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Tuesday, February 28, 2012 2:00 PM – 3:30 PM EST

BPHC Enrichment Series for Grantees: Stepping Up to Healthy Weight: Reducing and Preventing Overweight and Obesity in Health Center Populations. Tuesday, February 28, 2012 2:00 PM – 3:30 PM EST. Stepping Up to Healthy Weight: Learning Objectives. Define healthy weight

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Tuesday, February 28, 2012 2:00 PM – 3:30 PM EST

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  1. BPHC Enrichment Series for Grantees:Stepping Up to Healthy Weight: Reducing and Preventing Overweight and Obesity in Health Center Populations Tuesday, February 28, 2012 2:00 PM – 3:30 PM EST

  2. Stepping Up to Healthy Weight: Learning Objectives • Define healthy weight • Identify importance of maintaining a healthy weight • Identify challenges for maintaining healthy weight in health center populations • Describe grantee programs that have been successful at achieving healthy weight • Identify more TA Resources on healthy weight 2

  3. Agenda in Brief Welcome Dr. Sarah Linde-Feucht, HRSA Background: Identify Healthy Weight Dr. Robert Sigh, BPHC/HRSA Importance of Healthy Weight & Healthy Weight Challenges Dr. Shikha Anand, Staff Pediatrician, Codman Square Health Center; Director of Obesity Initiative, NICHQ Lessons from the Field Healthy Weight/Healthy Lifestyles, Deborah Horowitz, Care Process Coordinator, Adult Nurse Practitioner CAMcare Health Corporation, Camden, NJ The RiverStone Health Healthy Weight Collaborative John Felton, President & CEO / Health Officer Hilary Hanson, Director of Population Hearth Services / Deputy Health Officer Dr. Megan Littlefield, Medical Director RiverStone Health Clinic, Billings, MT 3

  4. Healthy Weight Overview Robert Sigh, MD Senior Clinical Advisor, North Central Division U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care 4

  5. National Obesity • 20 years ago no state had an obesity • rate higher than 20% • In 2010, no state had an obesity rate lower than 20% • The US average is roughly 33% obese 5

  6. Defining Obesity Calculate BMI: Weight (lb) / (Height (in) x Height (in)) x 703 6

  7. The Trouble with Obesity • Nearly ½ of HC patients are obese • Obesity accounts for 2/3 of Type 2 diabetes, as well as drives hypertension, high cholesterol, heart disease, stroke, osteoarthritis, certain types of cancer and more • Cost the US $147 billion in 2009, double from 1999 • Loss of life expectancy of 8-10 years, same as smoking! OBESITY 7

  8. Health Center Program Overview Calendar Year 2010 77 Million Patient Visits 1,124 Grantees 8,100+ Service Sites Over 132,000 Staff 9,500+ Physicians 6,300+ NPs, PA, & CNMs 19.5 Million Patients • 93% At or Below 200% Poverty • 38% Uninsured • 62% Racial/Ethnic Minorities • 1.1 Million Homeless Individuals • 863,000  Migrant/Seasonal Farmworkers • 173,000  Residents of Public Housing 8 Source: Uniform Data System, 2010

  9. Quality Terms Diagram Department, broad vision based on the three aims Bureau’s vision to implement NQS, improve FQHC care Grantee level processes, including operational and financial Actionable items (QI/QA plan, risk management systems, etc.) 9

  10. Obesity Initiatives • Patient Centered Medical Home (focus on infrastructure and HIT support) • HRSA’s Healthy Weight Collaborative • 2 new healthy weight measures implemented in 2011 • Alignment with national initiatives (e.g., Million Hearts) • Continued focus on obesity related clinical measures (HTN, DM) 10

  11. Clinical Quality MeasuresUniform Data System (UDS) Clinical Measures Previous Measures New for 2011 Child & adolescent weight assessment & counseling Adult weight screening & follow up Tobacco use assessment & counseling Asthma therapy (pharmacologic) • Low birth weight babies • Entry into prenatal care • Childhood immunization • Pap tests • Adult hypertension (blood pressures) • Adult diabetes (HbA1c levels) 11

  12. Resources for Obesity • Accreditation: http://bphc.hrsa.gov/policiesregulations/accreditation.html • PCMHHI: http://bphc.hrsa.gov/policiesregulations/policies/pal201101.html • Health Weight Collaborative: http://www.collaborateforhealthyweight.org/ 12

  13. Robert Sigh, MD Senior Clinical Advisor U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care North Central Division 5600 Fishers Lane, 15C-26 Rockville, MD 20857 Telephone: 301-594-4131 rsigh@hrsa.gov Thank you! 13

  14. Obesity in Community Health Centers Shikha Anand, MD, MPH Director of Obesity Programs National Initiative for Children’s Healthcare Quality Pediatrician, Codman Square Health Center 14

  15. The Concern • More than one-third of children ages 10–17 are obese (16.4%) or overweight (18.2%). • State-specific rates ranged from a low of 9.6 percent in Oregon to a high of 21.9 percent in Mississippi. • A 2009 study by the Centers for Disease Control and Prevention found that the direct and indirect cost of obesity "is as high as $147 billion annually" or 9.1 percent of medical spending in the US. • Relationship to diabetes, hypertension, cardiac disease, hyperlipidemia, depression. • Poor and minority children are disproportionately overweight and obese. 15

  16. HP 2020 Determinants of Health 16

  17. Factors that Impact Obesity in Underserved Communities • Limited access to healthy affordable foods • Food Deserts – limited numbers of full scale grocery stores • Limited access to fresh produce through farmers markets and other outlets • Easy access to unhealthy foods • Increasing portion sizes • Unhealthy foods prevalent in schools and workplaces • Abundance of unhealthy foods in drug stores, convenience stores, bodegas • Targeted marketing of high-energy-dense foods and sugar drinks 17

  18. Factors that Impact Obesity in Underserved Communities • No safe and appealing place in many communities to be active • High rates of television and media use, limiting physical activity • Limited community support for breastfeeding • Effect of parenting styles/skills impacting feeding behaviors/ food choices for children • Cultural barriers to weight loss – body image, food insecurity 18

  19. Impact on CHCs • Fewer than one of five overweight patients were told they were overweight by their provider. • Slightly over half of obese patients reported being told they were overweight by their provider. • Patients told they were overweight by a health provider were almost nine times as likely to believe their weight was damaging to their health as those who were not told this. • After adjusting for provider advice regarding weight status, both Non-Hispanic Black and Hispanic patients were half as likely as white patients to believe their weight was damaging to their health. N. H. Durant, B. Bartman, S. D. Person et al., "Patient Provider Communication About the Health Effects of Obesity," Patient Education and Counseling, published online Nov. 26, 2008 19

  20. Obesity Measures • Meaningful Use/ UDS • Children: Percentage of patients aged 2 to 17 for whom BMI percentile, counseling for nutrition, and counseling for physical activity are documented • Adults: Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented 20

  21. Obesity Measures • HEDIS • Children: Children ages 3–17 years who had an outpatient visit with a PCP or OB/GYN and evidence of BMI percentile documentation, counseling for nutrition, counseling for physical activity and counseling for screen time during the measurement year • Adults: Percent members 18-74 years of age who had an outpatient visit and who had their BMI documented during the measurement year or the year prior the measurement year 21

  22. What You Can Do in Your CHC • Incorporate obesity prevention, and management into preventive visits • Conduct planned visits, consider using team-based care • Understand resources in your community for healthy eating and active living, including farmers markets, CSAs, parks, community walks, other organized programs for physical activity • Partner with community programs to promote healthy eating and active living – CHC-based physical activity programs, farmers market prescriptions, etc. • Advocate for policy, systems and environmental changes 22

  23. Preventive Visits For all patients: • Obtain BMI, consider waist circumference in adults • Assess weight status (underweight, healthy weight, overweight, obese) • Provide information about recommended eatingand activity (also consider breastfeeding and sleep) For patients who are overweight or obese: • Assess patient/ family readiness to make changes • Assess comorbiditiesand determine treatment based on algorithm • Create a healthy weight plan including lifestyle goals, treatment, and plan for follow up 23

  24. Assessing and Classifying BMI • Remember to measure height • Calculate BMI (weight in kg/ height in m2) • In children: use age and gender based CDC curves for BMI percentiles, available at: http://www.cdc.gov/growthcharts/clinical_charts.htm • In adults: • Underweight <18.5 kg/m2 • Normal weight 18.5–24.9 kg/m2 • Overweight 25–29.9 kg/m2 • Obesity (Class 1) 30–34.9 kg/m2 • Obesity (Class 2) 35–39.9 kg/m2 • Extreme obesity (Class 3) ≥40 kg/m2 http://www.nhlbi.nih.gov/guidelines/obesity/prc 24

  25. Dietary Recommendations Fruits and Vegetables: • Make half of each plate fruits and vegetables • 5 servings of fruits and vegetables per day • Fresh is better than frozen which is better than canned Grains: Make at least half of grains whole Beverages: • Drink water instead of sugary drinks • Switch to fat-free or low-fat (1%) milk Portion Control: • Enjoy your food, but eat less, consider reducing plate size • Avoid oversized portions: buffets, supersize http://www.choosemyplate.gov/food-groups/downloads/MyPlate/MyPlateCommunityToolkit.pdf 25

  26. Activity recommendations Children1: • 60 minutes (1 hour) or more of physical activity daily • 120 minutes (2 hours) or less of screen time daily Adults2: • All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week. • Initially, encourage moderate levels of activity for 30 to 40 minutes per day, three to five days per week. • Set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week. • http://www.cdc.gov • http://www.nhlbi.nih.gov/guidelines/obesity/prc 26

  27. Moderate Physical Activity Examples Common Chores Sporting Activities Playing volleyball for 45–60 minutes Playing touch football for 45 minutes Walking 1 3/4 miles in 35 minutes (20 min/mile) Basketball (shooting baskets) for 30 minutes Bicycling 5 miles in 30 minutes Water aerobics for 30 minutes Swimming laps for 20 minutes Basketball (playing a game) for 15–20 minutes Jumping rope for 15 minutes Running 11/2 miles in 15 minutes (15 min/mile) • Washing and waxing a car for 45–60 minutes • Washing windows or floors for 45–60 minutes • Gardening for 30–45 minutes • Wheeling self in wheelchair for 30–40 minutes • Pushing a stroller 1 1/2 miles in 30 minutes • Raking leaves for 30 minutes • Walking 2 miles in 30 minutes (15 min/mile) • Shoveling snow for 15 minutes • Stairwalking for 15 minutes 27

  28. Evaluating Readiness/ Goal Setting • Evaluate readiness: • reasons and motivation for weight loss • previous attempts at weight loss • support expected from family and friends • understanding of risks and benefits of weight loss • attitudes toward physical activity • time availability • potential barriers to the patient’s adoption of change • Consider motivational interviewing techniques • Set self-management goals • Consider food and activity diary to develop discrepancies between goals and practice 28

  29. Weight Loss • Children: • For growing children, goal is to maintain weight and decrease BMI as height increases • For adolescents who are growing slowly or not at all, use adult recommendations • Adults: • Initially, attempt to reduce body weight by approximately 10 percent from baseline. With success, attempt further weight loss, if indicated, through further assessment. • Reduce weight at a rate of about 1 to 2 lb per week for six months. An individually planned diet creating a deficit of 500 to 1,000 kcal per day should be an integral part of any program aimed at achieving a weight loss of 1 to 2 lb per week. • Base subsequent strategies on the amount of weight lost 29

  30. Managing Obesity in Children Pediatric Treatment Guidelines PEDIATRICS Vol. 120 Supplement December 2007, pp. S164-S192 30

  31. Managing Obesity in Adults Pharmacotherapy • BMI ≥30 kg per m2 with no accompanying obesity-related risk factors or diseases, and for patients with a BMI ≥27 kg per m2 accompanying obesity-related risk factors or diseases. • Not effective after cessation of drug therapy. Surgery • BMI ≥40 kg per m2 or with a BMI ≥35 kg per m2 with comorbid conditions) when less invasive methods have failed and the patient is at high risk for obesity-related morbidity and mortality. • Snow V et al. Ann Intern Med 2005;142:525-531, http://www.nhlbi.nih.gov/guidelines/obesity/prc 31

  32. Planned Obesity Visits • Both adult and pediatric guidelines emphasize frequent follow up – planned obesity visits • Determine treatment response • Reinforce self-management plan and set new goals • Can be difficult to conduct in usual clinic flow • Consider team-based obesity care model • Care is reorganized so that provider, nutritionist and CHW are all accessible to family at the same time • Provider champion: cardiovascular risk assessment, family history review, lab analysis, physical exam, billing • Nutritionist: 24 hour food recall, skipped meal, sweetened beverage and fruit and vegetable consumption, billing • CHW: activity assessment, local activity resources • All: motivational interviewing/ health behavior change techniques, goal setting Anand et al, Health Aff April 2010 vol. 29 no. 4 712-717 32

  33. Beyond the Clinical Encounter • Partner with community and public health agencies to create innovative programs and consistent messages for families • Create more opportunities for healthy eating and physical activity at your CHC • Advocate for policy, systems, and environmental change in your community • Schools: Healthy food options, daily quality physical education • Community: • Encourage the food industry to provide reasonable food and beverage portion sizes • Encourage food outlets to increase the availability of low-calorie, nutritious food items • Create opportunities for physical activity in communities • Connect to a national movement 33

  34. Connect Nationally • Join a learning community • Childhood Obesity Advocacy Network (http://www.nichq.org) • Collaborate for Healthy Weight (http:// www.collaborateforhealthyweight.org) • RWJF Childhood Obesity Community (http://community.rwjf.org ) • NACCHO - Obesity in people with disabilities (http://www.naccho.org/topics/HPDP/healthdisa/learncomm.cfm) • Obesity Society (http://www.softconference.com/obesity/default.asp) • Use evidence based patient materials to reinforce your message • Eating Better on a Budget: (http://www.choosemyplate.gov/food-groups/downloads/TenTips/DGTipsheet16EatingBetterOnABudget.pdf) • NHLBI Obesity Tools: (http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/tools.htm) • CDC Healthy Weight (http://www.cdc.gov/healthyweight/index.html) 34

  35. Connect Nationally Advocate for environmental change Be Our Voice Advocacy (http://www.nichq.org/advocacy) NPLAN (http://www.nplanonline.org) Add your effort to a resource map Preventobesity.net (http://www.preventobesity.net ) Community Commons (http://www.communitycommons.org ) Host or attend an event in your area Lets Move! (http://www.letsmove.gov ) U.S. Surgeon General Benjamin's Walk for a Healthy and Fit Nation (http://www.surgeongeneral.gov/library/obesityvision/) 35

  36. Contact Information Shikha Anand, MD, MPH National Initiative for Children’s Healthcare Quality 617-391-2700 sanand@nichq.org www.nichq.org 36

  37. CAMcare Health Corporation Healthy Weight Initiative Deborah Horowitz APNc MSN CDE Care Process Program Coordinator CAMcare Health Corporation 37

  38. CAMcare Health Corporation • Federally funded urban health centers located in Camden, NJ • 8 offices reaching out to the medically underserved: 26.7% Uninsured • Healthcare services: Internal Medicine, Pediatric, Ob/Gyn, Dental and Podiatry • CAMcare has 33,322 active patients serving 41.7% Camden City • 88% Hispanic or Black/African American • 52.6% Adults > BMI 29 38

  39. Healthy Weight Approach 39

  40. Organizational Outcome Measures 70% Obese patients will have a self-management goal 25% Obese patients will have a documented weight loss > 10 lbs. within one year 25% Obese patients will have attended a nutrition education program 25% Obese patients will have an individualized exercise program 40

  41. Initial Program Plan • Define healthy weight guidelines • Formalize program • Integrate Healthy Weight and Nutrition referrals into EMR system • Track patients participating in the program • Improve outcome measures 41

  42. CAMcare Healthy Weight Clinical Guidelines GUIDELINE TIMING RESULT Measure height (inches) w/out shoes Yearly 10% Below Baseline Weight (lbs) without shoes Every Visit 10% Below Baseline BMI Quarterly If not morbidly obese < 25 Lipid Profile Yearly Total Cholesterol: < 200 HDL: >40 Male; >50Female LDL: < 160(0-1 RISK FACTOR) < 130 (2+ RISK FACTOR) < 100 (CHD,DM) Fasting Glucose Yearly Glucose < 106 HbgA1c A1c<6.5% Blood Pressure Every visit < 140/90 Patients with HTN <130/80 Patients with DM Refer to nutrition At least once at diagnosis Nutrition assessment Set self-management goal Waist Circumference Quarterly ≤ 40inches Male ≤ 35 inches Female Refer to “Healthy Weight Class” At least once at diagnosis Set self-management goal Attend 6 Classes Exercise Within the last 12 month 3Times a week/20 Minute 42

  43. Population Recruitment • Healthy Weight Initiative “Kick Off ” Walk • Referral System: paper → EMR • Health Fairs • Word of Mouth • Outreach Team • Flyers 43

  44. Healthy Weight EMR Referral 44

  45. Healthy Weight Initiative Patient Learning Objectives Upon completion of the Healthy Weight Program the patient will: • Name three health conditions associated with obesity • Describe how diet and lifestyle changes can reduce the risk of/and help manage chronic diseases • Plan a menu and describe healthy meal preparation methods to help manage weight • Incorporate exercise as a means of sustaining weight loss  • Build a social network to support each other’s efforts 45

  46. Healthy Weight Class Collaborated with Rutgers University Cooperative Extension Education Program: curriculum established Baseline BMI collected and tracked Self-management goal set Program goals met for attendees except exercise Presents: “Healthy Weight Program” Join us in weekly classes Staying Sweet with Less Sugar Fat Out Label Me Healthy Quick, Low Cost Meals The Food Pyramid What is My BMI? Lose weight for the spring months a head. Feel good about yourself. Learn what healthy eating is all about! Classes are held every Tuesday 12:30-1:30 PM CAMcare Gateway Center 817 Federal Street Camden, NJ 08103 46

  47. Self Management Tool 47

  48. Baseline Obesity Data • 42 clients were identified with a BMI > 30 and referred to the program. • All clients were contacted via phone or mail a week before starting the program. Two clients had a scheduling conflict. • 16 clients attended at least one class. 48

  49. Follow-up Outcome Measurements At the end of six weeks: • Weight change of 2% or more was achieved by 38% of the clients participating in the program • One client’s BMI was reduced from the obese to the overweight category 49

  50. Integration of Exercise Program • Piloted exercise program in March 2011 • Class scheduled to follow “Healthy Weight Class” to improve attendance of both weight class and introduce exercise into program • Program announcement was made at staff meetings, e-mails and flyers to patients Let’s march with CAMcare Health Corporation We’re now offering an hour of exercise FREE-All Welcome Place: Gateway Center- 1st Floor 817 Federal St. Camden, NJ 08103 Starting: Every Tuesday March 8, 2011 Time: 2-3PM Register: Rachel King 856-635-0905 PLEASE DRESS COMFORTABLE AND BRING WATER 50

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