Addressing childhood obesity through partnerships between healthcare and community

1. Addressing childhood obesity through partnerships between healthcare and community Sarah E. Barlow, MD, MPH Baylor College of Medicine

2. IOM report Preventing Childhood Obesity 2005

3. Addressing Obesity within the Healthcare System Benefits of this setting + Framing the condition in terms of health rather than appearance + Care of associated medical problems + Care of individual and of family

4. Addressing Obesity within the Healthcare System Disadvantages of this setting • Time • Reimbursement • Expertise • Office visit structure • Accessibility for patient

5. Office visit model Symptoms and signs Diagnosis Treatment Headaches with nausea Medication Migraines Education, motivation, parenting skills, social work, screen and address comorbidities Soda, fast food, school food, video games, poverty, unsafe neighbor-hood, single mother, poor parenting, depression Obesity

6. Pediatricians feel overwhelming sense of futility “I just feel kind of powerless…what more can I do?” “Giving them handouts just placates me” “I can talk until I’m blue in the face…you know at home these kids are just following the [overweight] parents’ footsteps, and there’s not really anything that’s going to change that”

7. Hercules carrying the world

8. Addressing Obesity within Community Setting Benefits: + Accessibility + Implementation as well as education + Opportunity for environmental change + Context of behavioral setting

9. Addressing Obesity within Community Setting Disadvantages: • Low intensity • Limited scope or duration • Exercise class, nutrition class • Lack of individualization • Medical • Behavioral

10. Community programsShape Up Somerville Somerville MA and 2 control communities: grades 1-3 Intervention Before school: breakfast, walk to school During school: staff development, food service, curriculum, recess After school: aftercare curriculum, walk from school Home: newsletter, coupons, family events Community: farmers market, Ethnic-minority group collaborations, city ordinances on walkability, bike-ability Economos 2007; Obesity 15, 1325

11. Shape Up Somerville Estimated effect on weight over 8 months: Boys – 0.82 lb Girls – 0.95 lbs

12. Integrating Healthcare and Community Resources

13. Chronic Care Model Environment Medical System Family/Patient Self-Management Family School Worksite Community Information Systems Decision Support Delivery System Design Self Management Support

14. Chronic Care Model Self-Management Patients have a central role in determining their care Decision Support Health organizations integrates guidelines into day-to-day practice Delivery System Design Providers have clear roles and tasks; patient information is centralized and up-to-date. Clinical Information SystemInformation systems can track individual as well as groups of patients. Organization of Health Care Health care systems can create an environment in which organized efforts to improve chronic illness care flourish. Community Healthcare forms partnerships with state, local, and private entities. Wagner EH. Effective Clinical Practice. 1998;1(1):2-4

15. Expert Committee Recommendations for Prevention, Assessment and Treatment of Child and Adolescent Obesity BMI Category (calculated yearly from weight and height) Assessment Medical risk Behaviors Attitude Prevention Treatment Stages 1 Prevention Plus 2 Structured Weight Management 3 Comprehensive Multidisciplinary 4 Tertiary Care Intervention Barlow SE and Expert Committee, 2007. Pediatrics 120; suppl 4.

16. Stages of intervention Intensity Tertiary Care Age BMI Medical status Motivation Comprehensive Multidisciplinary Structured Weight Management Prevention Plus Who What and How

17. WHAT 5+ fruits and vegetables 2 hours screen time ≥ 1+ hours physical activity Reduce sweet drinks Eating behaviors (3 meals, family meals, etc.) Family-based change HOW Office-based Trained office support MD, PNP, PA, RN Scheduled follow-up visits Advance to next level depending on response and interest 1. Prevention Plus

18. WHAT Reduced calorie eating plan ≤ 1 hour screen time > 1 hour physical activity Monitoring HOW RD, MD, RN with training in assessment, counseling Office-based Support from referrals and outside programs Monthly visits Advance if needed 2. Structured Weight Management

19. Goals with community partners: coordinating programs Programs for physical activity • Fun • Inclusive (rather than select) • Available and affordable/free • Some targeted for overweight children Programs for better nutrition • Parent education, culturally appropriate • Child education • Access (Farmers markets, supermarkets)

20. Healthy Kids-Houston(Project KidFIT) Partners: Baylor College of Medicine Texas Children’s Hospital Houston Parks and Recreation Dept Houston Metropolitan Authority 6-week after-school physical fitness and nutrition education program • 128 children 6-12 years of age • 61% African American, 39% Hispanic • 54% with BMI > 95th %ile

21. Healthy Kids-Houston: Decreased weight and BMI in obese youth Bush CL et al. J Peds 2007; 151:513

22. Viva La Salud Infantil Weight Loss Intervention Pilot Study Baylor College of Medicine, Children’s Nutrition Research Center, Nancy Butte PhD, principal investigator Ripley House—Neighborhood Center “Bringing resources, education and connection to underserved neighborhoods” To compare a 4 month intervention for overweight Hispanic 7-12 year olds and families • weekly diet behavior modification vs. • weekly diet behavior modification plus structured aerobic exercise 3x a week

23. Viva La Salud Results 24 children enrolled, 21 completed • Weekly sessions: 94% • Exercise sessions: 84% Weight change both groups -2.2 kg ± 2.7 diet -3.3 kg ± 2.7 diet + ex Improved Quality of Life (p=0.04)

24. Viva La Salud Infantil Weight Loss Intervention Pilot Study

25. 2 week residential camp • Partners: • Camp Cho-Yeh, Livingston TX • Texas Children’s Hospital / Texas Children’s Pediatric • Associates • Baylor College of Medicine • USDA/ARS Children’s Nutrition Research Center • Harris County Hospital District Foundation

26. Kamp K’aana

27. Lessons Daily for 1 hour 4 nutrition 6 behavior Healthy food 1 pass cafeteria line Unlimited salad 1800 kcal per day Traffic Light labels Kamp K’aana Program

28. Kamp K’aana Activities

29. Kamp K’aana Outcome • Improved weight: -3.7 ± 1.2 kg -1.6 ± 0.5 kg/m2 • Improved self-esteem Kamp K’aana 2009 www.bcm.edu/kampkaana Wong w et al. JPGN 2009 in press.

30. Adult program: Community referral for promoting physical activity among primary care patients Kevin O. Hwang, MD, MPH, UT Houston Partners: YMCA and UT Houston Physicians General Clinic Prescription for physical activity alone vs. prescription plus referral to YMCA and vouchers Results: both groups increased physical activity, with no difference between the groups

31. Stages of interventionImprove, integrate, and evaluate Intensity Tertiary Care Kamp K’aana Comprehensive Multidisciplinary Viva La Salud Healthy Kids Houston Structured Weight Management Healthcare Alliance Texas Pediatric Society toolkit Prevention Plus

32. Obesity care is a team activity:Healthcare and community partnerships