(3)

Stage 3 Comprehensive Multidisciplinary Intervention(3)

Stage 4 Tertiary Care InterventionTreatment

Prevention

Assessment

Health Risks?(1)

Maintain Weight Velocity & Reassess Annually

Maintain Weight or Gradual Loss(4) &

Reassess Every 3-6 Months

Maintain Weight or Decrease Velocity & Reassess Every

3-6 Months

Gradual to Moderate Weight

Loss(5) & Reassess Every 3-6 Months

9

10

Children and Adolescents age 2 to 18 years of age

In Our Backyard

11

12

Health Foundation Healthy Weight Strategy

GOAL: Reduce the prevalence of overweight and obesity from 15% to 5% of Monroe

County children ages 2-10 by 2017

[from 12,144 kids to 4,081 kids]

GOAL: Reduce the prevalence of overweight and obesity from 15% to 5% of Monroe

County children ages 2-10 by 2017

[from 12,144 kids to 4,081 kids]

Increase physical activity and

improve nutrition

Engage the clinical

community

Advance policy and practice

solutions

Execute a community

communications campaign

Evidence-based Behavioral Strategies

•Breastfeed

•Limit sugar-sweetened beverages

•Consume the recommended fruits and vegetables

•Eat daily breakfast

•Limit fast food

•Use appropriate portion size

•Eat meals together as a family

•Limit television and screen time and keep televisions out of children’s bedrooms

•Encourage moderately vigorous physical activity of 60 min/day or more

•Ensure adequate sleep; 1-3yr: 12hr, 3-5yr: 11hr, 5-12: 10hr and try to get teens

after 8.5 hrs of sleep at night

13

Parents estimation of child’s weight status vs. measured weight, 2-9yo

14

Estimation of weight 193 parent/child dyads from Strong Pediatrics

Tschamler, et al, Clin Peds, 2010;49:470

GROC Breakthrough Series (12 Months)

Select Topic

Planning Group

Develop Framework & Changes

Participants

Pre-work

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Expert Meeting

Stages of Improvement

-test

-implement

-hold the gain

-spread

Beyond LS 3

How well do successful teams “hold the gains”

after LS3?

Supports

-Emails

-Office Visits

-Phone Conferences

-Monthly Team Reports

-Assessments

Borrowed from IHI

16

17

18

19

Percentage of Charts With Counseling on Nutrition and Physical Activity

95% 95%

0%

20%

40%

60%

80%

100%

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11

Cycle 1

Cycle 2

Goal

Some Results from Our Practices

20

OBESITY CHRONIC CARE MODELSelf Management

SupportDecision Support

Delivery System Design

Clinical Information Systems

Emphasize the patient’s central role

Organize resources to provide support

Use effective self-management strategies that include assessment, goal setting, action planning, problem solving, & follow up

Embed evidence-based guidelines into daily clinical practice

Integrate specialist expertise and primary care

Use proven provider education methods

Share guidelines and information with patients

Define roles and distribute tasks among team members

Use planned interactions to support evidence-based care

Provide clinical case management service for high risk patients

Ensure regular follow-up

Give care that patients understand and that fits their culture

Provide reminders for providers and patients

Identify relevant patient sub- populations for proactive care

Facilitate individual patient care planning

Share information with providers and patients

Monitor performance of team and system

Healthy Weight

BMI 5 - 84%ile

Overweight

BMI 85 - 95%ile

Obese

BMI 95 - 98%ileBMI >=99%ile

Healthy Weight

BMI 5-84%ile

Overweight

BMI 85-94%ile

Obese

BMI 95-98%ileBMI >=99%ile

Assess Behaviors & Attitudes - Eating, Physical Activity, Sedentary Time, Motivation

Assess Medical Risks - Family History, Review of Systems, Physical Examination (BMI, BP)

Assess Fasting Lipid Profile

YesNo

Assess ALT, AST, Fasting Glucose(2)

Other Tests as Indicated by Health Risks

Prevention Counseling - Empathize/Elicit - Provide - Elicit

Stage 1 Prevention Plus(3)

Stage 2 Structured Weight Management(3)

Stage 3 Comprehensive Multidisciplinary Intervention(3)

Stage 4 Tertiary Care InterventionTreatment

Prevention

Assessment

Health Risks?(1)

Maintain Weight Velocity & Reassess Annually

Maintain Weight or Gradual Loss(4) &

Reassess Every 3-6 Months

Maintain Weight or Decrease Velocity & Reassess Every

3-6 Months

Gradual to Moderate Weight

Loss(5) & Reassess Every 3-6 Months

Primary Care Setting ?

22

3yr old WCC w/ pt Not Mykid

23

Pt NW, first seen at 3yrs and noted to be obese

PNP informed pt in ‘Red zone’ as unhealthy. Can we discuss?

24

Pt MN

Dr. Colpoys at Genesee Pediatrics

Penfield Pediatrics

Unity Pediatrics

More Unity Pediatric Pics

29

Monroe County, NY – Estimated Birth Cohort = 1,015

Cycle 3 56.0% n= 26

Cycle 2 46.3%

(n = 17)

Extent of Community Reach

Cycle 1 24.8%n=9

30

OBESITY CHRONIC CARE MODEL

Community Resources and Policies Health Care Organization

Encourage patients to participate in effective programs

Form partnerships with community organizations to support or develop programs

Advocate for policies to improve care

Visibly support improvement at all levels, starting with senior leaders

Provide incentives based on quality of care

Promote effective improvement strategies aimed at comprehensive system change

Encourage open and systematic handling of problems

Development of agreements for care coordination

31

Results

Monroe County, NY

5.0% - 10.0%

10.1% - 15.0%

15.1% - 20.0%

20.1% - 24.0%

Obesity by Neighborhood

Healthy Food

Source

Unhealthy Food

Source

RFEI =

Maps of Parks and Recreation Centers

32

Rec on the Move

33

“Rec on the Move” comes to the Doc Office

34

Foodlink Curbside Market

35

36

Additional Partners / Tools

37

Pediatric e-Practice: Optimizing Your Obesity Care

Healthy Active Living for Families

Structured Weight Management

AAP & Academy of Nutrition

and Dietetics (former ADA):

• Set of visits with PCP and RD

• Based on motivation at start

• Self monitoring and uses

tracking forms

One City’s “Communities of Solution”

41

Note: Political boundaries, shown in solid lines, often bear little relation to a community’s problem-sheds or its medical trade area.

Adopted from Folsom M. Health is a Community Affair: Report of the National Commission on Community Health Service, 1967

Next steps

• Pediatric Primary Care Practices and using EMR

• Writing reports for data collection

• CDC piloting EMR templates for surveillance

• Linking Resources in Community with Patient Centered Medical Home

• STRONG Pediatrics has medical home designation

• RGH completing pediatric medical home

• Highland FM and Anthony Jordan

• Create Linkage and Test Stage 2: Structured Weight Managment

• STOP Obesity Alliance: Community Health Benefit

• Children’s Hospital Association: Focus on a Fitter Future / Stage 3:CMWM

42

4343

4444

Thank you

Department of Pediatrics, GCH@URMC