PRACTICAL OBESITY CARE: LESSONS FROM PRACTICE

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1 PRACTICAL OBESITY CARE: LESSONS FROM PRACTICE Christopher F. Bolling, MD National Program Chair, AAP Provisional Section on Obesity Obesity Chair, Kentucky Chapter, AAP

2 LESSON #1 There is no time like the present

3 GUIDELINES EXIST American Academy of Pediatrics 2007 recommendations

4 AND MORE SUPPORT TOO NICHQ and the Childhood Obesity Action Network

5 THE PROVISIONAL SECTION ON OBESITY

6 ACKNOWLEDGMENT TO DO THE RIGHT THING HEDIS measure from NCQA

7 AND NOT JUST ACKNOWLEDGED, BUT MANDATED HEDIS measure from NCQA Healthcare providers should document BMI percentile for age and gender annually in every patient s chart between the ages of two and seventeen years. Healthcare providers should document evidence of counseling for good nutrition and activity annually in every patient s chart between the ages of two and seventeen years.

8 SOME POWERFUL PARTNERS The Clinton Foundation & The American Heart Association

9 WITH GREAT RESOURCES Alliance for a Healthier Generation

10 SUPPORT AT THE HIGHEST LEVELS Let s Move!

11 SOME GOOD TEAMWORK Physicians should screen for BMI percentile Physicians should give a prescription for good nutrition and increased activity

12 MY STATE (KENTUCKY) IS REPRESENTATIVE

13 THE NEED IS STILL VERY HIGH The National Survey of Children's Health, Overweight and Physical Activity Among Children: A Portrait of States and the Nation 2005; HRSA,Health, United States, U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National Center for Health Statistics, 2007.

14 LESSON #2 Take Credit for What You Are Already Doing!

15 KEEP SCREENING BMI PERCENTILE! BMI Percentile for age and gender And the less savory alternatives: Abdominal circumference Body fat analysis Fitness assessment

16 PRACTICE BASIC PREVENTION Promote breastfeeding Encourage on demand feeding Limit juice starting early on Talk about feeding cues Prepare parents for neophobia Some great programs (more to follow!)

17 LESSON #3 Know your community

18 LIVE THE SOCIO- ECOLOGICAL MODEL You are not alone!

19 AND KNOW YOUR LOCAL RESOURCES Boy s and Girls Clubs Weight Watchers TOPS YMCA JCC Health Clubs Physical Therapy sites Dietitians Personal trainers Health Clubs Parks and Recreation School systems Libraries Child care providers Churches Neighborhood groups Hospitals Community Centers Colleges Culinary Schools Professional schools Nurse organizations Chambers of Commerce Children and Nature Dairy Council Professional Sports Teams City Council members Military recruiters State legislators Members of congress Interested parents United Way Wellness committees Media Various non-profits Boy Scouts Girl Scouts Extension Services 4 H And so many more

20 LESSON #4 Obesity Care in your office is completely scalable

21 AND SCALABLE IN DIFFERENT WAYS Severity Timing Complexity

22 LESSON #5 Pay attention to readiness

23 IS READINESS THE KEY? Our Internal Medicine/Family Medicine brethren get this because of dealing with substance abuse Our patients behavior is their behavior Pediatrics is very prescriptive Cold turkey is never an option We can t let challenges with behavior change cause us to blame our patients

24 MOTIVATIONAL INTERVIEWING Provides us with a great opportunity to be more effective Fits well into practice Allows a lot (or a little) for you to do Increasing numbers of training opportunities Helps you overcome the I don t have time for that! hurdle And lastly It s fun!

25 LESSON #6 Set a good example

26 SO, WHAT DOES THAT MEAN? Does not mean you need to be perfect, just trying your best The value of advocacy Office wellness Let your patients and parents see you out there!

27 THINKING GLOBALLY AND ACTING LOCALLY

28 EVERYBODY INTO THE ACT

29 SEEING YOU IN ACTION

30 LESSON #7 Make it your own

31 BASE YOUR LEVEL OF INTERVENTION ON Your motivation Your level of comfort Your resources Your community Your patients need

32 OUR PROGRAM Basic Training 14 MD s, 3 NP s, 2 PA s Open to other patients, but all have been our own All providers trained in screening and basic adapted MI Patients referred after screening and readiness addressed Referring provider orders basic labs I do the initial visits (at least currently) Follow-up with either me, our NP Amber (Nutrition Guru) or PA Rachell (Activity Guru) Use CBT basic goal setting with MI counseling techniques Patients pick goals and follow-up schedule Frequently use local resources

33 BASIC TRAINING INFO SHEET Handed out to interested families

34 OUR LAB SHEET

35 GOAL SHEET

36 SPECIALIZED BEHAVIOR SHEETS FROM CDC, USDA ETC

37 OR FROM OTHER PROGRAMS

38 GET CREATIVE!

39 LESSON #8 Pick some good workhorses

40 A GOOD PREVENTION STRATEGY

41 KEEPING IT GOING

42

43

44 LESSON #9 Pay attention to outcomes, but keep them in perspective

45 OUTCOMES Very important for many reasons Keep your improvement cycles going Weight management programs are notoriously difficult to gauge as successful Hard to move the BMI needle, so look at proven intermediate steps Measure absolutely, but don t let it paralyze you from acting

46 LESSON #10 Organize your referral strategy

47 THE OBESITY SPECTRUM Prevention & Healthy Lifestyle Promotion Identification Practice Intervention Midlevel Referral High Level Referral Surgical Intervention Treatment Failure Environment Community Interventions Schools Hospital Based Programs Various Medical Providers

48 KNOW YOUR TERTIARY CENTER Diverse and effective centers Obesity is a chronic disease: think ADHD, asthma Stay engaged Know your other resources, especially dietitians

49 A FEW OTHER THOUGHTS ON REFERRALS Co-morbidities may need more than you can give, but address them as your comfort level increases Severe obesity-these patients can really derail you if you aren t careful The social services dilemma Easy to forget that readiness is still a factor

50 TEN LESSONS 1) No time like the present 2)Take credit for what you are already doing 3)Know your community 4)It s scalable 5)Pay attention to readiness 6)Set a good example 7)Make it your own 8)Pick some good workhorses 9)Be practical about outcomes 10)Organize your referral strategy

51 QUESTIONS? Please feel free to contact me Christopher F. Bolling, MD office cell fax

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