Transcript Slide 1

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?
DISPARITIES PERSIST
To date, only Philadelphia has reported major
progress in closing the disparities gap.
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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…”
Bruch H. Pediatric Annals: 1975
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Adolescents’ Perceptions of Peers
Being Teased or Bullied:
The Reason Why
Perceptions of weight-based victimization among
N=1555 high school students in Connecticut
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Percentage of teen girls who report frequent weight
teasing
Neumark-Sztainer. J Adolesc Health.
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2009;44:206-213.
Assess Behaviors & Attitudes - Eating, Physical Activity, Sedentary Time, Motivation
Obesity
Algorithm
Assess Medical Risks - Family History, Review of Systems, Physical Examination (BMI, BP)
Healthy Weight
Overweight
Obese
BMI 5-84%ile
BMI 85-94%ile
BMI 95-98%ile
1) Example – medical risk or behavioral
risk
BMI >=99%ile
Assess Fasting Lipid Profile
Health Risks?(1)
No
Yes
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
Assess ALT, AST, Fasting Glucose(2)
Other Tests as Indicated by Health Risks
4) Age 6-11yr = 1 lb/month, Age 12-18yr
= 2 lbs/week average
Prevention Counseling - Empathize/Elicit - Provide - Elicit
5) Age 2-5yr = 1 lb/month, Age 6-18yr = 2
lbs/week average
Stage 1 Prevention Plus(3)
Maintain Weight Velocity &
Reassess Annually
Maintain Weight or
Decrease Velocity
& Reassess Every
3-6 Months
Maintain Weight or
Gradual Loss(4) &
Reassess Every 3-6
Months
Gradual to
Moderate Weight
Loss(5) & Reassess
Every 3-6 Months
Stage 2 Structured Weight Management(3)
Stage 3 Comprehensive Multidisciplinary Intervention(3)
Assessment
Prevention
Treatment
Stage 4 Tertiary Care Intervention
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Children and Adolescents age 2 to 18 years of age
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In Our Backyard
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Health Foundation
Healthy Weight Strategy
GOAL: Reduce the prevalence of overweight
GOAL: Reduce the prevalence of overweight
and obesity from 15% to 5% of Monroe
and obesity from 15% to 5% of Monroe
County children ages 2-10 by 2017
County children ages 2-10 by 2017
[from 12,144 kids to 4,081 kids]
[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
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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
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Parents estimation of child’s weight
status vs. measured weight, 2-9yo
Estimation of weight 193 parent/child
dyads from Strong Pediatrics
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Tschamler, et al, Clin Peds, 2010;49:470
GROC Breakthrough Series (12 Months)
Participants
Select
Topic
Expert
Meeting
Planning
Group
How well do
successful teams
“hold the gains”
after LS3?
Pre-work
P
Develop
Framework
& Changes
A
P
D
A
S
LS 1
Stages of Improvement
D
S
LS 2
LS 3
Supports
-test
-Emails
-implement
-Office Visits
-hold the gain
-Phone Conferences
-spread
-Monthly Team
Reports
-Assessments
Borrowed from IHI
Beyond
LS 3
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Some Results from Our Practices
Percentage of Charts With Counseling on
Nutrition and Physical Activity
100%
95%
95%
80%
60%
Cycle 1
40%
Cycle 2
Goal
20%
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0%
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9 Month 10 Month 11
OBESITY CHRONIC CARE MODEL
Self Management
Delivery System
Clinical Information
Decision Support
Support
Design
Systems
 Emphasize the
 Embed evidence-  Define roles and
 Provide reminders
patient’s central role
based guidelines
distribute tasks
for providers and
 Organize resources
into daily clinical
among team
patients
to provide support
practice
members
 Identify relevant
 Use effective self Integrate specialist  Use planned
patient submanagement
expertise and
interactions to
populations for
strategies that
primary care
support evidenceproactive care
include assessment,  Use proven
based care
 Facilitate individual
goal setting, action
provider education  Provide clinical case
patient care planning
planning, problem
methods
management service  Share information
solving, & follow up  Share guidelines
for high risk patients
with providers and
and information
 Ensure regular
patients
with patients
follow-up
 Monitor performance
 Give care that
of team and system
patients understand
and that fits their
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culture
Health Risks?(1)
No
Yes
Assess ALT, AST, Fasting Glucose(2)
Overweight
Healthy Weight
BMI 85 - 95%ile
BMI 5 - 84%ile
Obese
>=99%ile
Other
as IndicatedBMI
by Health
Risks
BMI
95 - Tests
98%ile
Prevention Counseling - Empathize/Elicit - Provide - Elicit
Stage 1 Prevention Plus(3)
Maintain Weight Velocity &
Reassess Annually
Maintain Weight or
Decrease Velocity
& Reassess Every
3-6 Months
Primary Care
Setting
?
Maintain Weight or
Gradual Loss(4) &
Reassess Every 3-6
Months
Gradual to
Moderate Weight
Loss(5) & Reassess
Every 3-6 Months
Stage 2 Structured Weight Management(3)
Stage 3 Comprehensive Multidisciplinary Intervention(3)
Assessment
Prevention
Treatment
Stage 4 Tertiary Care Intervention
3yr old WCC w/ pt Not Mykid
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Pt NW, first seen at 3yrs and noted to be obese
PNP informed pt in ‘Red zone’ as unhealthy. Can we discuss?
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Pt MN
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Dr. Colpoys at Genesee Pediatrics
Penfield Pediatrics
Unity Pediatrics
More Unity Pediatric Pics
Extent of Community Reach
Monroe County, NY –
Estimated Birth Cohort = 1,015
Cycle 1
24.8%
n=9
Cycle 2
46.3%
(n = 17)
Cycle 3
56.0%
n= 26
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OBESITY CHRONIC CARE MODEL
Community Resources and Policies



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
Health Care Organization
Promote effective 
improvement
strategies aimed at
comprehensive
system change

Encourage open
and systematic
handling of
problems
Development of
agreements for
care coordination
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Results
Monroe County, NY
Unhealthy
Food
Source
RFEI =
Healthy
Food
Source
Obesity by
Neighborhood
5.0% - 10.0%
10.1% - 15.0%
15.1% - 20.0%
20.1% - 24.0%
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Maps of Parks and Recreation Centers
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Rec on the Move
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“Rec on the Move” comes to the Doc Office
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Foodlink Curbside Market
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Additional Partners / Tools
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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”
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
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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
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Thank you
Department of Pediatrics, GCH@URMC