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Session # G1a October 16, 2015 A Population Health Approach to Managing Obesity Using a Primary Care Behavioral Health Clinical Pathway Anne C. Dobmeyer,

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Presentation on theme: "Session # G1a October 16, 2015 A Population Health Approach to Managing Obesity Using a Primary Care Behavioral Health Clinical Pathway Anne C. Dobmeyer,"— Presentation transcript:

1 Session # G1a October 16, 2015 A Population Health Approach to Managing Obesity Using a Primary Care Behavioral Health Clinical Pathway Anne C. Dobmeyer, PhD, ABPP, Chief Psychologist, PCBH Directorate, Deployment Health Clinical Center Jennifer L. Bell, MD, Associate Director, PCBH Directorate, Deployment Health Clinical Center Christopher L. Hunter, PhD, ABPP, DoD Program Manager for Behavioral Health in Primary Care Proposal # : “A Population Health Approach to Managing Obesity Using a Primary Care Behavioral Health Clinical Pathway”, is scheduled for presentation on Friday, October 16, 2015 as session number G1a in Period 1, for 40 minutes. Collaborative Family Healthcare Association 17th Annual Conference October 15-17, Portland, Oregon U.S.A. Collaborative Family Healthcare Association 12th Annual Conference

2 Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months. CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message. The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community. Collaborative Family Healthcare Association 12th Annual Conference

3 Learning Objectives At the conclusion of this session, the participant will be able to:
Identify two key conclusions of outcome literature on treatment of obesity in primary care settings. Discuss the rationale for implementing a primary care-based, population health approach to obesity using the primary care behavioral health (PCBH) model of service delivery. Describe three key elements in a PCBH clinical pathway for obesity. Collaborative Family Healthcare Association 12th Annual Conference

4 Bibliography / References
Dobmeyer, A. C., Goodie, J. L., & Hunter, C. L. (2014). Health care provider and systems interventions promoting health behavior change. In K. A. Riekert, J. K. Ockene, & L. Pbert (Eds.), The Handbook of Health Behavior Change (4th ed.). New York: Springer (pp ). Thompson, C. A., & Foster, G. D. (2014). Dietary behaviors: Promoting healthy eating. In K. A. Riekert, J. K. Ockene, & L. Pbert (Eds.), The Handbook of Health Behavior Change (4th ed.). New York: Springer (pp ). Moyer, V. A., on behalf of the U.S. Preventive Services Task Force (2012). Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 157 (5), 1-7. Wadden, T. A., Butryn, M. L., Hong, P. S., & Tsai, A. G. (2014). Behavioral treatment of obesity in patients encountered in primary care settings: A systematic review. JAMA, 312 (14), Alexander, S. C., Cox, M.E., Boling Turer, C. L., Lyna, P., Østbye, T., Tulsky, J. A., Dolor, R. J., & Pollak, K. I.(2011). Do the five A’s work when physicians counsel about weight loss? Family Medicine, 43 (3), Continuing education approval now requires that each presentation include five references within the last 5 years. Please list at least FIVE (5) references for this presentation that are no older than 5 years. Without these references, your session may NOT be approved for CE credit. Collaborative Family Healthcare Association 12th Annual Conference

5 Learning Assessment A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation. Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements. Collaborative Family Healthcare Association 12th Annual Conference

6 Disclaimer The views expressed are those of the authors and do not reflect the official policy of the Department of Defense (DoD), the United States Public Health Service (USPHS) or the U.S. Government.

7 Acknowledgements The authors would like to acknowledge the following individuals who were instrumental in the development of the DoD PCBH Obesity Clinical Pathway: Kent Corso, PsyD Meghan Corso, PsyD Jay Earles, PsyD Matthew Nielsen, PhD Nicholas Polizzi, PhD Kathryn Waggoner, PhD

8 Overview Obesity treatment in primary care
Health behavior change and obesity treatment in primary care Role of Behavioral Health Consultants (BHCs) Primary Care Behavioral Health (PCBH) obesity pathway Key processes Supports needed Specific pathway content Future directions Program evaluation Pathway expansion and modification

9 What Do We Know about Improving Health Behaviors in Primary Care?
Intervention elements associated with improved health behavior outcomes1 Assessment of patient characteristics and needs and subsequent tailoring of intervention elements to address assessment Behavioral interventions (especially those that include self-monitoring, collaborative goal setting and active problem solving) Combined behavioral and pharmacologic interventions Supportive elements (both within and outside of intervention) Use of multiple modalities Multiple contacts Inclusion of organizational or system elements to prompt patients and clinicians 1. Goldstein, Michael G., Evelyn P. Whitlock, Judith DePue, and Planning Committee of the Addressing Multiple Behavioral Risk Factors in Primary Care Project. "Multiple behavioral risk factor interventions in primary care: summary of research evidence." American Journal of Preventive Medicine 27, no. 2 (2004): Reiterate that even the most capable and efficient of physicians can’t do it all on their own

10 What Do We Know about Primary Care Providers (PCPs) and Obesity Treatment?
PCPs are reluctant to address weight management, especially among those who are not extremely overweight Less than half of obese individuals are advised by their physicians to lose weight1 Weight counseling declined from 1995–1996 to 2007–20082 Rates of diet, exercise, and weight-related counseling similarly declined. PCP attitudes about obesity and its treatment3 View obesity as largely a behavioral problem Share negative stereotypes about the personal attributes of obese people View obesity treatment as less effective than treatment of most other chronic conditions 1. Galuska, Deborah A., Julie C. Will, Mary K. Serdula, and Earl S. Ford. "Are health care professionals advising obese patients to lose weight?." JAMA 282, no. 16 (1999): 2. Kraschnewski, Jennifer L., Christopher N. Sciamanna, Heather L. Stuckey, Cynthia H. Chuang, Erik B. Lehman, Kevin O. Hwang, Lisa L. Sherwood, and Harriet B. Nembhard. "A silent response to the obesity epidemic: decline in US physician weight counseling." Medical Care 51, no. 2 (2013): 3. Foster, Gary D., Thomas A. Wadden, Angela P. Makris, Duncan Davidson, Rebecca Swain Sanderson, David B. Allison, and Amy Kessler. "Primary care physicians’ attitudes about obesity and its treatment." Obesity Research 11, no. 10 (2003): Physicians also experience less job satisfaction…As the patient became heavier, physicians judged them to be less healthy, worse at taking care of themselves, and less self-disciplined. In addition, as patient BMI increased, physicians reported liking their jobs less, having less patience, and less desire to help the patient. Physicians also reported that seeing obese patients was a greater waste of their time and that heavier patients were more annoying than patients with lower body weights. Furthermore, physicians predicted that heavier patients would be less likely to comply with medical advice and would be less likely to benefit from counseling

11 Physicians and the “5 As”
Ask: Physician asks about weight, nutrition, and/or exercise. Advise: Physician provides the patient with clear, strong advice. “You need to get 30 minutes of exercise a day, 5 days a week.” “Because of your diabetes, it is important for you to exercise.” Assess: Physician verbally assesses patient’s readiness to change. “Is losing weight something you want to do in the near future?” “Do you see yourself getting more exercise in the coming months?” Assist: Physician provides brief counseling or self-help materials. “What might get in the way of your plan to exercise three times a week?” “How are you feeling about being able to make this change?” “Is your family supportive of your attempts to eat better?” Arrange: Physician arranges for follow-up with physician or nutritionist. “Why don’t you call me in 2 weeks to let me know how the weight loss plan is going?” “I will schedule an appointment for you to see our nutritionist.” Alexander, Stewart C., Mary E. Cox, Christy L. Boling Turer, Pauline Lyna, Truls Østbye, James A. Tulsky, Rowena J. Dolor, and Kathryn I. Pollak. "Do the five A’s work when physicians counsel about weight loss?” Family Medicine 43, no. 3 (2011): 179 – 184. 77% 63% 13% 5% 4% Red: In 384 out of the 461 recorded encounters (83%), physicians used at least one of the Five A’s: Asked (77%), Advised (63%), Assisted (13%), Arranged (5%), and Assessed (4%). Note that the change in the 5 A words are what were used in the study as opposed to what we used in the previous slide of Assess, Advise, Agree, Assist, Arrange

12 “Do the Five A’s Work When Physicians Counsel About Weight Loss?”
Ask and Advise are more common, but they do not help physicians learn what patients are actually willing to do, so don’t help the physicians help patients formulate an action plan for change. The results… Associations Between Five A’s and Dietary Fat and Fiber Intake Advised: Increased motivation to change dietary fat and fiber intake. Advised: Increased confidence to improve diet. Assisted and Arranged: Patients were more likely to report improving their diet. Association Between Five A’s and Weight Loss Advised: Patients had significantly higher improvements in confidence to lose weight. Assessed: Patients were more likely to improve their confidence. Arranged: Patients had a significant difference in measured weight loss. Alexander, Stewart C., Mary E. Cox, Christy L. Boling Turer, Pauline Lyna, Truls Østbye, James A. Tulsky, Rowena J. Dolor, and Kathryn I. Pollak. "Do the five A’s work when physicians counsel about weight loss?." Family medicine 43, no. 3 (2011): NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Fam Med. Author manuscript; available in PMC 2012 June 05. Alexander et al. Page 4 framework to deliver weight loss counseling. Physicians tailor the intensity of their We report three important findings. Physicians use some components of the Five A’s Discussion related to patients changing their behaviors. counseling based on patient characteristics. Some components of the Five A’s seem to be encounters with overweight and obese patients. This did not seem to differ based on that physicians were using at least some portion of the Five A’s technique in most Despite receiving little or no formal training in the Five A’s for discussing obesity, we found yet infrequently Assess, Assist, or Arrange. These findings are consistent with previous physicians’ training in obesity counseling. Physicians were more likely to Ask and Advise, given that physicians are trained in information giving and seeking (Ask and Advise) and has been found in the smoking literature.23,24 The emphasis on advice is not surprising, research in Five A’s counseling in primary care.17 Additionally, this finding mirrors what Advise are more common, the problem with predominantly using these behaviors is that are less frequently trained in more partnership building types of behaviors. Though Ask and physicians appear to realize the importance of weight loss counseling and are attempting to may, therefore, not be able to help patients formulate an action plan for change. Though they do not help physicians learn what patients are actually willing to do, and the physicians Physicians seem to tailor their weight loss advice. Encouragingly, physicians provided more counsel, they may be missing an opportunity to maximize impact. physicians are more likely to target their counseling to heavier patients.17 Physicians also perhaps need it more. This finding is consistent with previous research that has shown that comprehensive counseling—used a greater number of Five A’s—with heavier patients, who confidence to lose weight. Our own work indicates that physicians are reluctant to counsel used more of the Five A’s with more motivated patients and with patients who reported less but also may choose to do more with patients with whom they think they will have the physicians do more for those who need more, those who are less confident and are heavier, patients who do not want to change.25 Findings from the current study suggest that Overall, use of the Five A’s seemed to influence patients to be more motivated to change, biggest impact, namely those who are motivated. and continued behavior change over the long term.26,27 When physicians provide strong, confidence are important as they have been correlated with weight loss, weight maintenance, more confident to change, and more likely to change. Improvements in motivation and concern; the converse might be true when physicians do not provide advice. clear advice, patients might be able to recognize the importance of weight as a health change in one fat-related eating behavior, like trimming the fat off of meat often instead of improvements in actual dietary fat intake change scores. This modest improvement reflects a Indeed, results suggest that patients whose physicians Assisted or Arranged showed cheeses less frequently, or from switching from 2% to non-fat milk. These are minor dietary sometimes or by eating bread/rolls without butter or margarine less often, eating lower fat clinically significant improvement. This supports the use of explicit planning by the enough to result in weight loss in some patients. Thus, the difference likely represents a adjustments but ones that can reduce energy intake by 100 or 200 kcal/day, a deficit large medical nutrition therapy, which are an important component of multi-disciplinary weight physician-patient team in improving nutrition behavior. It may also reflect referrals for Alexander et al. Page 5 intensive behavioral interventions are often unable to improve physical activity.28 loss strategy. No changes were found for actual exercise, but this is not surprising as even follow-up visit were more likely to have lost weight 3 months following the visit. This is Only one of the A’s was linked to actual weight loss. Patients whose physicians Arranged a encouraging that physicians were more likely to Arrange a follow-up visit for patients with behavior change; it may reflect the patient’s feeling accountable to their physician. It is consistent with the notion that frequency of contact is an important element for influencing A major strength of this study is that these primary care patients were not enrolled in a higher BMI. limitations. First, the results may not generalize to younger, lower income patients. Second, Another strength is the large and ethnically diverse sample. The study also has several weight-loss trial and therefore were not self-selected to be highly motivated to lose weight. visit covariates, unmeasured confounding variables may still account for at least part of the the study was observational. Though we adjusted for a broad set of patient, physician, and found for Assessing, Arranging, and Assisting. Although this is not surprising, the low with P values near 0.05 must be interpreted with caution. Fourth, there were low frequencies observed associations. Third, multiple comparisons were done, so significant associations techniques on weight loss. Finally, the analysis is limited by the use of self-reported dietary frequencies of these techniques make it difficult to detect the effectiveness of these behavior, which would have made the interpretation of results more complicated. have been more accurate; however, such involved measures could invoke changes in fat and fiber intake and physical activity measures. A food diary and an accelerometer may loss counseling in the primary care encounter and subsequent weight-related behavior This is the first study to assess the relationship between actual use of the Five A’s in weight whether some of the A’s are qualitatively more important than others. Further, given these Assessed, Assisted, or Arranged. Next steps for this work would be to examine more closely change. Physicians routinely Asked and Advised patients about weight; however, they rarely counseling. that attempts to teach physicians how to incorporate the Five A’s in their weight loss preliminary results, a randomized controlled trial might be warranted to test an intervention All these take TIME!

13 From: Screening for and Management of Obesity in Adults: U. S
From: Screening for and Management of Obesity in Adults: U.S. Preventive Services Task Force Recommendation Statement Ann Intern Med. 2012;157(5): doi: / Note: In 2003, the U.S. Preventive Services Task Force (USPSTF) recommended that clinicians screen all adults for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults (B recommendation: high certainty that net benefit was moderate or moderate certainty that net benefit was moderate to substantial). The USPSTF, however, concluded that evidence was insufficient to recommend for or against moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults (I recommendation: insufficient evidence to assess benefit and harm balance). The USPSTF concluded that evidence was insufficient to recommend for or against counseling of any intensity and/or behavioral interventions to promote sustained weight loss in overweight adults (I recommendation). Figure Legend: Screening for and management of obesity in adults: clinical summary of U.S. Preventive Services Task Force recommendation. Date of download: 2/21/2015 Copyright © American College of Physicians. All rights reserved.

14 "Effectiveness of primary care–relevant treatments for obesity in adults: a systematic evidence review for the USPSTF” Behaviorally based treatments are safe and effective for weight loss and maintenance Behavioral treatment trials providing 12 to 26 intervention sessions during the first year lost 4- 7 kg (average, 6% of baseline weight) at 12 to 18 months, compared with little to no weight loss in control groups. Adding Orlistat to intensive behaviorally based intervention resulted in a 5-10 kg loss (avg, 8% of baseline weight), compared with 3- 6 kg in the placebo groups. Most trials showed that behavioral interventions had a statistically significant effect on weight loss at 12 to 18 months LeBlanc, Erin S., Elizabeth O'Connor, Evelyn P. Whitlock, Carrie D. Patnode, and Tanya Kapka. "Effectiveness of primary care–relevant treatments for obesity in adults: a systematic evidence review for the US Preventive Services Task Force." Annals of Internal Medicine 155, no. 7 (2011): Behavioral treatment trials were fairly recent and of high quality. However, orlistat trials were generally lower quality.

15 Do We Really Need All Those Appointments?
More appointments associated with greater weight loss Behavioral interventions lasting longer (24 to 54 months) continued to show greater weight loss (2 to 4 kg) compared with controls Weight loss could be maintained for an additional year or more after completion of an active weight-loss phase, particularly with additional support Higher intensity interventions associated with greater loss Most higher-intensity interventions included self-monitoring, setting goals, addressing barriers to change, and strategizing about maintaining long-term changes. No component was associated with degree of weight loss in meta-regression. Specific articulation of essential elements of effective interventions was not possible. LeBlanc, Erin S., Elizabeth O'Connor, Evelyn P. Whitlock, Carrie D. Patnode, and Tanya Kapka. "Effectiveness of primary care–relevant treatments for obesity in adults: a systematic evidence review for the US Preventive Services Task Force." Annals of Internal Medicine 155, no. 7 (2011):

16 How Might BHCs Help in Obesity Treatment?
Train PCPs on 5As for obesity Formal teaching Consultative feedback over time Provide intervention for obese patients Ensure patients receive all of the 5As (especially Assist and Arrange) Provide “higher intensity interventions” Evidence-based, brief behavioral interventions Self-monitoring, goal setting, behavior change Increase overall number of appointments patients receive Patients may receive appointments with PCP, BHC, nurse, dietician… Provide care over time/relapse prevention Improve care coordination Ensure patients and PC team have shared treatment goals and plan Advocate for organizational/system elements to prompt clinicians

17 PCBH Obesity Clinical Pathway

18 Overview of Key Processes in Pathway
Identify Identify Methods to identify patients Criteria for pathway inclusion Connect Ways to link patients to BHC Intervene Evidence-based assessment and intervention from BHC Measure Outcomes Type of outcome data to collect Connect Intervene Measure Outcomes

19 Supports Needed Interdisciplinary team support Pathway materials
Clinic leaders Behavioral Health Consultant (BHC) Primary Care Providers (PCP) Nurses Administrative personnel Pathway materials Outline for primary care staff Assessment and intervention materials for BHC Patient handouts System supports Registries (or ability to pull patient lists) Secure messaging between patients and providers (desired, but not required) Clinical reminders/prompts in electronic health record (EHR) “Mineable” data entry fields in EHR

20 Identify Criteria for inclusion Processes for identification
BMI > 30 Patients with a diagnosis of obesity Processes for identification Morning huddle review of PCP’s patient roster for the day Weight screening at PCP appointment (by nurse/technician) PCP identification during appointment Data pull from Electronic Health Record (EHR) – BMI or obesity diagnosis Self-referral Referral from other providers/clinics

21 Connect When identified during PCP appointment:
Same-day appointment (warm hand-off) with BHC Scheduled future appointment with BHC When identified through data pull: Primary care staff (nurse, technician) calls patient to schedule a future BHC appointment. Uses standard pathway telephone script Primary care staff sends secure message to patient (using standard pathway language) encouraging a BHC appointment If patients declines BHC appointment: PCP may ask BHC to review available medical information and provide recommendations for care based on the available data

22 Connect: Standard Telephone Script
“Hello. I am Mr./Ms. _______________, a nurse/technician at ________ Clinic. Your PCP, Dr. __________, wanted me to give you a call about some of the details she noticed in your record related to your weight. As part of good comprehensive care for you, she would like you to schedule an appointment with our clinic’s Behavioral Health Consultant, who assists Dr. ___________ by providing recommendations and strategies for better weight management. The appointments are 30 minutes long and are right here in our clinic. Can I get you scheduled for an appointment within the next week or two? If the patient has questions about how a BHC appointment might be helpful for weight management, please provide one or two examples of interventions that the BHC might recommend. “The IBHC might work with you on: Making eating behavior changes that fit with your lifestyle that can make it easier lose weight and keep it off Setting a physical activity plan that fits with your preferences that can make it easier lose weight and keep it off Setting a plan to help manage stress. For many people being able to effectively manage stress makes it easier to lose weight and keep it off”

23 Intervene: Initial BHC Appointment
Biopsychosocial assessment questions specific to obesity Describe your typical eating habits. Describe your typical exercise habits. How long have you been overweight? How long have you been trying to address your weight? Factors related to onset (or worsening) of weight problem. Course of weight gain and weight loss efforts. Which prior weight loss efforts have been most/least successful? How is weight impacting: work performance, relationships, social and/or recreational activities, physical activities, health? Assessment measures Weight/Height, BMI Behavioral Health Measure-20 (BHM-20), a broad-spectrum measure of health and behavioral health

24 Intervene: Initial BHC Appointment (cont’d)
Intervention options: BHC and patient collaboratively select the evidence-based intervention(s) most appropriate for the patient’s difficulties and readiness for change Education on healthy weight loss with a focus on healthy eating and physical exercise Motivational interviewing to determine importance and readiness for change Identifying and problem-solving barriers to change Goal setting for improved health behaviors (e.g., changes to eating, increases to physical activity) Instruction in use of a food and activity diary Education and goal setting for behavior modification strategies for weight management Linking to other PCMH team members or external resources (e.g., dietician, etc.)

25 Example of a patient handout from obesity handout
Example of a patient handout from obesity handout. This is designed to assist with motivational interviewing interventions to increase readiness to increase physical activity/exercise. This is Page 1.

26 This is from Page 2 of the patient handout on physical exercise.

27 This is from an obesity clinical pathway handout on healthy food choices

28 Intervene: Follow-Up Appointments
Follow-up intervals Tailored to patient, based on: Readiness to change Likelihood of successfully making changes with self-management Nature of intervention selected Often, follow-up interval is between 2 to 4 weeks Number of appointments Some patients may improve aspects of weight management in 1 to 4 appointments Many patients will need continuity consultation (> 4 appointments, spaced at longer intervals) to maintain behavior changes Consider monthly or every other month appointments Consider alternating appointments with BHC, PCP, dietician

29 Intervene: Follow-Up Appointments (cont’d)
Assessment BMI and BHM-20 Interview Adherence to behavior change plan Identify barriers to success Change in symptoms (weight) and functioning Intervention options Motivational interviewing Problem solving around identified barriers Goal setting Food/activity diary Calorie reduction plan Replacing high calorie meals or snacks Changing how one eats (e.g., stimulus control, behavior modification) Avoiding or managing high risk situations

30 Process outcome examples
Measure Outcomes Process outcome examples Does pathway implementation lead to improved rates of collaborative care? Compare: % of enrolled population with BMI > 30 who have seen BHC in 6 months prior to pathway, with % who have had > 1 appointment with BHC for obesity during first 6 months of implementation Do pathway patients (those seeing BHC for obesity) accept a referral to nutritional medicine (and keep their scheduled appointments) more frequently than those not seeing BHC? Do patients enrolled in the pathway receive appropriate care from BHC? Minimum of 3 appointments with BHC for obesity Content of intervention appropriate (record review of select charts). Use of at least 2 specified evidence-based interventions must be documented

31 Clinical outcome examples
Measure Outcomes Clinical outcome examples Do patients enrolled in the pathway demonstrate improved clinical outcomes? Change in BMI Percent of total weight lost Do patients enrolled in the pathway show improved health indicators? Decreased blood pressure Decreased cholesterol Decreased A1C (if diabetic) Do patients who show a significant decrease in weight maintain that weight over time? (6 month and 12 month follow-up) 6 month follow-up on above 12 month follow-up on above

32 Future Directions Conduct program evaluation
Consider evaluating standard clinical pathway package + minimal training, versus enhanced implementation support Modify pathway to also target overweight population Tailor pathway for comorbid obesity and diabetes Incorporate shared medical appointments into pathway intervention options

33 Q & A/Summary What are two key conclusions of outcome literature on treatment of obesity in primary care settings? What is a rationale for implementing a primary care-based, population health approach to obesity using the PCBH model of service delivery? What are some key elements in a PCBH clinical pathway for obesity?

34 Thank you! Session Evaluation
Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you! This should be the last slide of your presentation Collaborative Family Healthcare Association 12th Annual Conference


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