PRACTICAL OBESITY CARE: LESSONS FROM PRACTICE
Christopher F. Bolling, MD National Program Chair, AAP Provisional Section on Obesity Obesity Chair, Kentucky Chapter, AAP
LESSON #1
There is no time like the present
GUIDELINES EXIST
American Academy of Pediatrics 2007 recommendations
www.aap.org/obesity
AND MORE SUPPORT TOO
NICHQ and the Childhood Obesity Action Network www.nichq.org/childhood_obesity
THE PROVISIONAL SECTION ON OBESITY
ACKNOWLEDGMENT TO DO THE RIGHT THING
HEDIS measure from NCQA
AND NOT JUST ACKNOWLEDGED, BUT MANDATED
HEDIS measure from NCQA
Healthcare providers should document BMI percentile for age and gender annually in every patients chart between the ages of two and seventeen years.
Healthcare providers should document evidence of counseling for good nutrition and activity annually in every patients chart between the ages of two and seventeen years.
SOME POWERFUL PARTNERS
The Clinton Foundation & The American Heart Association
WITH GREAT RESOURCES
Alliance for a Healthier Generation
SUPPORT AT THE HIGHEST LEVELS
Lets Move!
SOME GOOD TEAMWORK
Physicians should screen for BMI percentile Physicians should give a prescription for good nutrition and increased activity
MY STATE (KENTUCKY) IS REPRESENTATIVE
THE NEED IS STILL VERY HIGH
www.ncsl.org/.../programs/health/ObesityMap.jpg The National Survey of Children's Health, Overweight and Physical Activity Among Children: A Portrait of States and the Nation 2005; HRSA,Health, United States, U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National Center for Health Statistics, 2007.
LESSON #2
Take Credit for What You Are Already Doing!
KEEP SCREENING BMI PERCENTILE! BMI Percentile for age and gender
And the less savory alternatives: Abdominal circumference Body fat analysis Fitness assessment
PRACTICE BASIC PREVENTION
Promote breastfeeding Encourage on demand feeding Limit juice starting early on Talk about feeding cues Prepare parents for neophobia Some great programs (more to follow!)
LESSON #3
Know your community
LIVE THE SOCIOECOLOGICAL MODEL
You are not alone!
AND KNOW YOUR LOCAL RESOURCES
Boys and Girls Clubs Weight Watchers TOPS YMCA JCC Health Clubs Physical Therapy sites Dietitians Personal trainers Health Clubs Parks and Recreation School systems Libraries Child care providers Churches Neighborhood groups Hospitals Community Centers Colleges Culinary Schools Professional schools Nurse organizations Chambers of Commerce Children and Nature Dairy Council Professional Sports Teams City Council members Military recruiters State legislators Members of congress Interested parents United Way Wellness committees Media Various non-profits Boy Scouts Girl Scouts Extension Services 4H And so many more
LESSON #4
Obesity Care in your office is completely scalable
AND SCALABLE IN DIFFERENT WAYS
Severity Timing Complexity
LESSON #5
Pay attention to readiness
IS READINESS THE KEY?
Our Internal Medicine/Family Medicine brethren get this because of dealing with substance abuse Our patients behavior is their behavior Pediatrics is very prescriptive Cold turkey is never an option We cant let challenges with behavior change cause us to blame our patients
MOTIVATIONAL INTERVIEWING
Provides us with a great opportunity to be more effective Fits well into practice Allows a lot (or a little) for you to do Increasing numbers of training opportunities Helps you overcome the I dont have time for that! hurdle And lastly Its fun!
LESSON #6
Set a good example
SO, WHAT DOES
THAT MEAN?
Does not mean you need to be perfect, just trying your best The value of advocacy Office wellness Let your patients and parents see you out there!
THINKING GLOBALLY AND ACTING LOCALLY
EVERYBODY INTO THE ACT
SEEING YOU IN ACTION
LESSON #7
Make it your own
BASE YOUR LEVEL OF INTERVENTION ON
Your motivation Your level of comfort Your resources Your community Your patients need
OUR PROGRAM
Basic Training 14 MDs, 3 NPs, 2 PAs Open to other patients, but all have been our own All providers trained in screening and basic adapted MI Patients referred after screening and readiness addressed Referring provider orders basic labs I do the initial visits (at least currently) Follow-up with either me, our NP Amber (Nutrition Guru) or PA Rachell (Activity Guru) Use CBT basic goal setting with MI counseling techniques Patients pick goals and follow-up schedule Frequently use local resources
BASIC TRAINING INFO SHEET
Handed out to interested families
OUR LAB SHEET
GOAL SHEET
SPECIALIZED BEHAVIOR SHEETS FROM CDC, USDA ETC
OR FROM OTHER PROGRAMS
GET CREATIVE!
LESSON #8
Pick some good workhorses
A GOOD PREVENTION STRATEGY
KEEPING IT GOING
LESSON #9
Pay attention to outcomes, but keep them in perspective
OUTCOMES
Very important for many reasons Keep your improvement cycles going Weight management programs are notoriously difficult to gauge as successful Hard to move the BMI needle, so look at proven intermediate steps Measure absolutely, but dont let it paralyze you from acting
LESSON #10
Organize your referral strategy
THE OBESITY SPECTRUM
Prevention & Healthy Lifestyle Promotion
Identification
Practice Intervention
Midlevel Referral
High Level Referral
Surgical Intervention
Treatment Failure
Environment Schools
Community Interventions Hospital Based Programs
Various Medical Providers
KNOW YOUR TERTIARY CENTER
Diverse and effective centers Obesity is a chronic disease: think ADHD, asthma Stay engaged Know your other resources, especially dietitians
A FEW OTHER THOUGHTS ON REFERRALS
Co-morbidities may need more than you can give, but address them as your comfort level increases Severe obesity-these patients can really derail you if you arent careful The social services dilemma Easy to forget that readiness is still a factor
TEN LESSONS
1) No time like the present 2)Take credit for what you are already doing 3)Know your community 4)Its scalable 5)Pay attention to readiness 6)Set a good example 7)Make it your own 8)Pick some good workhorses 9)Be practical about outcomes 10)Organize your referral strategy
QUESTIONS?
Please feel free to contact me Christopher F. Bolling, MD [email protected] 859-341-5400 office 859-630-8403 cell 859-578-3172 fax
