Flood* Control… it takes a village.(*whatever the inundation)

The NECON Initiative as a Case Study in Collaborative Obesity Control

David L. Katz, MD, MPH, FACPM, FACPDirector, Prevention Research CenterYale University School of Medicine

www.davidkatzmd.com

National Obesity Action ForumJune 5, 2006

NECON, 101

• New England Coalition for Health Promotion

• Established in 1984 • Mission: to serve as an instrument for the development and

enhancement of disease prevention and health promotion public policies in New England

• Has evolved into: a coalition of the New England state health departments, the region's schools of public health, and federal health agencies led by Region I of the U.S. Department of Health & Human Services, as well as medical societies, legislators, and representatives from industry, labor, and voluntary associations

• Funding sources include charitable trusts and foundations, private industry, voluntary sectors, and federal agencies

• Responsive to the New England Governors’ Conference 

www.neconinfo.org

A cast of thousands.

• Or, at least…• Mr. Bert Yaffe

A weighty charge-

• regional Task Force to develop a Strategic Plan for the Prevention and Control of Overweight and Obesity in New England

• chaired by Dr. Walter Willett, Harvard School of Public Health

• extensive and regionally representative working group of over 100 members 

No problem!*

• Work began 2001; report issued 2003• http://www.neconinfo.org/02-11-2003_Strategic_Plan.pdf

*possible problem…stay tuned

Health Care Provider Working Group

• Focus on health care providers*

• One of several such working groups (media, schools, worksites, government, etc.)

• *hence, the name

Working Group Members

• Dr. Lon Sherman

• Dr. Jennifer Tremmel• Carol Apovian; Joanne Bean; David Blackburn;

Jill Braverman-Panza; Bob Breen; Diana Cullum-Dugan; Katherine McManus; Barry Pailet; Judy Phillips; Donald Swartz

• Serena Domolky

Key ConceptsInforming Recommendations:

• Evidence is the best basis for recommendations, but is substantially deficient in this field.

• Professional judgment, expert opinion, and practical insights serve where evidence is lacking.

Health Care Provider Recommendations:

• Recognize the epidemic of obesity as a by-product of environmental change rather than individual failure.

• Provide non-judgmental and supportive weight control counseling to all patients.

• Recognize evidence of weight control modalities that have proven effectiveness, and recognize false product and program claims.

• Recognize and convey to patients the importance of lifelong approaches to weight control that are consistent with overall health promotion, rather than short-term diets that may fail to address salient aspects of nutritional health (e.g., abundant intake of fresh vegetables and fruit).

Health Care Provider Recommendations, cont.

• Providers should routinely counsel every patient about the benefits of weight control rather than waiting until a patient develops an obesity-related disease.*

• Providers should routinely monitor the BMI of both adults and children, in conjunction with non-judgmental feedback to patients regarding healthy weight.

• Clinicians should encourage an inter-generational, family-based approach to weight control that focuses on overall health promotion, not just weight.

• Health care providers should practice healthful eating and regular physical activity, for their own sake, as well as to serve as an example for patients as to what is realistic and achievable.

*willful digression from: www.prevent.org/ncpp & http://www.ahcpr.gov/Clinic/uspstf/uspsdiet.htm

Policy Recommendations

• A regional clearinghouse, readily accessible to all providers, should be established that will gather and distribute information about nutrition, physical activity, weight-control counseling, clinic-based resources and innovations.

• Medical schools should prepare future providers for effective weight control counseling, including multi-cultural competency, by dedicating time in training curricula to this goal and offering practicing physicians opportunities for continuing medical education in this field.

• Weight control counseling should be a reimbursable clinical service.

And now the bad news-

• Another PDF, gathering dust (or the cyberspace equivalent…)*

* possible problem, noted earlier

Counseling Can Matter:• Fallon EA, Wilcox S, Laken M. Health care provider advice for African American adults not meeting health behavior recommendations. Prev Chronic Dis.

2006 Apr;3(2):A45. Epub 2006 Mar 15. • Staten LK, Gregory-Mercado KY, Ranger-Moore J, Will JC, Giuliano AR, Ford ES, Marshall J. Provider counseling, health education, and community

health workers: the Arizona WISEWOMAN project. J Womens Health (Larchmt). 2004 Jun;13(5):547-56• Patrick K, Sallis JF, Prochaska JJ, Lydston DD, Calfas KJ, Zabinski MF, Wilfley DE, Saelens BE, Brown DR. A multicomponent program for nutrition and

physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med. 2001 Aug;155(8):940-6• Calfas KJ, Sallis JF, Zabinski MF, Wilfley DE, Rupp J, Prochaska JJ, Thompson S, Pratt M, Patrick K. Preliminary evaluation of a multicomponent program

for nutrition and physical activity change in primary care: PACE+ for adults. Prev Med. 2002 Feb;34(2):153-61• Bradbury J, Thomason JM, Jepson NJ, Walls AW, Allen PF, Moynihan PJ. Nutrition counseling increases fruit and vegetable intake in the edentulous. J

Dent Res. 2006 May;85(5):463-8• Ammerman AS, Lindquist CH, Lohr KN, Hersey J. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of

the evidence. Prev Med. 2002 Jul;35(1):25-41• Stevens VJ, Glasgow RE, Toobert DJ, Karanja N, Smith KS. Randomized trial of a brief dietary intervention to decrease consumption of fat and increase

consumption of fruits and vegetables. Am J Health Promot. 2002 Jan-Feb;16(3):129-34• Wong SY, Lau EM, Lau WW, Lynn HS. Is dietary counselling effective in increasing dietary calcium, protein and energy intake in patients with

osteoporotic fractures? A randomized controlled clinical trial. J Hum Nutr Diet. 2004 Aug;17(4):359-64• Goldstein MG, Whitlock EP, DePue J; Planning Committee of the Addressing Multiple Behavioral Risk Factors in Primary Care Project. Multiple

behavioral risk factor interventions in primary care. Summary of research evidence. Am J Prev Med. 2004 Aug;27(2 Suppl):61-79• McInnis KJ. Diet, exercise, and the challenge of combating obesity in primary care. J Cardiovasc Nurs. 2003 Apr-Jun;18(2):93-100; quiz 101-2• van Weel C. Dietary advice in family medicine. Am J Clin Nutr. 2003 Apr;77(4 Suppl):1008S-1010S• Pignone MP, Ammerman A, Fernandez L, Orleans CT, Pender N, Woolf S, Lohr KN, Sutton S. Counseling to promote a healthy diet in adults: a summary

of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med. 2003 Jan;24(1):75-92• Sciamanna CN, DePue JD, Goldstein MG, Park ER, Gans KM, Monroe AD, Reiss PT. Nutrition counseling in the promoting cancer prevention in primary

care study. Prev Med. 2002 Nov;35(5):437-46• Saelens BE, Sallis JF, Wilfley DE, Patrick K, Cella JA, Buchta R. Behavioral weight control for overweight adolescents initiated in primary care. Obes Res.

2002 Jan;10(1):22-32• Kreuter MW, Cheda SG, et al. How Does Physician Advice Influence Patient Behavior? Evidence for a Priming Effect. Arch Fam Med 2000;9: 426-433 • Nawaz H, Adams M, Katz DL. Weight loss counseling by health care providers. Am J Public Health. 1999;89:764-767• Schectman J, Stoy D, Elinsky E. Association between physician counseling for hypercholesterolemia and patient dietary knowledge. Am J Prev Med.

1994;10:136-139• Ockene I et al. Arch Intern Med. 1999;159:725-731• Katz DL. Effective dietary counseling: helping patients find and follow "the way" to eat. W V Med J. 2002;98:256-9 • Nawaz H, Katz DL. American College of Preventive Medicine Practice Policy statement. Weight management counseling of overweight adults. Am J Prev

Med. 2001;21:73-8

…but it’s no Sunday picnic!

• Moore H, Adamson AJ. Nutrition interventions by primary care staff: a survey of involvement, knowledge and attitude. Public Health Nutr. 2002;5:531-6

• Brotons C, Ciurana R, Pineiro R, Kloppe P, Godycki-Cwirko M, Sammut MR; EUROPREV. Dietary advice in clinical practice: the views of general practitioners in Europe. Am J Clin Nutr. 2003;77(4 Suppl):1048S-1051S.

• Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA. 1999;282:1576-8

• Kushner R. Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners. Prev Med. 1995;24:546-552

• Goodson P, Smith MM, Evans A, Meyer B, Gottlieb N. Maintaining prevention in practice. Survival of PPIP in primary care settings. Am J Prev Med. 2001;20:184-9

• Hiddnick G, Hautvast J, Woerkum Cv, Fieren C, Van't Hof MA. Nutrition guidance by primary-care physicians: perceived barriers and low involvement. Eur J Clin Nutr. 1995;49:842-51

An impasse; but impassable?

• Providers won’t counsel without reimbursement

• Payers won’t reimburse without evidence that providers can counsel

Not for a village…

• of villages.

Training On-line to Overcome the Counseling Impasse-

• Of CME credits, controlled trials, & cost-effectiveness

Leading Theories

• Theory of Reasoned Action

• Health Beliefs Model

• Social Cognitive Theory/Self-efficacy

• Transtheoretical Model/Stages of Change & Processes of Change

Institute of Medicine. Health and Behavior: the Interplay of Biological, Behavioral, and Societal Influences. National Academy Press. Washington, D.C. 2001

Primary care adaptations,a la Goldilocks…

• WATCH• Ockene IS et al. Effect of physician-delivered nutrition counseling training and an office-

support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Intern Med. 199912;159:725-31

• PACE• Calfas KJ et al. Preliminary evaluation of a multicomponent program for nutrition and

physical activity change in primary care: PACE+ for adults. Prev Med. 2002;34:153-61

• Green Prescription• Kerse N et al. Is physical activity counseling effective for older people? A

cluster randomized, controlled trial in primary care. J Am Geriatr Soc.

2005;53:1951-6

• STEP• Petrella RJ et al. Can primary care doctors prescribe exercise to improve

fitness? The Step Test Exercise Prescription (STEP) project. Am J Prev Med. 2003;24:316-22

Home grown, & simple-minded:

• Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001;32:66-72

From Here, to There, with the Right “M/O”

• M = maximizing motivation

• O = overcoming obstacles

Pressure Tactics

Pressure System Model:

As wind blows from high to low pressure,behavior is moved by the greater force.

Motivation Difficulty

Maintenance of status quo Change

Pressure System Model:

Why behavior may not changeeven if you’re highly motivated

Motivation Difficulty

Maintenance of status quo Change

Current focus of behaviorchange efforts:

Here But:

Motivation Difficulty

Maintenance of status quo Change

Assessing need

• in 2 loaded questions:

Katz DL. Prev Med. 2001;32:66-72

Counseling Algorithm:

1.Are you currently eating a diet based mostly on vegetables, grains, and fruits?

YES: Category 3 NO, I have been, but stopped temporarily: Category 4 NO, I have tried one or more times, and given up: Category 5 NO, I never have been: Go to question 2

2.Are you ready to start eating a healthful diet?

YES: Category 2 NO: Category 1

PSM Categories:

• Engaged in healthful behavior?• No: go to question 2• Yes: (D)

• Interested?• No, never (A)• Yes (B)• Maybe; recently lapsed (C)• No; tried many times & failed (C)

The PSM Categories

• Category A (no/no) is unprepared for change• Category B (no/yes) is on the brink of change• Category D (yes) is in the midst of change

Category C (no) is a temporary lapse or the futility and discouragement that come from multiple, unsuccessful attempts

Counseling ProtocolsHELP is on the way…

• A = low motivation

• B = motivated, but anticipating barriers

• C = relapse / burnout

• D = maintenance

• Focus on “M”

• Focus on “O”

Raising Motivation

• More than just encouragement…

Motivational Interviewing

General Principles:

• 1) express empathy / acknowledge ambivalence• 2) develop discrepancy• 3) avoid argumentation• 4) roll with resistance• 5) support self-efficacy• 6) encourage social contracting

– Miller WR. Addict Behav. 1996; Rollnick S. Int J Obes. 1996

Decision Balance

• Lets patient “talk themselves” into behavior change

• Change emphasis of counseling as indicated by sources of patient’s ambivalence

Decision Balance for Physical Activity. Cells in the balance show some hypothetical entries.

Increase Physical Activity

  

Advantages

Weight loss

Better health

More energy

 

 

  

Disadvantages

Hard work

Limited time

Unsure how

 

 

Maintain Current Activity Level

  

Advantages

Easy

Comfortable

Avoid injury

Avoid sweating

 

  

Disadvantages

No weight loss

No health benefits

Possible weight gain 

 

Motivation can be the sound of one hand clapping…

Overcoming Resistance

• Acknowledge obstacles

• Convert obstacles into challenges/opportunities• Identify/surmount universal barriers

• Identify/surmount patient-specific barriers

PSM Study Team• David L. Katz, MD, MPH, FACPM: PI; Yale Prevention Research Center, Yale

Schools of Medicine & Public Health

• Paula Milone-Nuzzo, RN, PhD, FAAN : co-PI; Yale School of Nursing

• Philip Troped, MS, PhD; Harvard Prevention Research Center

• Karen Schultz, MPH; Yale Prevention Research Center

• Rosalie G. Barretta, PhD; Yale Prevention Research Center

• Anna-leila Williams, MPH, PA-C; Yale Prevention Research Center

• Loretta DiPietro, PhD; Yale School of Public Health

• Melinda Irwin, PhD; Yale School of Public Health

• Barbara Ainsworth, PhD; University of South Carolina Prevention Research Center

• Karen Calfas, PhD; San Diego State University School of Medicine

• Acknowledgements to:• the Yale Affiliated Hospitals/Medical Residency Programs• American Heart Association

Methods

• Randomized allocation of hospitals in Yale-affiliated system

• Focus on 1st year medical residents, ambulatory clinics

• Training of residents vs. usual instruction for controls

• Provision of materials to clinics

Proof (promise) in the Pudding (pedometers)…

In a randomized trial of the PSM among 1st year medical residents in the Yale-affiliated hospital system, patient (n = 316) physical activity increased significantly from baseline (1.77+/- 0.84; p=0.0376 & 1.94+/-0.98; p=0.0486 respectively) at 6 months and 12 months of intervention, as measured by the YPAS, in the intervention group; no change in the control group

Manuscript under review, 5/06: Acad Med

The Trouble in Getting to Solla Sollew…

• Doesn’t take many troubles, not even a few. A single intractable trouble will do!

Impediment Profiling

• Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001;32:66-72

• Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC. Impediment profiling for smoking cessation. Preliminary experience. Behav Modif. 2003;27:524-37

• O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan W, Katz DL. Impediment profiling for smoking cessation: results of a pilot study. Am J Health Promot. 2003;17:300-3

• O'Connell ML, Freeman M, Jennings G, Chan W, Greci LS, Manta ID, Katz DL. Smoking cessation for high school students. Impact evaluation of a novel program. Behav Modif. 2004;28:133-46

• More papers in press

Obstacles to Eating Well in the Modern World:

• physiology / metabolism

• sociocultural influences

• psychological influences

• & the modern world itself (environmental influences)

– Katz DL. The Way to Eat. Sourcebooks: 2002

In pursuit of…NnOLEDGE

• NIH funded project to establish impediment profiling for dietary change now on-going

The Vision-

• On-line training

• CME credits

• Quality control indicators embedded

• Controlled access at first

• Cost-utility analysis

• Trust, verify, disseminate

The game is afoot…

• The players include:• NECON

• Sanofi-Aventis

• Regional Insurers

• And…?

Our patients need all the help they can get….

For Whom the Bell Curve Tolls-

Obesity Surgery Increases by 600 Percent

Safer Techniques, More Insurance Coverage and Celebrity Patients Make It More Appealing

http://abcnews.go.com/Health/story?id=2025533&page=1

• By BHARATHI RADHAKRISHNAN, ABC News Medical Unit

May 31, 2006

BMIBMI

2525 4040

For Whom the Bell (Curve) Tolls…For Whom the Bell (Curve) Tolls…

PopulationPopulation

To contain a flood…

No single sandbag will do!

I look forward to stacking sandbags with you!

david.katz@yale.eduYale Prevention Research Center

130 Division St.Derby, CT 06418

www.davidkatzmd.com