1. Health not Cosmetics: Four Years of Group Visits Treating Obesity in an Urban Underserved Community José E. Rodríguez MD, Kimberly Painter, MD, MPH Gloria Bent MSRD Florida State University, Albert Einstein College of Medicine, Jacobi Medical Center Society of Teachers of Family Medicine April 28, 2006

3. Overview The problem of obesity in an urban underserved community Use of group visits to aid behavior change Teaching medical students to teach patients Results

4. 1996 1991 Obesity Trends* Among U.S. Adults (*BMI 30, or about 30 lbs overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% 2004

5. The Bronx The Bronx 1 Population 1.5 million 48% Hispanic 31% African American 14% Caucasian 28% Living below poverty 1 U.S. Census Bureau, “Demographic Characteristics-Bronx Community 1990-2000.” http://www.nyc.gov/html/dcp/pdf/census/demonyc.pdf and http://www.nyc.gov/html/dcp/pdf/census/socionyc.pdf

6. Obesity in the Bronx versus NYC

7. Disparities

8. Copyright restrictions may apply. 2 Goel, M. S. et al. JAMA 2004;292:2860-2867. Adjusted Body Mass Index of Foreign-Born Individuals (n = 4631) by Years of US Residence Impact of Immigration on Obesity Rates 2

9. Challenges to Healthy Lifestyles Time Cost Cultural Acceptability Misconceptions Space Desire to Change

10. Attitudinal Barriers “My baby isn’t eating.” “I don’t want to be skinny” (AIDS) Food is love/Eating is family time “We don’t exercise!” “Only big people need to exercise”

11. Misconceptions Energy Metabolism in Lean and Obese Subjects 3 Energy Expenditure (k/cal/d) Resting Energy Expenditure *P<0.05 vs lean subjects 3 Ravussin et al. Am J Clin Nutr 1982;35:566. Total Energy Expenditure Lean (BMI=21 kg/m 2 ) Obese (BMI=38 kg/m 2 ) * *

12. Space Emotional Feeling unsafe outside Lack of recreational space Many cars Many buildings

13. Desire to Change: A Community Survey 4 67% of overweight patients thought their weight was not a problem 63% of obese patients thought their weight was not a problem 63% wanted the help of a physician to lose weight 4 José Rodgriguez, MD (2006) Mobile Health Unit for Minority Obesity Education: Attitudes and Perceptions among County Residents. Manuscript submitted for publication.

15. Health Not Cosmetics: A Drop in Group Medical Appointment (DIGMA) Weekly group visits supporting lifestyle modification Free of charge, no appointment necessary Patient and provider website for education Resource for community residents Rotation within the Albert Einstein College of Medicine Family Medicine Clerkship.

16. The Class

17. Components of Behavioral Therapy for Obesity Wadden and Foster. Med Clin North Am 2000:84:441. Self Monitoring Problem Solving Contingency Management Cognitive Restructuring Social Support Stress Management Stimulus Control

18. DIGMA Logistics Patients registered and weighed by clinic staff Lifestyle modification discussion led by medical students Exercise Personalized Videos Time after class for individual concerns Short note on class written in charts by provider

19. Materials Produced DVD Healthier lifestyles—one step at a time Resistance Training Poster Food Diary Magnets Pyramid Handouts Healthy Alternatives

23. Diffusion of Materials Weekly Group Visits Website: http://www.healthnotcosmetics.org/ Vehicle Assisted Nutrition

25. Results

26. Subjective Impact for participants’ “My kids and I became conscious of what we’re eating and of our portion size. We now read labels.” “I never knew how much nutrition information was available on the internet.” “My favorite part is doing the exercises.” “I only came once but I would love to come again if I had more time.” “I loved it!”

27. Demographics of Class 103 Women, 40 Men Average BMI for women-33 Average BMI for men-31 Average age 36

28. Weight Loss

29. MaleFemale sex 100 80 60 40 20 0 Count Yes No Pt participated 1 or more times Participation by Sex

30. Hemoglobin A1C

31. Qualitative Student Feedback “Dr. Rodriguez is so enthusiastic its gripping” “The issue is crucial to healthcare in America” “It was fulfilling and fun but just too time intensive” “Dr. Rodriguez was great. Project is awesome. I wish more participants came to the classes”

32. Student Feedback

33. Project Evaluations

34. Improvement in Student Skills

35. Contact Information Jose E. Rodriguez, MD www.healthnotcosmetics.org josé.rodriguez@med.fsu.edu Florida State University College of Medicine Department of Family Medicine and Rural Health 850 645 6850 Kimberly Painter MD, MPH Painter.kim@gmail.com Department of Family Medicine Albert Einstein College of Medicine 718-918-8750

38. Acknowledgements Dr. Jean Burg Dr. Darwin Deen Dr. Alice Fornari Dr. Marji Gold Mrs. Rodriguez Gladys Valdivieso My children for motivating me to make positive changes in my life All of the medical students, whose projects helped to create these slides William Werbel