1. Maine Center for Public Health Maine Chapter – American Academy of Pediatrics 1 Maine Youth Overweight Collaborative Improving the Prevention, Identification, and Treatment of Youth Overweight

2. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 2 Why Youth Overweight? Why Now? Enormous problem! –Prevalence of youth overweight tripled in past two decades –Hugely costly Human costs Economic costs Known gaps in care, opportunities for improvement

3. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 3 JAMA, April 5, 2006, Vol 295, No. 13, 1549-1555 How many children are overweight? Since 1963, the number of overweight children in the U.S. has tripled! Kaiser Permanente R EGIONAL H EALTH E DUCATION

4. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 4 Youth Overweight in Maine… Nearly one-third youth in Maine at risk for overweight or overweight! One in six Maine youth are currently overweight (BMI  95%’ile for age/gender) o15.3% Maine youth 6-11yo o15.4% youth 12-19yo 36% of Maine kindergarteners at risk for overweight or overweight!

5. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 5 Do overweight children grow up to be overweight adults ? The older the overweight child is, the more likely he/she will continue to be overweight as an adult. 8 out of 10 overweight teens will continue to be overweight as adults. Preventive Medicine 1993; Vol. 22:pp. 167-177 Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452 Kaiser Permanente R EGIONAL H EALTH E DUCATION

6. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 6 The Bottom Line ENERGY IN ENERGY OUT!! EXCEEDS >>

7. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 7 Individuals & Families Who’s Job is it to Promote Healthy Weight? Schools & Universities Healthcare Organizations Public Health Housing & Community Clinicians Family & Home Business & Employers Childcare providers

8. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 8 Informed, Activated Patient ProductiveInteractions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design DecisionSupport Clinical Information Systems Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization (Chronic)Care Model

9. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 9 MYOC2 Key Changes Assess BMI % for age/gender on all children (2-18yo) annually; follow recommendations for med assessment of overweight youth Educate families & patients about healthy lifestyles (5210 survey!), and risks, complications of overweight; provide compassionate support for change Identify care team in practice to promote change, clarify roles for team members Use registry to improve care Partner with community organizations to impact healthy lifestyles for youth

10. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 10 For ALL children on annual preventive visit: Have parents / child complete 5-2-1-0 Survey Calculate BMI and Plot BMI% for Age For children determined to be overweight, or at risk of overweight Perform in-depth medical assessment Determine weight goals Order screening lab tests Provide brief focused advice & goal setting Arrange for follow-up visit or phone call Annual Well Child Care Visit A Practical Approach to Overweight Children Kaiser Permanente R EGIONAL H EALTH E DUCATION

11. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 11 STEP 1: Assess Weight Using BMI % age Measure height & weight Calculate BMI % for age/gender on all children 2-18yo at least once annually, on annual preventive health visit

12. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 12 BMI % for age / gender

13. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 13 Why do we use BMI? Consistent with adult standards and tracks childhood overweight into adulthood BMI for age relates to health risks including cardiovascular disease, hypertension and type 2 diabetes In the absence of sufficient evidence, recognition must precede solutions BMI measurement is recommended by the AAP, CDC, IOM, AHA at all well child care visits 2 years & older Pediatrics Vol. 112 No. 2 Aug 2003 Pediatrics Vol. 116 No. 1 July 2005 Kaiser Permanente R EGIONAL H EALTH E DUCATION

14. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 14 Tools for Measuring BMI

15. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 15 STEP 2: Classify Weight Status BMI % for age/gender – Underweight < 5% – Healthy weight: 5-84 th % – At Risk of Overweight (Overweight) 85-94 th % – Overweight (Obese)  95 th % (1) Pediatrics Vol. 101 No. 3 March 1998 (2) Pediatrics Vol. 105 No. 5 May 2000 Early Adiposity Rebound (4Y) Kaiser Permanente R EGIONAL H EALTH E DUCATION

16. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 16 Diagnosing Overweight Early Adiposity Rebound –Definition: Adiposity rebound is the point when the BMI is the lowest for a child before it increases again –Experiencing early adiposity rebound (rebound before 5-6 years old) is a risk factor for subsequent adiposity in adulthood (1) and is associated with parental obesity (2) (1) Pediatrics Vol. 101 No. 3 March 1998 (2) Pediatrics Vol. 105 No. 5 May 2000 Early Adiposity Rebound (4Y) Kaiser Permanente R EGIONAL H EALTH E DUCATION

17. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 17 STEP 3: Assess & Promote Healthy Behaviors Use “5-2-1-0” survey to assess current behaviors and encourage healthy lifestyles (do 5210 survey at least once annually, on annual preventive health visit)

18. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 18 What behaviors are related to youth overweight? Not enough physical activity. Too much TV & video games. Not enough milk, dairy, fruits and vegetables. Too many sweetened drinks (e.g., soda, juice drinks, sports drinks) and too much fast food. Skipping meals and breakfast. Position Paper - Prevention of Childhood Overweight What Should Be Done? Center for Weight and Health - U.C. Berkeley 10/02 Kaiser Permanente R EGIONAL H EALTH E DUCATION

19. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 19 Healthy Lifestyle Behaviors  Five or more fruits or vegetables per day  Two hours or less of total “screen time”  One hour or more of physical activity every day  Limit soda and sugared drinks or whole milk

20. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 20 5-2-1-0 Preventive Message 5 or more fruits or vegetables per day 2 hours or less of total “screen time” 1 hour or more of physical activity daily Zero sugared drinks or whole milk

21. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 5-2-1-0 Survey

22. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 22 Can overweight among children be prevented? Breastfeed for the first year. Wean from the bottle at 12 months of age. Limit juice and other sweetened drinks to 4-6 ounces per day max. Limit TV - none before 2 years, 1 hour or less over 2 years of age. Avoid using food as a reward for good behavior. J Pediatr Vol. 141 No. 6 December 2002 JAMA Vol. 285 No. 19 May 2001 Kaiser Permanente R EGIONAL H EALTH E DUCATION

23. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 23 STEP 4: Identify Next Steps Use Youth Overweight & Medical Evaluation algorithms to determine appropriate next steps based on weight classification, risk factors Determine need for further evaluation, management

24. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 24 Guidelines for Prevention & Management of Overweight in Children 2-18 yrs ALL PATIENTS at ANNUAL Preventive Well-Child Check 1. Measure and plot Ht & Wt 2. Calculate BMI and plot BMI% for age/gender  classify weight 3. Ask patient / family to complete “Keep ME Healthy 5-2-1-0” Survey BMI 5%- 84% ’ile for age/gender Ideal wt BMI 85-94%’ile for age/gender “At Risk for Overweight” BMI  95% ’ile for age/gender “Overweight” Reinforce healthy eating & physical activity with “5-2-1-0” messages Family Hx, Physical Exam + FH 1 familial hyperlipidemia, early vascular disease 2, or type 2 diabetes, OR Phys exam findings c/w overweight comorbidity 3, OR rapidly accelerating wt gain 4 1.Perform medical evaluation for overweight 2.Assess mental health and readiness to change Assess nutritional needs; consider referral for education and support of weight management goals; Consider referral to medical and/or mental health specialist(s) as indicated Re-evaluate annually Follow up 5 to reinforce behavioral changes in 1-2 mos, then every 1-2 mos X2-3 Recheck BMI q 3-4mos Follow up 5 to reinforce behavioral changes every 1 month X3 visits; then q3-4 mos Recheck BMI q3mos Promote healthy eating & physical activity with “5-2-1-0” messages Assess family patterns & dynamics, food & phys activity habits, and discuss goal setting; if patient/family ready to change, discuss goal setting Normal FH and Phys Exam Assess family patterns & dynamics, food & phys activity habits, mental health and readiness to change; if patient/family ready to change, discuss goal setting Promote healthy eating & physical activity with “5-2-1-0” messages & tools (e.g. “healthy plate”, pedometer, referral to community physical activity resource) Maine Center for Public HealthOctober 2004

25. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 25 Clinical Guidelines (Medical Evaluation)

26. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 26 “ What should my child weigh?” Tell parent what weight would be for BMI 85% Focus is on making improvements in family lifestyles –Making better food choices –Being more active, not on weight or weight loss Advise that physician / health professional will follow child’s height, weight and BMI, and provide follow up on how family is doing Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29 Kaiser Permanente R EGIONAL H EALTH E DUCATION

27. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 27 What are recommended weight goals? Older Adolescents and Adults: 10% weight loss from baseline over 6 months Kaiser Permanente R EGIONAL H EALTH E DUCATION

28. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 28 STEP 5: Support Appropriate Goal Setting Use “brief focused negotiation” and other motivational techniques to… –Identify patient & family’s readiness to make changes –Set realistic behavior change goals Kaiser Permanente R EGIONAL H EALTH E DUCATION

29. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 29 The Role of the Physician and Practitioner All Children Get up and play hard Cut back on TV and video games Eat 5 helpings of fruits and vegetables/day Cut down on sodas & juice drinks A DVISE I DENTIFY Children at Risk or Overweight Screen with BMI starting at age 2 for all children Focus on key intervention ages M OTIVATE Families at Risk to Make Changes Ask permission to discuss weight Negotiate areas of improvement Assess readiness to change Explore ambivalence Offer information, referral if indicated and follow-up Kaiser Permanente R EGIONAL H EALTH E DUCATION

30. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 30 What are more sensitive ways to address overweight? Obesity Ideal Weight Personal Improvement Focus on Weight Diets or “Bad Foods” Exercise Overweight Healthier Weight Family Improvement Focus on Lifestyle Healthier Food Choices Play or Activity Effective Communication with Families, Kaiser Permanente, © 2004 Kaiser Permanente R EGIONAL H EALTH E DUCATION

31. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 31 Lifestyle Advice (All Families) To stay healthy and energized, Get up and play hard 30-60 minutes each day Limit TV / video games to <1 hour each day Eat five helpings of fruits and vegetables each day Limit soda and juice drinks to <1 small cup each day Effective Communication with Families, Kaiser Permanente, © 2004 Kaiser Permanente R EGIONAL H EALTH E DUCATION

32. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 32 Brief Focused Advice Step #1: Engage the Patient / Parent Can we take a few minutes to discuss your health and weight? How do you feel about your health and weight? Effective Communication with Families, Kaiser Permanente, © 2004 Kaiser Permanente R EGIONAL H EALTH E DUCATION

33. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 33 Brief Focused Advice Step #2: Share Information (optional) Your current weight puts you at risk for developing heart disease and diabetes. What do you make of this? Some ideas for staying healthy include…. (see 5-2-1-0 Survey) What are your ideas for working toward a healthy weight? Effective Communication with Families, Kaiser Permanente, © 2004 Kaiser Permanente R EGIONAL H EALTH E DUCATION

34. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 34 Step #3: Make a Key Advice Statement I would strongly encourage you to… –Get up and play hard, 30-60 minutes a day. –Cut back on TV & video games to 60 min/day. –Eat 5 helpings of fruits of vegetables every day. –Cut back on sodas & juice drinks to 1 small cup/day. –Use patient ideas from step #2 Brief Focused Advice Effective Communication with Families, Kaiser Permanente, © 2004 Kaiser Permanente R EGIONAL H EALTH E DUCATION

35. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 35 Step #4: Arrange for Follow up Would you be interested in more information on ways to reach a healthier weight? AND / OR Let’s set up an appointment in 1-4 weeks to talk about this further. Brief Focused Advice For more info on Brief Focused Advice, see Kaiser Permanente-learning module at http://www.kphealtheducation.org/PWM_Gold/conversation.html http://www.kphealtheducation.org/PWM_Gold/conversation.html Effective Communication with Families, Kaiser Permanente, © 2004 Kaiser Permanente R EGIONAL H EALTH E DUCATION

36. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 36 Who can you ask for help? Joan Orr –Maine Center for Public Health - MYOC Project Director –207.629.9272; jorr@mcph.org Lisa Letourneau MD –MaineHealth - Senior Director, Clinical Integration –MYOC Physician Advisor –207.541.7521; letoul@mmc.orgletoul@mmc.org Tory Rogers MD –MMC – Barbara Bush Children's Hospital - Director, Kids COOP –MYOC Quality Improvement Advisor –207.662.2410; rogerv@mmc.orgrogerv@mmc.org Susan Levenseler –Maine Medical Partners - Clinical Quality Improvement Manager –207.523.3246; levens@mmc.org Naomi Anderson MPH –MaineHealth – Healthy Weight Program Manager –207.541.7554; andern@mmc.org

37. Maine Center for Public Health Maine Chapter- American Academy of Pediatrics 37 With Thanks to… Maine Center for Public Health Maine Chapter American Academy of Pediatrics Dr. Scott Gee, Kaiser Permanente Regional Health Education