Pediatric Obesity: Provider Skill Sets for Improved Care

1. Pediatric Obesity: Provider Skill Sets for Improved Care Scott Gee, MD Kaiser Permanente February 18, 2010 French Camp, CA

2. Disclosure Pediatric Skill Sets for Improved Care • I have no relevant financial relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.” • “I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.”

3. Workshop Objectives • Provide the Vision for this Toolkit Plus Training • Provide tips for setting up your provider trainings • Review Toolkit Plus Training Materials • CMAF Child & Adolescent Obesity Provider Toolkit • Health Net/CMAF companion flip chart • Quick & Basic Training Guide & health education tools

4. Workshop Objectives • Explain why AMA Expert Committee & NICHQ pediatric obesity guidelines & recommendations support skill sets • Review Provider Role and Practice Pediatric Obesity Provider Skills: • BMI Screening • Preventive Counseling • Clinical Follow-up & Resources

5. Tips for Obesity Training • Regional or Community Wide CME Event • Weekday breakfast, lunch or dinner, Saturday morning • Good food more important than CME • Usually 1-2 hours long • Physicians, Nurses and Dieticians • Office Training • Lunch or dinner • Good food more important than CME • Usually 45 – 60 minutes long • Physicians, Nurses, and Medical Assistants • More effective with academic detailing • May be hard to set up a LCD projector 5

6. Obesity Training – Overcoming Challenges Lack of Patient Motivation & Provider Skills Not Enough Time No Reimbursement • Brief Focused Advice • Motivational Interviewing • Office Systems and Tools • Team Based Care • Coding Strategies • Advocacy 6

7. Obesity Training – Keeping It Simple • For All Children over 2 Years… • Measure BMI Annually • Provide Counseling Annually • For Overweight or Obese Children… • Order Lab Tests • Arrange for Treatment & Follow-Up

8. Recommended Lab Screening • BMI 85-94%ile Without Risk Factors- 2 Years and Older • Fasting Lipid Profile • BMI 85-94%ile Age 10 Years & Older With Risk Factors • Fasting Lipid Profile • ALT and AST • Fasting Glucose • BMI >= 95%ile Age 10 Years & Older • Fasting Lipid Profile • ALT and AST • Fasting Glucose • Other Tests as Indicated by Health Risks The AHA & AAP recommend screening at 2 years of age if there is a family history of lipid abnormalities or if risk factors are present in the absence of a positive family history Every 2 Years Every 2 Years 8

9. Treatment & Follow-Up Overview Treatment Goals Behavioral Goals and Parenting Skills Self Esteem and Self Efficacy BMI Velocity, Weight Loss Targets and BMI % ile A Staged Approach from the AMA Expert Committee - promotes brief, office-based intervention then a systematic intensification of efforts, tailored to the capacity of the clinical office, the motivation of the family, the presence of risk factors and the degree of obesity. Prevention Plus Structured Weight Management Comprehensive, Multidisciplinary Intervention Tertiary Care Intervention Families progress to the next stage if there has been no improvement in BMI/weight or velocity after 3-6 months and if the family is willing and ready.

10. A Staged Approach - Overview Stage 1 - Prevention Plus Family visits with physician or health professional Frequency individualized to family needs and risk factors Stage 2 - Structured Weight Management Family visits with physician or health professional with training in childhood weight management. Visits can be individual or group. May include visits with a dietitian, exercise therapist or counselor May include self-monitoring, goal setting and rewards Frequency monthly or individualized to family needs and risk factors

11. A Staged Approach - Overview Stage 3 - Comprehensive, Multidisciplinary Intervention Multidisciplinary team with experience in childhood obesity Frequency often weekly group sessions for 8-12 weeks with follow up Stage 4 - Tertiary Care Intervention (for select children only when provided by experienced programs with established clinical or research protocols) Medications - sibutramine, orlistat Very-low-calorie diets Weight control surgery - gastric bypass or banding (not FDA approved for children but in clinical trials)

12. NICHQ National Initiative for Children’s Healthcare Quality refined the AMA Expert Committee Recommendations into: Step 1: Obesity Prevention at Well Care Visits (Assessment and Prevention) Step 2: Prevention Plus Visits (Treatment) Step 3: Going Beyond Your Practice (Prevention and Treatment)

13. Obesity Algorithm

14. BMI Screening Module 1 See Pages 8-11 of the Training Guide Scott Gee, MD, FAAP

15. Why do we use BMI? Consistent with adult standards and tracks childhood obesity into adulthood BMI for age relates to health risks including cardiovascular disease, hypertension and type 2 diabetes BMI measurement is recommended by the AAP, CDC, IOM, AHA and USPSTF annually beginning at 2 years and older

16. What are the challenges of BMI? • Small errors in height measurement lead to large errors in BMI • BMI cannot distinguish between increased fat mass and increased fat-free mass (e.g., muscle mass) • Waist circumference may add greater specificity but there are not nationally accepted standards for children

17. BMI percentile during the measurement year as identified by administrative data or medical record review. ICD-9-CM Diagnosis - V85.5 Medical Record Review: Documentation must include a note indicating the date on which the BMI percentile was documented and evidence of either of the following. BMI percentile, or BMI percentile plotted on age-growth chart For adolescents 16–17 years, documentation of a BMI value expressed as kg/m2 is acceptable. HEDIS 2009… Weight Assessment

18. Expert Committee - Assessment Overview Medical Risks Height, Weight, BMI, Blood Pressure, Pulse Family History Review of Systems Physical Examination Laboratory Tests Behaviors and Attitudes Diet Behaviors Physical Activity Behaviors Attitudes

19. Measure BMI Annually Measure BMI annually for children 2-18 years Obtain an accurate height and weight Calculate BMI Plot BMI on BMI for age growth chart Make a weight diagnosis Communicate weight status to family Document the BMI Code weight status as a visit diagnosis (for Health Plans) ICD-9-CM Diagnosis - V85.5 For CHDP, use the CHDP Screening/Billing Report form, PM 160 to document BMI

20. Accurate Height and Weight Obtain an Accurate Height Measure to the quarter inch Shoulder blades, buttocks and heels all touching the measurement surface Child looking straight ahead, arms at side, toes straight and knees together Shoes off, feet flat and heels almost together Obtain an Accurate Weight Balance scale to zero Weigh in pounds to the nearest ounce Weigh in undergarments/gown/lightweight clothing Socks/bare feet

21. Calculate BMI & Make a Weight Diagnosis Calculate BMI BMI (English):[ weight (lb) ÷ height (in) ÷ height (in) ] x 703 BMI (metric):[ weight (kg) ÷ height (cm) ÷ height (cm) ] x 10,000 Make a weight diagnosis using BMI %tile for age < 5%ile Underweight 5-84%ile Healthy Weight 85-94%ile Overweight 95-98%ile Obesity >=99%ile Early Adiposity Rebound (4Y)

22. Practice Tools Make it Easier!!! Accurate Scale & Stadiometer CDC BMI for Age growth Chart BMI Wheel Calculator

23. What are more sensitive ways to address obesity and overweight? Obesity Overweight Fat or Chubby Weight is a very sensitive issue for children and adults. Weight or Extra Weight Body Mass Index (BMI) Increased Risk for Diabetes

24. Clinical Follow-up & Resources Module 3 See Pages 15-20 of the Training Guide Scott Gee, MD, FAAP

25. The Prevention Plus Visit

26. The Prevention Plus Visit (NICHQ) Review Labs Discuss Treatment Options and Referrals Motivational Interviewing or Brief Negotiation Cognitive Behavior Skills Arrange for Follow-Up as Necessary

27. Who needs a Prevention Plus Visit? All obese children Overweight children with other risk factors or co-morbid conditions Acanthosis nigricans Elevated blood pressure Suspected sleep apnea Other…

28. How often should visits occur? First Follow-Up Visit When lab results back and in-depth survey completed usually 1-8 weeks Format: in-person, sometimes by phone Subsequent Visits As needed based on risk factors conditions & readiness to change Frequency Range – 1 week to 2-3 months BMI checks – every 3-6 months (Z-Score if able) Format: in-person, phone, group, e mail (MD, NP, RD, HE) Families progress to structured weight management if there has been no improvement in BMI/weight or velocity after 3-6 months and if the family is willing and ready

29. Treatment Goals - Health Behaviors Lifelong healthy behaviors such as physical activity will improve health outcomes regardless of weight change Improving self esteem and self efficacy can also improve health outcomes Small consistent changes over time can make a big difference! Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap which leads to excess weight gain in some children. Changes in excess dietary intake (eg, eliminating one sugar-sweetened beverage at 150 kcal/can) may be easier to attain than increases in physical activity levels (1.9 hours walking for an extra 150 kcal). Pediatrics Vol. 118 No. 6 December 2006 pp. e1721-1733

30. Treatment Goals - BMI The long term BMI goal will need to be individualized based on risk factors and genetics BMI < 85%ile - Ideal long term goal BMI 85-94%ile - Some children can be healthy in this range Short term BMI goals will need to be individualized based on genetics, risk factors and the intensity of the intervention Decrease in BMI velocity Weight maintenance Weight loss Younger and more mildly obese children should change weight more gradually than older, more severely obese youth

31. Prevention Plus Visit Challenges Non-compliance with lab tests Non-compliance with follow-up visits Family readiness to change Perception by providers that the follow-up visit does not have enough content/substance to justify the cost

32. Improve compliance with the follow-up visit… Ask only high-risk patients to return. “I am very concerned about your blood pressure, can we re-check it in 2 weeks?” Ask about interest in returning. “Would be interested in returning in 1-2 weeks to discuss your lab results, treatment options and any issues you would like to work on?” Make a strong advice statement. “I am really concerned about your health and would like you to return in 2 weeks so we can discuss this further.” Ask about follow-up preferences. “Would you be interested in coming back for a follow visit or would a phone call be more convenient?

33. Using Resources & Materials Presenter: David Bodick, MPH Health Educator Office of Multicultural Health (OMH)

34. Disclosure Using Resources for Pediatric Skill Sets for Improved Care Nothing to disclose as to financial relationships or commercial interests

35. CHDP Community Program Resources Resource List for Prevention and Treatment of Child and Adolescent Overweight and Obesity The list identifies programs according to the type of service: Medical, Nutrition, Physical Activity and Behavioral Program Details of the program: age served, language(s) & cost Larger county programs update their lists quarterly

36. San Joaquin CHDP Resource GuideSample-available upon request

37. Community Program Resources Goal – Refer to community resources to extend provider counseling and improve outcomes Lifestyle support important for behavior change Link between clinical recommendations for wellness and community resources Motivates families and provides peer interaction/support

38. Community ResourcesAvailable in most communities WIC: New Healthy Habits Campaign Nutrition Network Programs Youth Programs: YMCA & YWCA Parks and Recreation Programs School and After-School Programs School Lunch University Cooperative Extension

39. WIC Healthy Habits Every DayOffered by all local WIC programs

40. CHDP Provider Toolswww.dhcs.ca.gov/services/chdp Available by downloading from the CHDP website Provider Office Training(supplement to training) Body Mass Index (BMI) Training How to Accurately Weigh and Measure Children for the CHDP Well Child Exam Counseling the Overweight Child Cholesterol and Glucose Screening (coming soon) Educational Tools(see handout section of Training Guide) BMI Job Aid: Body Mass Index for Age Percentile Counseling Flow Sheet: Counseling the Overweight Child Tips for Encouraging Behavior Change My Healthy Lifestyle Goal Tracker (Eng. & Sp.)

41. Medi-Cal Managed Care Health PlansPediatric Obesity & Patient Education Resource Guide-at your table Collection of contributed patient education materials from the health plans Multilingual patient education materials supplement the California Medical Association Foundation's Child and Adolescent Obesity Provider Tool Kit Please contact the health plan representative listed for each material regarding approval to use and/or modify the materials

42. Resource Guideof Health Education Materials Title of material Material type (brochure, poster, etc.) Topic (nutrition, physical activity or both) Target Audience & Grade Level Reading Level Languages

43. Resource Guide Brief Description & Format Full Color or Black & White Link to website or other ordering information (if available) Regularly updated Available on CHDP and Medi-Cal Managed Care Division’s websites in March 2010 Please contact Irene Reveles-Chase, MPH for more information: Irene.Reveles-Chase@dhcs.ca.gov

44. Workshop Post Evaluation In the next 4-6 months workshop participants will get an e-mail (Survey Monkey Link). Survey will include questions about: How you used your new training skills and materials Recommendations for future workshops. Evaluation information will provide us with valuable information about the usefulness of the training and to what extent the training was used by participants. Please submit your responses to Survey Monkey as soon as you receive it!

45. “Childhood obesity is no one’s fault, but it is everyone’s responsibility.” Dr. Phil McGraw Governor’s Summit on Health, Nutrition and Obesity – September 15, 2005