6 Highlights 5210 Basics Next Steps Put it into Play TOMORROW Stuff you need to knowNext StepsEngaging the PatientPut it into Play TOMORROW
7 11 year old well visit – obese Doc #1.Give HPV, Menactra, and Tdap and make appt for next year.Doc #2.Ask, “Is it ok if we talk about your weight?”Doc #3.Say, “I have some concerns about your health and want to set you up to see my partner.”
9 (Polycystic Ovary Syndrome) The BasicsType 2 DiabetesWe actually know that obesity is not a good thing.Impaired GlucoseToleranceMetabolic SyndromeDyslipidemiaHypertensionHyperandrogenism(Polycystic Ovary Syndrome)Growth and Puberty
10 The Basics Cholelithiasis (gall stones) Obstructive Sleep Apnea (8% of obese kids)Slipped Capital Femoral Epiphysis (SCFE)Tibea Vera – Blounts Disease (bowed legs) (2.5%)Pseudotumor cerebri (head aches)PsychBody imageSelf esteemDepression, AnxietyAlienation from friends, distorted peer relationships
11 Ineffective Interventions If you implement what I have talked about so far, you will not be effective.I will now talk about what things you should already be doing and what things you can start doing in your office.Ineffective Interventions
13 Evidence Based National Guidelines Expert Committee 2007Comprehensive review of literature – evidence for Pediatrics 2007;120;S229-S2535210 are proven determinants of obesity.1
14 Evidence Based National Guidelines 2US Preventative Services Task Force 2010Reviewed 13 behavioral and 7 pharma trails.
15 GRADE B rec. USPSTF BMI is an Acceptable Measure Moderate – Intensive InterventionCounselingPhysical ActivityBehavioral Management TechniquesParent InvolvementPharma works modestly, but not recommended presently
16 Evidence Based National Guidelines White House’s Childhood Obesity Task Force 2010 – Let’s Move campaignMotivated partnerships for intervention– private, public partnerships.3As White House tackles obesity, lawmakers eye soda as culprit
18 Pediatric Obesity Clinical Decision Support Guide (5210 Flip Chart) Outlines basic initial MEDICAL EVALUATIONin the officeAnnual PhysicalSeparate Visit
19 Family History Counts BMI% PLUS…………… Family History ObesityDiabetesHyperlipidemiaEarly Heart DiseaseComorbidity Symptoms
20 EXAM Endocrine causes of obesity is more likely in the short kid Khagendra MagarWorld’s shortest 18 year old.2’ 5” tall from Nepal.Endocrine causes of obesity is more likely in the short kidor tall kid?
21 Facial hair and acne is sometimes a sign of what?Increased chocolate consumptionIncreased androgens
22 NECKNECKThis person has:A rash from a necklace.Bad eczemaAcanthosis NigricansUnderarm
23 B. Skid burn from the carpet C. Rapidly stretching skin This rash is from what?A. Cutting behaviorB. Skid burn from the carpetC. Rapidly stretching skinStriae
24 ExamSometimes helps. Low pay off, but does help identify disease that deserves further medical evaluation.Target:Cardiac examHepatomegallyHip issues
25 Should I Get Labs??????? Cholesterol Profile ALT or AST Fasting Glucose(now HgbA1C)TSH, free T4 – thyroid diseaseCortisol, creatinine – CushingsDHEAS, free testosterone, insulin - PCOSInsulin levels – fasting? 2hr GTT?? Ultrasound of liver ?? Sleep study, Xray of hips, Cardiac MRI (not yet)? Vitamin D?Over age 10yrs – Choseterol, ALTIf risk factors (Fhx DM, ethnic risk (black, indian, hispanic), physical exam (striae)) – glucoseIf findings, get the rest.
26 Initial Treatment 5210 Pick a piece, try it out. MOTIVATIONAL INTERVIEWINGAsk permissionElicit patient’s concernsProvide positive feedback, celebrate successes.Find discrepanciesDevelop patient based planExplore Motivation and ConfidenceSolely 5210 can result in a healthy weight for some…………..
27 5210 works better with help Let’s Go Core PrinciplesEnvironmental and policy change can influence behavior changeInterconnectivity across sectors is essentialStrategies are evidence-based and continuously evaluatedLet’s GoMessaging heard in more then 3 settings, increases probability of self reported change in behavior by 27%.
28 1. Connect to your community and the Let’s Go! community efforts: Required:The practice will hang a Let’s Go! poster in the waiting room and ALL exam rooms.Connect to your community and the community efforts – this has been really important for our Let’s Go! communitiesHang a poster in your waiting room, exam rooms, bathroom, staff area
29 2. Accurately weigh and measure patients. Required:ALL providers regularly determine BMI percentile in patients 2-18 years during well visits.1. Accurately weigh and measure patients and determine BMI, BMI% and weight classification for patients 2 years and older. From birth to age 2 it is recommended to use the weight for length measurement and watch for crossing percentiles.
30 3. Have a respectful conversation around weight. Required:All providers regularly use the Let’s Go! Healthy Habits Questionnaire during 2-18 year well visits.Have a respectful conversation around weight and healthy habits.Use the 5210 healthy habits questionnaire to switch the conversation from weight to health?
31 Registered Let’s Go! Practices (As of 5/13)133 Practices667 Providers220,681 PatientsFunding provided byThe Harvard Pilgrim Health Care Foundationand MaineHealth
32 5-2-1-0 It starts the conversation For some it’s all they need For others – (esp. with BMI>95%) they need more
33 Summer/Fall 2013AAPNICHQLet’s GoMaine AAPAAP Section on ObesityLet’s Go OnlineTeaching Modules – Fall 2013
34 Next Steps Provides structure, format, and content to visit Uses “19 Theme Visits”For Engaged Patient
35 Next Steps, cont. Periods of Commitment Visits are over an extended period of time (?6-12 mo?) ”Touch Points”MOST IMPORTANT: Patient/Family/Provider Triad decides on themeClinician may need more training/skills - MI
36 THEMED VISITS A B C Critical Concepts for Choosing Themes: _Themes with greater pay off should happen earlier_The patient’s/family’s culture should be considered and incorporated into the visits_Provider’s expertise and knowledge base_Use Universal Messaging across all visits, such as 5210ABC
37 Total of 19 Themes 1 Theme 6 Themes 12 Themes (Tested against approx 25 providers (Peds, Family, Int Med, PA, RN),3 dietitians, 1 physical therapist, 2 counselors, and 1 linguist)A1 ThemeB6 ThemesC12 Themes
38 20 Minute Visit 5 5 1 5 4 Follow Up Wt/Check In Barriers Theme BMI %ileBarriersPEThemeFollow Up20 Minute Visit55154
39 ACategory A theme will hopefully set the foundation for all of the other visits.POSSIBLE FIRST THEMED VISITPurpose: Set the foundationDiscussion ThemeMaterial for DiscussionUnderstanding Health(Set a foundation for good health.)· Define the origins of health—some is genetic and some family derived· Focus should be on maintaining or improving current health· Work with patients and families to understand that they are managing their health
40 B The 6 Highest Pay-off Themes NEXT COUPLE VISITS THEMED VISITSBThe 6 Highest Pay-off ThemesNEXT COUPLE VISITSPurpose: Introduce concepts that are important to cover early for successDiscussion Theme for Each VisitMaterial for DiscussionUnderstanding Meaning of Healthy Food· Eat less processed food· Consume more fruit, vegetables, whole grains· Discuss where to get healthy foods· Discuss affordability of healthy foods· Eat foods that are closest to their natural state—can they be found in nature or at a farm?Home Environment· Create a supportive environment in house for success· Enlist other family members, same healthy meals for all, not just for patient· Be pro-active - get less healthy foods out of the house
41 NYC Behaviors and Emotions Around Eating · Encourage mindful eating—are you actually hungry?How do you know you are hungry?· Address typical triggers for eating. Eating when fighting Eating when bored Eating when sad, angry, or lonelyEating with Television· Most common solution= redirect to alternative activities to eating (e.g. go for a walk, play with a friend, do a craft)Portion Sizes(could be combined with label reading)Use balanced plate tool—consider giving out a physical example. (Picture of a plate with appropriate portions.)Sugary Beverages· Consider using tools to review beverages, sports drinks, juices, teas—sugar bottle display? Consider graph depicting recommended sugar limits compared with amount in beverage.· Combine with discussions about calcium, milk, and waterNYC
42 Parenting· Positive reinforcement is more powerful then punishments for behavior change. Target a high ratio of praise to commands/criticism.Practice this skill at office or with peers.· Make comments specific, immediate, and genuine.· Start small – target 1- 3 behaviors for change initially.· Physical praise works as well (high fives, stickers, ect).· Be prepared for resistance. Kids test limits or act out to see if parents mean what they said. Consistency pays off as an individual caregiver and between caregivers.5210
43 C THEMED VISITS LATER IN PROGRAM Physical Activity Body Image Label ReadingScreen TimeMeal PatternsNon Home Environment – school, childcare, afterschoolSnacksHolidaysCommunity PartnersBullying and TeasingUnintentional Disruptions
45 Who has the Conversation with the Patient/Family? PSYCHOLOGIST OR SOCIAL WORKERVISITS(PhD, LCSW, LCPC,)Behavioral and Emotional EatingMEDICAL PROVIDERVISITS(NP, PA, MD, DO, RN)Purpose of VisitsPhysical ActivityTelevisionBreastfeedingDIETITIAN VISITS(RD, Nutritionist, Health Educator)Understanding Healthy FoodPortion SizesLabel ReadingSnacksMeal PatternsCalorie BalancePHYSICAL THERAPIST VISITS(OT, PT, CPT, AT,PhysEd)Physical Activity
46 FOLLOW-UP – its hard!!!!1. TIE the reason to something else – asthma, lab recheck2. LOAD the plan for early program successes3. CONSIDER having patient and family define the frequency of follow up.Patients often do not come in for weight related follow-up visits. Behavior change is not easy work for the patient or provider. Providers must proactively increase the odds of patient success, including follow-up visits. You might be able to better engage your patients using one of the following strategies:
47 FOLLOW-UP – its hard!!!!4. GIVE a prescription 5. RECOGNIZE that follow up is most likely to happen if the patient perceives value to the visit. 6. CREATE an atmosphere of FUN in the office.
48 Red Flags to Treatment Abnormal Labs High BP When is it time to consider additional medical work up and/or involving a specialist?Abnormal Labs High BPAbnormal glucose, cholesterol, AST/ALTPE FindingsSignificantly short height — chronic illness or hormone abnormalities.Abnormal sleep patterns — sleep apnea.Acanthosis Nigricans — insulin resistance.Abnormal Menses — PCOSShortness of Breath or Exercise Intolerance — asthma.Significant Anxiety or DepressionOther ReasonsHigh BMI%ile and not progressing after 6-12 months towards a healthier weight.Patients with worsening comorbidities.Rapidly increasing BMI %ile.
60 Change Talk Parent/Patient Choses Theme, but Doc choses options That might be best.Change Talk
61 Themes Encountered Meaning of Health Physical Activity Goal Setting – (could have used 1-10 scale)Next Time – Could TargetParentingBeveragesUnintended Interruptions
62 Identify Solutions to barriers. What Is Your Readiness To Change?Reflective Listening.Identify Barriers.Identify Solutions to barriers.Praise Effort.Support.
63 www.LetsGo.Org Portland, ME Sept 11 – preconference on MI Sept – conferencePortland, MERobert Schwartz – Wake ForestReggie Washington - DenverDavid Ludwig – Boston ChildrensRobert Lustig – UCSFSandi Hassink – NemoursRobin Hamre – CDCChris Boling/Stephen Pont – AAPMany more
68 Sub objectives EVIDENCE BASED: National guidelines for assessment and treatment of Childhood Obesity – 5210 For Providers.PRACTICE BASED:“NEXT STEPS” - Planned visits using patient tailored themes as a method for goal setting.
69 This patient is at risk for: SnoringObstructive Sleep ApneaCardiomegallyAll of the above