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Pediatric Obesity: Provider Skill Sets for
Improved CareScott Gee, MD
Kaiser Permanente
February 18, 2010French Camp, CA
Disclosure
Pediatric Skill Sets for Improved Care• I have no relevant financial relationship with
the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.”
• “I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.”
Workshop Objectives
Provide the Vision for this Toolkit Plus Training Provide tips for setting up your provider trainings Review Toolkit Plus Training Materials
CMAF Child & Adolescent Obesity Provider Toolkit Health Net/CMAF companion flip chart Quick & Basic Training Guide & health education tools
Workshop Objectives
Explain why AMA Expert Committee & NICHQ pediatric obesity guidelines & recommendations support skill sets
Review Provider Role and Practice Pediatric Obesity Provider Skills:
1. BMI Screening2. Preventive Counseling3. Clinical Follow-up & Resources
Tips for Obesity Training Tips for Obesity Training Regional or Community Wide CME Event
Weekday breakfast, lunch or dinner, Saturday morning Good food more important than CME Usually 1-2 hours long Physicians, Nurses and Dieticians
Office Training Lunch or dinner Good food more important than CME Usually 45 – 60 minutes long Physicians, Nurses, and Medical Assistants More effective with academic detailing May be hard to set up a LCD projector
5
Obesity Training – Overcoming ChallengesObesity Training – Overcoming Challenges
6
Brief Focused Advice Motivational Interviewing
Office Systems and Tools Team Based Care
Coding Strategies Advocacy
Lack of Patient Motivation & Provider Skills
Not Enough Time
No Reimbursement
Obesity Training – Keeping It SimpleObesity Training – Keeping It Simple
For All Children over 2 Years… Measure BMI Annually Provide Counseling Annually
For Overweight or Obese Children… Order Lab Tests Arrange for Treatment & Follow-Up
7
Recommended Lab ScreeningRecommended Lab Screening
8
BMI 85-94%ile Without Risk Factors- 2 Years and Older
– Fasting Lipid Profile BMI 85-94%ile Age 10 Years & Older With
Risk Factors – Fasting Lipid Profile– ALT and AST– Fasting Glucose
BMI >= 95%ile Age 10 Years & Older – Fasting Lipid Profile– ALT and AST– Fasting Glucose– Other Tests as Indicated by Health Risks
The AHA & AAP recommend screening at 2 years of age if there is a family history of lipid abnormalities or if risk factors are present in the absence of a positive family history
Every 2 Years
Every 2 Years
Treatment & Follow-Up Overview Treatment Goals
Behavioral Goals and Parenting Skills Self Esteem and Self Efficacy BMI Velocity, Weight Loss Targets and BMI % ile
A Staged Approach from the AMA Expert Committee - promotes brief, office-based intervention then a systematic intensification of efforts, tailored to the capacity of the clinical office, the motivation of the family, the presence of risk factors and the degree of obesity. Prevention Plus Structured Weight Management Comprehensive, Multidisciplinary Intervention Tertiary Care Intervention
Families progress to the next stage if there has been no improvement in BMI/weight or velocity after 3-6 months and if the family is willing and ready.
A Staged Approach - Overview Stage 1 - Prevention Plus
Family visits with physician or health professional Frequency individualized to family needs and risk factors
Stage 2 - Structured Weight Management Family visits with physician or health professional with training
in childhood weight management. Visits can be individual or group.
May include visits with a dietitian, exercise therapist or counselor
May include self-monitoring, goal setting and rewards Frequency monthly or individualized to family needs and risk
factors
A Staged Approach - Overview Stage 3 - Comprehensive, Multidisciplinary Intervention
Multidisciplinary team with experience in childhood obesity Frequency often weekly group sessions for 8-12 weeks with
follow up Stage 4 - Tertiary Care Intervention (for select children only
when provided by experienced programs with established clinical or research protocols) Medications - sibutramine, orlistat Very-low-calorie diets Weight control surgery - gastric bypass or banding (not FDA
approved for children but in clinical trials)
NICHQ
National Initiative for Children’s Healthcare Quality refined the AMA Expert Committee Recommendations into: Step 1: Obesity Prevention at Well Care Visits
(Assessment and Prevention) Step 2: Prevention Plus Visits (Treatment) Step 3: Going Beyond Your Practice
(Prevention and Treatment)
Obesity Algorithm
BMI ScreeningModule 1
See Pages 8-11 of the Training Guide
Scott Gee, MD, FAAP
Why do we use BMI?• Consistent with adult standards and
tracks childhood obesity into adulthood
• BMI for age relates to health risks including cardiovascular disease, hypertension and type 2 diabetes
• BMI measurement is recommended by the AAP, CDC, IOM, AHA and USPSTF annually beginning at 2 years and older
8Y
10Y
What are the challenges of BMI?
• Small errors in height measurement lead to large errors in BMI
• BMI cannot distinguish between increased fat mass and increased fat-free mass (e.g., muscle mass)
• Waist circumference may add greater specificity but there are not nationally accepted standards for children
BMI percentile during the measurement year as identified by administrative data or medical record review.
– ICD-9-CM Diagnosis - V85.5
Medical Record Review: Documentation must include a note indicating the date on which the BMI percentile was documented and evidence of either of the following.
– BMI percentile, or
– BMI percentile plotted on age-growth chart
– For adolescents 16–17 years, documentation of a BMI
value expressed as kg/m2 is acceptable.
HEDIS 2009… Weight Assessment
Expert Committee - Assessment OverviewMedical Risks• Height, Weight, BMI, Blood Pressure, Pulse• Family History• Review of Systems• Physical Examination• Laboratory Tests
Behaviors and Attitudes• Diet Behaviors• Physical Activity Behaviors• Attitudes
Measure BMI Annually Measure BMI annually for children 2-18 years
1. Obtain an accurate height and weight
2. Calculate BMI
3. Plot BMI on BMI for age growth chart
4. Make a weight diagnosis
5. Communicate weight status to family
6. Document the BMI• Code weight status as a visit diagnosis (for Health Plans) ICD-9-CM
Diagnosis - V85.5
• For CHDP, use the CHDP Screening/Billing Report form, PM 160 to document BMI
Accurate Height and WeightObtain an Accurate Height– Measure to the quarter inch– Shoulder blades, buttocks and heels all touching the
measurement surface– Child looking straight ahead, arms at side, toes straight and
knees together– Shoes off, feet flat and heels almost together
Obtain an Accurate Weight– Balance scale to zero– Weigh in pounds to the nearest ounce– Weigh in undergarments/gown/lightweight clothing– Socks/bare feet
Calculate BMI & Make a Weight Diagnosis Calculate BMI• BMI (English):[ weight (lb) ÷ height (in) ÷ height (in) ] x 703• BMI (metric):[ weight (kg) ÷ height (cm) ÷ height (cm) ] x 10,000Make a weight diagnosis using BMI %tile for age• < 5%ileUnderweight• 5-84%ile Healthy Weight• 85-94%ile Overweight• 95-98%ile Obesity• >=99%ile
8Y
10Y
Early Adiposity Rebound (4Y)
Practice Tools Make it Easier!!!
• Accurate Scale &
Stadiometer
• CDC BMI for Age
growth Chart
• BMI Wheel
Calculator
Boys: 2 to 20 years
BMI BMI
BMIBMI
BMI
What are more sensitive ways to address obesity and overweight?
Obesity Overweight
Fat or Chubby
Weight or Extra Weight
Body Mass Index (BMI)
Increased Risk for Diabetes
Weight is a very sensitive issue for children and adults.
Clinical Follow-up & ResourcesModule 3
See Pages 15-20 of the Training Guide
Scott Gee, MD, FAAP
The
Prevention
Plus Visit
The Prevention Plus Visit (NICHQ)
Review Labs Discuss Treatment Options and Referrals Motivational Interviewing or Brief Negotiation Cognitive Behavior Skills Arrange for Follow-Up as Necessary
Who needs a Prevention Plus Visit?
All obese children Overweight children with other risk factors or
co-morbid conditions Acanthosis nigricans Elevated blood pressure Suspected sleep apnea Other…
How often should visits occur? First Follow-Up Visit
When lab results back and in-depth survey completed usually 1-8 weeks
Format: in-person, sometimes by phone Subsequent Visits
As needed based on risk factors conditions & readiness to change
Frequency Range – 1 week to 2-3 months BMI checks – every 3-6 months (Z-Score if able) Format: in-person, phone, group, e mail (MD, NP, RD, HE) Families progress to structured weight management if there
has been no improvement in BMI/weight or velocity after 3-6 months and if the family is willing and ready
Treatment Goals - Health Behaviors Lifelong healthy behaviors such as physical activity will improve
health outcomes regardless of weight change Improving self esteem and self efficacy can also improve health
outcomes Small consistent changes over time can make a big difference!
Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap which leads to excess weight gain in some children.
Changes in excess dietary intake (eg, eliminating one sugar-sweetened beverage at 150 kcal/can) may be easier to attain than increases in physical activity levels (1.9 hours walking for an extra 150 kcal).
Pediatrics Vol. 118 No. 6 December 2006 pp. e1721-1733
Treatment Goals - BMI The long term BMI goal will need to be individualized based on
risk factors and genetics BMI < 85%ile - Ideal long term goal BMI 85-94%ile - Some children can be healthy in this range
Short term BMI goals will need to be individualized based on genetics, risk factors and the intensity of the intervention Decrease in BMI velocity Weight maintenance Weight loss
Younger and more mildly obese children should change weight more gradually than older, more severely obese youth
Prevention Plus Visit Challenges
Non-compliance with lab tests
Non-compliance with follow-up visits
Family readiness to change
Perception by providers that the follow-up visit does not have enough content/substance to justify the cost
Improve compliance with the follow-up visit…
Ask only high-risk patients to return. “I am very concerned about your blood pressure, can we re-check it in 2 weeks?”
Ask about interest in returning. “Would be interested in returning in 1-2 weeks to discuss your lab results, treatment options and any issues you would like to work on?”
Make a strong advice statement. “I am really concerned about your health and would like you to return in 2 weeks so we can discuss this further.”
Ask about follow-up preferences. “Would you be interested in coming back for a follow visit or would a phone call be more convenient?
Using Resources & MaterialsPresenter:
David Bodick, MPH Health Educator
Office of Multicultural Health (OMH)
Disclosure
Using Resources for Pediatric Skill Sets for Improved Care
Nothing to disclose as to financial relationships or commercial interests
CHDP Community Program Resources Resource List for Prevention and Treatment of Child and
Adolescent Overweight and Obesity
The list identifies programs according to the type of service: Medical, Nutrition, Physical Activity and Behavioral
Program Details of the program: age served, language(s) & cost
Larger county programs update their lists quarterly
San Joaquin CHDP Resource GuideSample-available upon request
Community Program Resources
Goal – Refer to community resources to extend provider counseling and improve outcomes
Lifestyle support important for behavior change Link between clinical recommendations for
wellness and community resources Motivates families and provides peer
interaction/support
Community ResourcesAvailable in most communities
WIC: New Healthy Habits Campaign Nutrition Network Programs Youth Programs: YMCA & YWCA Parks and Recreation Programs School and After-School Programs School Lunch University Cooperative Extension
WIC Healthy Habits Every DayOffered by all local WIC programs
CHDP Provider Toolswww.dhcs.ca.gov/services/chdp
Available by downloading from the CHDP websiteProvider Office Training (supplement to training)– Body Mass Index (BMI) Training– How to Accurately Weigh and Measure Children for the
CHDP Well Child Exam– Counseling the Overweight Child– Cholesterol and Glucose Screening (coming soon)
Educational Tools (see handout section of Training Guide)– BMI Job Aid: Body Mass Index for Age Percentile – Counseling Flow Sheet: Counseling the Overweight Child – Tips for Encouraging Behavior Change– My Healthy Lifestyle Goal Tracker (Eng. & Sp.)
Medi-Cal Managed Care Health PlansPediatric Obesity & Patient Education Pediatric Obesity & Patient Education
Resource Guide-Resource Guide-at your tableat your table
• Collection of contributed patient education materials from the health plans
• Multilingual patient education materials supplement the California Medical Association Foundation's Child and Adolescent Obesity Provider Tool Kit
• Please contact the health plan representative listed for each material regarding approval to use and/or modify the materials
Resource Guideof Health Education Materials
• Title of material• Material type (brochure, poster, etc.) • Topic (nutrition, physical activity or both)• Target Audience & Grade Level• Reading Level• Languages
Resource Guide
• Brief Description & Format• Full Color or Black & White• Link to website or other ordering information (if
available) • Regularly updated• Available on CHDP and Medi-Cal Managed Care
Division’s websites in March 2010
• Please contact Irene Reveles-Chase, MPH for more information: [email protected]
Workshop Post Evaluation
• In the next 4-6 months workshop participants will get an e-mail (Survey Monkey Link).
• Survey will include questions about: – How you used your new training skills and materials– Recommendations for future workshops.
• Evaluation information will provide us with valuable information about the usefulness of the training and to what extent the training was used by participants.
• Please submit your responses to Survey Monkey as soon as you receive it!
“Childhood obesity is no one’s fault, but it
is everyone’s responsibility.”
Dr. Phil McGraw
Governor’s Summit on Health, Nutrition and Obesity – September 15, 2005