Kaiser Permanente Georgia s Experience with Operation Zero: A Group Medical Appointment to Address Pediatric Overweight

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1 CME helth systems Kiser Permnente Georgi s Experience with Opertion Zero: A Group Medicl Appointment to Address Peditric Overweight By Josephine Hinchmn, MPH Luke Beno, MD Adrienne Mims, MD, MPH Astrct Context: The rte of overweight (OW) in children in the United Sttes hs more thn tripled since The helth consequences of peditric OW include type 2 dietes nd significnt illness lter in life. Treting peditric OW is necessity; however, helth cre clinicins hve miniml ccess to successful nd comprehensive tretment modlities for ddressing it. Ojective: Kiser Permnente of Georgi (KPGA) offers group medicl ppointment clinic, Opertion Zero (O.Z.), s referrl progrm for predolescent nd dolescent ptients who re in the 85th or higher percentile for ody mss index (BMI) for their ge. The eight-session clinic uses fmily-oriented pproch nd provides supportive group environment with interctive lerning, gmes, physicl ctivity, nd cretive prolem solving. The gol of the progrm is to improve lifestyle ehviors for nutrition nd physicl ctivity. Cliniclly, meeting these gols cn mnifest s reductions in ody ft (BF), wist size, nd BMI-for-ge percentile. Two implementtion models help improve dissemintion of the progrm within KPGA. Design: Bseline nd eight-week postclinicl outcomes for O.Z. prticipnts were nlyzed to determine progrm effectiveness. A retrospective nlysis with control group looked t long-term clinicl outcomes to determine weight mintennce. Min outcome mesures were weight, BMI-for-ge percentile, wist size, nd percentge of ody ft (%BF). Results: At eight weeks fter progrm completion compred with seline, there were significnt reductions in %BF nd wist size for the totl smple nd specificlly for dolescents, preteens, nd prticipnts who ttended six or more sessions. Among O.Z. prticipnts, there were insignificnt increses in weight t six months fter progrm prticiption nd BMI-for-ge percentile t one yer fter prticiption. At six months, the men chnge in weight nd BMI in the O.Z. group ws sttisticlly less thn the men chnge in the control group. Conclusions: A structured, fmily-oriented weight mngement progrm is effective in chnging mesures consistent with improved weight mngement. Introduction Both the prevlence nd helth consequences of childhood overweight (OW) mke it n issue tht the helth cre industry cn no longer sidestep. Kiser Permnente Georgi (KPGA) hs stepped into ledership role y improving the delivery of cre for overweight peditric ptients nd those peditric ptients t risk for OW. Specificlly, KPGA offers nd strongly recommends n wrd-winning weight mngement group medicl ppointment progrm, Opertion Zero (O.Z.), for predolescent nd dolescent ptients who re in the 85th or higher percentile for ody mss index (BMI%) for their ge. (In 2005, the Cooper Institute conducted n in-depth review nd evlution of progrms ddressing childhood OW nd wrded O.Z. Gold Str.) The rte of OW in children, defined s BMI% 95th percentile, hs more thn tripled since 1980 in the United Sttes. Among children nd teens ged 6 to 19 yers, 16% re considered OW. 1 Compred with ntionl rtes, the rtes for the stte of Georgi show tht it hs prticulrly remrkle epidemic of childhood OW, where 33% of middle school nd 26% of high school students re OW or t risk for eing OW, defined s hving BMI% etween the 85th nd 95th percentile. 2 Likewise, mong youth ged 5 to 18 yers within KPGA, 17% re OW nd nother 17% re t risk for eing OW. 3 Josephine Hinchmn, MPH, (left) is Reserch Associte for the KPGA Reserch Deprtment nd Progrm Evlutor for the Deprtment of Prevention nd Helth Promotion. E-mil: josephine.hinchmn@kp.org. Luke Beno, MD, (center) is the Chief of Continuing Medicl Eduction for TSPMG nd the peditric chmpion for weight mngement inititives for the Georgi Region. Dr Beno is peditricin t the KP Southwood medicl fcility. E-mil: luke.eno@kp.org. Adrienne Mims, MD, MPH, (right) is the co-led for the Grfield Weight Mngement Inititive nd is clinicin t the KP Cscde medicl fcility. E-mil: drienne.mims@kp.org. 66 The Permnente Journl/ Fll 2006/ Volume 10 No. 3

2 Kiser Permnente Georgi s Experience with Opertion Zero: A Group Medicl Appointment to Address Peditric Overweight helth systems OW children re t risk for mny helth prolems. 4 Immedite physicl helth conditions re strongly correlted with OW, including orthopedic conditions, respirtory prolems nd sleep pne, nd gstrointestinl diseses. A child s mentl helth, self-esteem, nd ody imge cn lso e ffected y OW. 5 Perhps the gretest helth condition linked with peditric OW is insulin-resistnt dietes mellitus (type 2 dietes). One study documented ten-fold increse in the incidence of juvenile-onset type 2 dietes, with >90% of the new cses eing OW. 6 OW often leds to n incresed mgnitude of insulin resistnce, which in turn leds to type 2 dietes. 7,8 Childhood OW is the most prominent nd modifile risk fctor for type 2 dietes. 9 The long-term complictions of childhood OW re significnt. Dt suggest tht the risk of illness lter in life is proportionl to the level of OW in childhood. 10 These illnesses include coronry rtery disese, therosclerosis, colon cncer, rthritis, nd dietes. 4 Plus, the development of crdiovsculr risk fctors progresses with OW from childhood into dulthood. For exmple, prospective studies show tht OW children re nine-toten times more likely to develop hypertension in dulthood thn their non-ow mtched peers. 5 The helth complictions of childhood OW will eventully plce n ever-expnding urden on the helth cre system, underscoring the necessity to tret peditric OW efore it ecomes dult OW. Although different pproches hve een used t ll levels of helth cre to ddress peditric OW, helth cre clinicins hve hd few successful nd comprehensive lterntives to offer to OW peditric ptients nd their fmilies. In fct, there hs not een comprehensive progrm ddressing the mngement of peditric OW with sufficient smple sizes to demonstrte sttisticlly significnt improvements in primry cre prctices nd ptient outcomes. 11,12 For KPGA, finding solution to the prolem ws motivted y the need to fill the void tht hd een felt y peditric clinicins, memers, nd the overll helth system. Progrm Description O.Z., peditric OW group medicl ppointment clinic, is referrl progrm for t-risk-of-ow nd OW predolescent nd dolescent ptients. The clinic uses fmily-oriented pproch nd incorportes ehviorchnge strtegies to ddress the ehviors, knowledge, ttitudes, nd self-efficcy of ptients nd their prents regrding nutrition nd physicl ctivity. Monitoring clinicl outcomes on weekly sis, setting weekly gols, nd self-monitoring re integrl to the success of the progrm. Opertion Zero ws chosen s the nme ecuse the progrm s longterm gol is zero incidence of helth prolems ssocited with eing OW nmely, hypertension, hypercholesterolemi, nd type 2 dietes. The gols for O.Z. re weight mintennce in growing children nd dolescents nd improved knowledge out nd lifestyle ehviors regrding nutrition nd physicl ctivity. Cliniclly, these gols cn mnifest s reductions in ody ft, wist size, nd BMI%. Reductions in cost of cre re n expected long-term enefit for the Helth Pln. O.Z. includes weekly one-hour ppointments for two months (the core progrm), followed y nother four ppointments t three-month intervls (the After-O.Z. progrm), for mximum group of 15 ptients nd their prents. O.Z. provides supportive group environment with interctive lerning, gmes, physicl ctivity, nd cretive prolem solving. The O.Z. sessions re held either on weekdy evenings or Sturdy mornings. O.Z. is fmily-sed intervention tht requires one prent or gurdin to prticipte in ech session nd t home. Prticipnts nd prents receive n O.Z. mnul tht includes helth eduction, ctivities, nd recipes. Either helth eductor or clinicin fcilittes the group sessions with nursing stff support nd prticiption of either dietitin or professionl chef t vrious sessions. Every session egins with mesure- Dr Beno nd O.Z. stff review ptient s clinicl dt. From left to right, Melnie Bker, RD; Jonn Huffstickler, LPN; Luke Beno MD; Sherry Pierce, MA. Tle 1. Content of Opertion Zero progrm sessions Core progrm sessions Concept Wht s the Big Del? Motivtion Mking the Cut Knowledge deficit Get Moving nd Grooving Lifestyle ctivity Shping Up in the Kitchen Cooking techniques Who s to Blme? Disordered eting Lel It Before You Tle It Confusing lels Smrt Choices Eting Out Tempttion Opertion Snck Attck Mintining chnge After-Opertion Zero sessions Concept You Don t Et Met? Protein enefits Cooking with Bens Fier enefits Wht Are You Drinking? Empty clories Grilling to Perfection Helthy cooking Dt suggest tht the risk of illness lter in life is proportionl to the level of OW in childhood. 10 The Permnente Journl/ Fll 2006/ Volume 10 No. 3 67

3 helth systems Kiser Permnente Georgi s Experience with Opertion Zero: A Group Medicl Appointment to Address Peditric Overweight ment of weight, wist size, nd ody ft, s mesured y ioelectricl impednce, nd out 20 minutes of physicl ctivity followed y the min content of the session. The concepts covered in the O.Z. sessions re outlined in Tle 1. Strtegies for ddressing ttitudes nd uilding self-efficcy re incorported into the progrm, including pedometer gmes, interctive lerning, competition (for prizes), cooking demonstrtions, nd exercising s group. O.Z. is designed for prticipnts to sequentilly improve on specific ehviorl gols for nutrition nd physicl ctivity. Homework ssignments re provided weekly to move prticipnts stepwise towrd reching these ehviorl gols. Gols re designed to e esily chievle, yet lso help reverse the fctors contriuting to peditric OW The lifestyle gols re s follows: Increse milk consumption until drinking four glsses dy. Decrese milk ft until drinking ft-free milk. Increse fruit nd vegetle servings until eting five servings dy. Et rekfst every morning. Increse the numer of dys eing physiclly ctive for 60 minutes until ctive five dys week. Decrese sedentry ehvior to less thn one hour per dy. Increse the numer of steps per week on pedometer until tking 70,000 steps per week. O.Z. ws originlly designed y Luke Beno, MD, nd hs een successfully implemented with his helth cre tem t his medicl office since July In 2003, the Deprtment of Prevention nd Helth Promotion egn leverging O.Z. The progrm ws disseminted to dditionl medicl offices, nd process evlution ws conducted with stff memers nd fcilittors. This effort resulted in wreness of implementtion rriers, including stffing, ptient ttendnce, finncil support, nd enrollment issues. Most helth cre tems found end-of-dy stffing nd cute cre ptient demnd to e rriers to replicting O.Z. This led to creting two new implementtion models for the progrm: The Helth Cre Tem Model with support from the Helth Eduction Deprtment: A peditricin fcilittes the progrm on weekdy evenings; the helth cre tem supports the progrm with mnging referrls, scheduling, nd conducting mesurements; nd the Helth Eduction Deprtment supports the progrm fisclly nd with coordintion. The Helth Eduction Model: The Helth Eduction Deprtment supports nd coordintes the progrm y hving helth eductors fcilitte the progrm on the weekends. The models differ y vriles for fcilittion, scheduling (time of dy, dy of week), composition of support stff, nd prticipnts finncil input. The progrm gols, intervention strtegies, clinicin referrls, cofcilittion, nd progrm content remin consistent etween the two implementtion models. These new formts etter suit the needs of the other medicl offices nd improve dissemintion of the progrm within KPGA nd for the other Kiser Permnente (KP) regions tht hve expressed interest in replicting the O.Z. progrm. The cost of O.Z. is pproximtely $2000 for the core progrm nd $1200 for the After-O.Z. progrm. With full prticiption, the cost is equivlent to $137 nd $80 per prticipnt for the core nd After-O.Z. progrms, respectively. These costs include consulttion fees nd/or slry for chefs, dietitins, helth eductors, nd nursing stff memers nd costs for clss supplies, including pedometers, workout videos, nd prizes. Costs lso include in-kind contriution for physicin fcilittion. O.Z. fcilittors, cofcilittors, nd nursing stff memers commit pproximtely two hours per week for n O.Z. session, whether it is the core or After-O.Z. progrm. Progrm Evlution Between 2001 nd 2003, there were 135 prticipnts in the O.Z. progrm. KPGA nlyzed this smple to descrie progrm prticiption nd to determine the extent to which O.Z. is effective. Dt collection occurred s prt of the O.Z. progrm, not specificlly for progrm evlution, nd dt re often incomplete ecuse of ttrition nd poor documenttion. Tle 2. Chrcteristics of Opertion Zero prticipnts ( ) Count (n = 135) Percentge Sex Femle Mle Age ctegory Youth ( ge 10 yers) Preteen (ge yers) Adolescent ( ge 13 yers) Insulin resistnce t seline Yes No Attendnce < 6 sessions 6 sessions BMI% t seline < 85th percentile 85th percentile 95th BMI%, percentile for ody mss index for ge. Testing for insulin resistnce is not prerequisite for prticiption in O.Z., so dt re missing. In 18 cses, height ws missing nd BMI% could not e determined. 68 The Permnente Journl/ Fll 2006/ Volume 10 No. 3

4 Kiser Permnente Georgi s Experience with Opertion Zero: A Group Medicl Appointment to Address Peditric Overweight helth systems Exmintion of smple of the prticipnts (Tle 2) shows: Insulin resistnce (defined s the rtio of fsting glucose to fsting insulin of < 7) 17 in 87% of prticipnts OW in 73% of prticipnts Risk of OW in 22% of prticipnts Risk for developing type 2 dietes for the mjority of O.Z. prticipnts ecuse they re OW nd my lredy hve insulin resistnce. During the eight-week core progrm, prticipnts demonstrted men weight chnge of 0.47 ls nd ody mss index chnge of 0.11 kg/m 2 (Tle 3). BMI% ws reduced, on verge, y 0.04%, nd there were men reductions in percentge of ody ft (%BF) nd wist size. Pired smples t-tests were conducted to determine whether eight-week post-test vlues were significntly different thn seline vlues for weight, BMI%, %BF, nd wist size. There were no significnt reductions in weight or BMI%, ut significnt reductions in %BF nd wist size were demonstrted with the totl smple (Tle 3) nd specificlly mong ptients who ttended six or more sessions, preteens nd dolescents. Among oys, there were significnt reductions in %BF only, nd mong girls, there were significnt reductions in wist size, plus trend for significnt reductions in %BF (Tle 4). There were no significnt reductions in ny ody composition vrile for children who ttended fewer thn six sessions nd for youth ged eightto-ten yers. Retrospective Anlysis Although the short-term ltertion in ody ft nd wist size is n exciting outcome, long-term weight mintennce nd susequent decreses in BMI% re other importnt outcomes for O.Z. A retrospective nlysis ws conducted to determine long-term clinicl outcomes for O.Z. prticipnts nd control smple. We strcted weight, BMI, nd BMI% from medicl records for smple of ptients ged 11-to-17 yers (youth were omitted) who completed O.Z. in nd control smple of memers who never ttended O.Z. nd were mtched for ge, sex, nd BMI% (Tle 5). Dt were pulled from clinic visits, where ody ft, wist circumference, nd sometimes height were not routinely documented. For the control group, dt from clinic visit in 2002 were used s seline. Clinic visits 4 months to 8 months lter were regrded s 6-month postvisit nd visits 9 months to 18 months lter s 1-yer postvisit. Pired smples t-tests were conducted to determine whether six-month nd one-yer postvisit vlues were significntly different from seline vlues for weight, BMI, nd BMI%. O.Z. prticipnts hd n insignificnt weight gin of 2.35 ± 9.90 ls, wheres the control group hd significnt weight gin of 7.64 ± ls t the six-month postvisit (Tle 6). For oth the control nd O.Z. groups, there were insignificnt increses in BMI or BMI% t the six-month postvisit. From seline to the one-yer postvisit, for oth the O.Z. nd control groups, there were significnt increses Tle 3. Chnge in ody composition vriles from seline to fter intervention nd significnce testing for the totl smple Body composition vrile n Men chnge Rnge (minimum mximum) SD p vlue (1-tiled) Weight chnge (l) to BMI chnge (kg/m 2 ) to BMI% chnge (%) to Body ft chnge (%) to <.05 Wist size chng e (in.) to <.05 BMI, ody mss index; BMI%, percentile for ody mss index for ge;, not significnt. t vlue = t vlue = Tle 4. Sttisticlly significnt supopultions of the totl smple Smple Vrile n Men chnge SD p vlue (1-tiled) Attended 6 sessions Wist (in.) <.05 Body ft (%) <.05 Preteens (ge yers) Wist (in.) <.05 c Body ft (%) <.05 d Adolescents (ge 13 yers) Wist (in.) <.05 e Body ft (%) <.05 f Girls Wist (in.) <.005 g Body ft (%) h Boys Body ft (%) <.05 i t(27) = 2.085, p <.05. t(44) = 2.500, p <.05. c t(5) = 2.114, p <.05. d t(19) = 1.84, p <.04. e t(15) = 1.790, p <.05. f t(30) = 2.023, p <.05. Tle. 5 Chrcteristics of retrospective nlysis popultion Count (%) Sex Femle Mle Age ctegory Preteen (ge yers) Adolescent ( ge 13 yers) BMI% t seline 85th 94.99th percentile 95th percentile Attendnce t Opertion Zero < 6 sessions 6 sessions Opertion Zero group (n = 43) 24 (56%) 19 (44%) 19 (44%) 24 (56%) 1 (2%) 39 (98%) 19 (44%) 24 (56%) g t(18) = 3.005, p <.005. h t(36) = 1.626, p =.06. i t(30) = 2.109, p <.05. Control group (n = 42) 19 (45%) 23 (55%) 18 (42%) 24 (57%) 5 (15%) 29 (85%) NA NA BMI%, percentile for ody mss index for ge; NA, not pplicle. The Permnente Journl/ Fll 2006/ Volume 10 No. 3 69

5 helth systems Kiser Permnente Georgi s Experience with Opertion Zero: A Group Medicl Appointment to Address Peditric Overweight O.Z. is ffordle nd presents resonle long-term outcomes for weight mintennce. in weight nd BMI. For the control group, there ws lso significnt increse in BMI% of 0.76% ± 1.86%, nd the O.Z. group hd n insignificnt increse of 0.22% ± 1.22% (Tle 7). Independent smple t-tests were conducted to determine whether men chnges in weight, BMI, nd BMI% in the O.Z. group differed from the men chnges in the control group. From seline to the six months postvisit, there ws significnt difference etween the men scores for weight nd BMI for the O.Z. nd control groups (Tle 6). The O.Z. group hd significntly lower men chnges thn the control group. From seline to the one-yer postvisit no significnt difference ws demonstrted for ny men score (Tle 7). Conclusions The results demonstrte tht the O.Z. progrm helps children reduce %BF nd wist size within the eight weeks of the core progrm. These levels of significnce re mintined mong ptients who ttend more thn six sessions, preteens nd dolescents. There re no significnt reductions or trend for significnt reductions, long ny ody composition vrile, for youth ged eight-to-ten yers. As result, KPGA now offers the progrm to only preteens nd dolescents ged 11 to 17 yers. Prticipnts must ttend six or more sessions (75% of the progrm) to relize the immedite enefits. To help olster retention, progrm improvements were implemented in 2005, including use of weekly reminder clls nd plcement of the most stisfying sessions erly in the progrm. In ddition, clinicins re encourged to e selective with their referrls, referring ptients nd prents who re redy to chnge nd willing to commit to n eight-week progrm. Long-term clinicl dt for O.Z. prticipnts nd control smple suggest tht the progrm is effective for weight mintennce t six months fter completion ut not t one yer fterwrd. The trend for sttisticlly significnt increses in BMI% over the course of yer ws not true for the O.Z. group. However, the men chnge in BMI% in the O.Z. group ws not different from the men chnge in the control group. Although these results demonstrte tht the progrm is on trck for ttining its gol of eing long-term weight mintennce progrm, more effort is needed to keep prticipnts on course with weight mintennce for one yer fterwrd. One explntion for this long-term result cn e ex- Tle 6. Men chnges from seline to six months fterwrd nd significnce testing Body composition Men chnge from seline to six months fterwrd p vlue (1-tiled) vrile Arm n Men SD Pired t-test Independent t-test Weight (l) O.Z. group <.05 Control group <.05 BMI (kg/m 2 ) O.Z. g roup <.05 c Control group BMI% O.Z. group Control group BMI, ody mss index; BMI%, percentile for ody mss index for ge;, not significnt; O.Z., Opertion Zero. t(17) = 3.246, p <.05. t(42) = 1.736, p <.05. c t(20) = 2.129, p <.05. Tle 7. Men chnges from seline to one yer fterwrd nd significnce testing Body composition Men chnge from seline to one yer fterwrd p vlue (1-tiled) vrile Arm n Men SD Pired t-test Independent t-test Weight (l) O.Z. group <.05 Control group <.05 BMI (kg/m 2 ) O.Z. g roup <.05 c Control group <.05 d BMI% O.Z. g roup Control group <.05 e BMI, ody mss index; BMI%, percentile for ody mss index for ge;, not significnt; O.Z., Opertion Zero. t(35) = 6.228, p <.05. t(27) = 6.791, p <.05. c t(23) = 2.124, p <.05. d t(17) = 2.973, p <.05. e t(17) = 1.741, p < The Permnente Journl/ Fll 2006/ Volume 10 No. 3

6 Kiser Permnente Georgi s Experience with Opertion Zero: A Group Medicl Appointment to Address Peditric Overweight helth systems plined y the After-O.Z. progrm. After-O.Z. ws not implemented during the erly yers of O.Z., from which the retrospective smple ws pulled. Plus, KPGA hs experienced troule with implementing well-ttended nd effective After-O.Z. progrm ever since. Developing nd implementing successful methods for follow-up progrm my improve long-term results for O.Z. The power of the nlysis might hve een limited y the smll smple size of oth the progrm evlution nd retrospective nlysis. The dt hd een collected t either n O.Z. session or clinic visit, nd dt collection ws often incomplete nd inconsistent. Body ftness dt were not ville from clinic visits, so we were unle to follow whether decreses in ody ft nd wist size were sustined over time. This evlution looked solely t clinicl vriles; however; implementtion of lifestyle chnges is n importnt gol of O.Z. A current study is mesuring lifestyle chnges for O.Z. prticipnts nd sustinility of chnges. This sme study, funded y the Grfield Weight Mngement Inititive, is lso evluting the two implementtion models of O.Z. nd the process of disseminting the progrm to the Mid-Atlntic Sttes Region. Other future studies cn exmine cost svings, reversl of insulin resistnce, outcomes for prents nd silings, nd whether certin homework gols re more importnt nd effective thn others. Expense is going to e concern for ny helth pln interested in replicting O.Z. Funding decisions re sed oth on expense nd relistic long-term outcomes. O.Z. is ffordle nd presents resonle longterm outcomes for weight mintennce. A structured, fmily-oriented weight mngement progrm tht is ffordle to implement in helth cre setting is effective in chnging mesures consistent with improved weight mngement. O.Z. offers successful nd comprehensive lterntive for peditric clinicins to offer OW ptients nd their fmilies. Acknowledgment Kthrine O Moore-Klopf of KOK Edit provided editoril ssistnce. References 1. Hedley AA, Ogden CL, Johnson CL, Crroll MD, Curtin LR, Flegl KM. Prevlence of overweight nd oesity mong US children, dolescents, nd dults, JAMA 2004 Jun 16;291(23): Georgi Deprtment of Humn Resources, Division of Pulic Helth. Overweight nd oesity in Georgi, 2005 [monogrph on the Internet] April [cited 2006 Jun 27]. Puliction numer: DPH05.023HW [64 pges]. Aville from: nutrition/oesityrep.dph05.023hw.pdf. 3. Hinchmn J, Beno L, Dennison D, Trowridge F. Evlution of trining to improve the ssessment nd mngement of peditric overweight. J Contin Educ Helth Prof 2005 Fll;25(4): Greger N, Edwin CM. Oesity: peditric epidemic. Peditr Ann 2001 Nov;30(11): Must A, Struss RS. Risks nd consequences of childhood nd dolescent oesity. Int J Oes Relt Met Disord 1999 Mr;23(suppl 2):S Pinhs-Hmiel O, Doln LM, Dniels SR, Stndiford D, Khoury PR, Zeitler P. Incresed incidence of non-insulindependent dietes mellitus mong dolescents. J Peditr 1996 My;128(5 Pt 1): Slyper AH. The peditric oesity epidemic: cuses nd controversies. J Clin Endocrinol Met 2004 Jun;89(6): Limn I, Arslnin S. Type 2 dietes in childhood: the Americn perspective. Horm Res 2003;59(suppl 1): Brlow SE, Dietz WH. Oesity evlution nd tretment: expert committee recommendtions. The Mternl nd Child Helth Bureu, Helth Resources nd Services Administrtion nd the Deprtment of Helth nd Humn Services. Peditrics 1998 Sep;102(3):E Eeling CB, Pwlk DB, Ludwig DS. Childhood oesity: pulic-helth crisis, common sense cure. Lncet 2002 Aug 10;360(9331): US Preventive Services Tsk Force. Screening nd interventions for overweight in children nd dolescents: recommendtion sttement [monogrph on the Internet]. AHRQ Puliction No A, 2005 July [cited 2006 Jun 27]. Agency for Helthcre Reserch nd Qulity, Rockville, MD [out 17 pges]. uspstf05/choverwt/choverrs.htm. 12. Summerell CD, Ashton V, Cmpell KJ, Edmunds L, Kelly S, Wters E. Interventions for treting oesity in children. Cochrne Dtse Syst Rev 2003;(3):CD Sle AD, Weyer C, Hrper I, Lindsy RS, Rvussin E, Ttrnni PA. Assessing risk fctors for oesity etween childhood nd dolescence: II. Energy metolism nd physicl ctivity. Peditrics 2002 Aug;110(2 Pt 1): Jnz KF, Levy SM, Burns TL, Torner JC, Willing MC, Wrren JJ. Ftness, physicl ctivity, nd television viewing in children during the diposity reound period: the Iow Bone Development Study. Prev Med 2002 Dec;35(6): Knowler WC, Brett-Connor E, Fowler SE, et l; Dietes Prevention Progrm Reserch Group. Reduction in the incidence of type 2 dietes with lifestyle intervention or metformin. New Engl J Med 2002 Fe 7;346(6): Ludwig DS, Peterson KE, Gortmker SL. Reltion etween consumption of sugr-sweetened drinks nd childhood oesity: prospective, oservtionl nlysis. Lncet 2001 Fe 17;357(9255): Silfen, ME, Mnio AM, McMhon DJ, Levine LS, Murphy AR, Oerfield SE. Comprison of simple mesures of insulin sensitivity in young girls with premture drenrche: the fsting glucose to insulin rtio my e simple nd useful mesure. J Clin Endocrinol Met 2001 Jun;86(6): The Permnente Journl/ Fll 2006/ Volume 10 No. 3 71