1. Sweetened Beverage Screening QI Project WHFHC 2011-2012

2. Youtube clip “Man eating sugar. New York City Health Department”

3. Background Children younger than 12 yr old account for only 18% of the US total population, but consume 28% of all juice and juice drinks By 1 year of age, almost 90% of infants consume juice. Toddlers consume a mean of ~ 6 oz/day of juice. Almost 20% of children 2-5 years old drink more than 12 oz/day. Between 56% and 85% of children consume at least 1 soft drink daily in school.

4. AAP recommendation Intake of fruit juice should be limited to 4 to 6 oz/d for children 1 to 6 years old. For children 7 to 18 years old, juice intake should be limited to 8 to 12 oz or 2 servings per day. “The Use and Misuse of Fruit Juice in Pediatrics”, Pediatrics, May 2001

5. Why do we care?

6. Our Aim Our aim is to improve rates of nutritional screening for sweetened beverage consumption in children ages 2-6 years old from the July 2011 baseline of 46% to 80% by the end of the academic year with emphasis on promoting reduction of total daily consumption to 6 fl oz or less.

9. Baseline data Percentage of charts recorded

10. PDSA Cycles Cycle #1: November 2011, Use CHALK handout as both nutrition counseling and prompt to providers To be given to parent by PFA at time of registration Zero pts received handout

12. PDSA Cycles Cycle #2: December 2011, Didactic session for providers on sugary beverage counseling, MA attaches sugary beverage questionnaire to chart as prompt for providers 100% of patients 2-6 yrs received form Chart review of those visits where handout was given: 75% providers checked off dietary concerns 58% providers checked off juice/sweetened beverages

13. Top counseling points for providers 1. Limit sweetened beverage intake 1-6yo: 4-6 oz 7-18yo: 8-12 oz 2. Whole fruits are superior 3. Read labels to check for 100% juice content 4. Juice should be part of meal or snack, not sipped throughout day 5. Do not give unpasteurized juice

14. PDSA Cycles cont Cycle #3: March, 2012, Efficacy of screening to increase provider by-in (and hopefully continue to increase screening rates and documentation) 0/6 patients mentioned the link between sweet beverages and obesity 3/6 associated them with hyperactivity, 1/6 mentioned cavities Cycle #4: Create English/Spanish hand-out emphasizing link between sugary beverage intake and obesity Poll parents re: efficacy of handout Survey parents re: link between sugary beverages and obesity before and after WCC Survey providers

16. PDSA Cycle #4: Efficacy of handout – do parents like it? Parents opinion: 100% pointed to picture as helpful 0% found the handout unclear 100% correctly summarized handout in their own words 88% stated they were already aware of sugar-fat connection 100% felt handout was useful to reinforce message

17. Efficacy of Handout – is it helping during visits? Post visit questionnaire: Has your opinion about the amount of juice your child drinks changed? If so, how? Has your opinion about sweet beverages changed? If so, how? Did your doctor use the handout to discuss these issues with you

18. Efficacy of handout - Provider survey 80% found handout clear 100% thought handout gave right message 80% thought handout would be helpful 98% maybe to very likely to use handout

19. End of year data review Percentage of charts recorded

20. Conclusion Childhood obesity is an extremely challenging but important issue to tackle within pediatrics. Sweetened beverage intake is an important contributor to excess calories, which may lead to obesity. We are doing a good job with counseling – but what are parents hearing? Handout helps parents see link between sugary and obesity and may help with physician screening

21. Limitations Provider-only project PDSA cycles and chart reviews did not include BMI Medically complex patients

22. What can we spread New handout!

25. References Gidding, S.S., Dennison, B.A., Birch, L.L., et al. AHA Scientific Statement: Dietary Recommendations for Children and Adolescents, A Guide for Practitioners. American Heart Association. Sept 2005. Baker, S.S., Cochran, W.J., Greer, F.R, et al. The Use and Misuse of Fruit Juice in Pediatrics. American Academy of Pediatrics Committee on Nutrition. Vol 107 No. 5 May 2001. Spear, B.A., Barlow, S.E., Ervin, C., et al. Obesity Recommendations for Treatment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007. 120;S254. American Academy of Pediatrics, The use and misuse of fruit juice in pediatrics. Pediatrics. 2001 New York City Department of Health anti-sugar campaign

26. THANK YOU 181st! Attendings: Annie Armstrong, Steve Caddle, Melanie Gissen, Rebecca Friedman, Adriana Matiz, Dodi Meyer, Kim Noble, John Rausch, Minna Saslaw, Dana Sirota Residents: Edna Akoto, Serine Avagyan, Emily Eida, Anna Gay, Carly Gomes, Faith Ihekweazu, Laura Kurek,Ted Macnow, Amy Ost, Sarah Richman, Vanessa Salcedo, Zoya TreysterKristen Williams, Jason Winkler, Daniel Yu MAs: Aurora Gomez, Maribel Jimenez, Carmen Nicasio, Petra Ortiz, Candida Rodriguez RNs: Joan Mahoney, Jessie Mane, Gerthy Michel PFAs: Cindy Ferrer, Sheila Grant Mclean, Jasmin Pena, Ivelisse Rodriguez, Lelanie Vinales