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 Bolling.cf@gmail.com 859-341-5400 office 859-630-8403 cell 859-578-3172 fax