Healthy Me- Childhood Obesity Program: Prevention and Treatment Mark Sabo, MD Jennifer Sabo, MS, RD Primary Care Coalition of Connecticut June 27, 2016
Outline Overview of Healthy Me Program Creation and Design Treatment Details Day to Day Motivational Interviewing Preliminary Results Prevention Details Infrastructure Utilization Impact Questions
Childhood Obesity OBESITY IN AMERICA IS SO WIDESPREAD AND SUCH A PRODUCT OF OUR CULTURE THAT COMBATING IT IS NEARLY IMPOSSIBLE. We need to change almost everything about the way we live, more or less simultaneously. In order to succeed, an edgier strategy is needed. Hastings center report 2013
The Scope Overweight/obesity ranges from 20-43% of the pediatric population at each ProHealth practice. Obesity rates in the U.S., Connecticut and ProHealth continue rise and require a unique and bold approach to treating this epidemic. Obesity treatment does not include dieting or quick weight loss, but long term behavior changes that are reachable and sustainable. If you want them to lose weight tomorrow, then you should have started 10 years ago.
Program Timeline Development started ~ November 2011 Pilot ran at two pediatric practice sites (Simsbury and Somerset Pediatrics) from: October 2013 through May 2014 Provider satisfaction overwhelmingly positive Program roll out began in June 2014 and continued through January 2015.
Healthy Me - Origins Every Pediatric Overweight and Obesity intervention has failed WHY? Primary Care Provider not involved Destination not local Unfamiliar providers Interventions time limited
CHILDHOOD OBESITY PROGRAM: TREATMENT A Team Approach (PCP and RD) Takes place in child s office PCP to utilize Motivational Interviewing to assess readiness Specifically tailored resources provided to those in pre/contemplative phases IF ready for program: family meets w/ Team (at least) q 2 months PCP reviews pre-visit questionnaire with family, conducts PE, reviews labs and codes appropriately (15 minute visit), then: Family meets with RD (45 minutes) Referral to PHP Physical Therapy and Behavioral Health as necessary Targeted text messages, emails, and phone calls at weekly intervals in between visits
Recruitment Conversation Examples Would you be willing to spend a minute discussing your child s health today? Do you have any specific health concerns regarding your child s nutrition and/or physical fitness? Were you planning on making a change to your child s nutrition or sedentary time over the next 6 months? Are you interested in discussing ways to stay healthy and energized? Would you be interested in participating in a more in-depth part of the Healthy Me program, working with your pediatrician and a pediatric dietitian to help you make any planned changes during this next 6 months? Would you like to schedule your first visit with the dietitian, right at your physician s office, where you will work with them both to create a health plan that works for you and your family?
Pre-visit Questionnaires How long have you been concerned about your child s weight/health/nutrition/exercise habits? What changes have you tried to make in the past? What barriers to change have you found? Is there anyone else in the family who struggles with this problem? Yes No Is there anyone in the family who has succeeded in making changes? Yes No As a result of this issue, has your child ever: -expressed feelings of low self-esteem? Yes No -experienced any bullying? Yes No -experienced shortness of breath or exercise intolerance? Yes No -experienced snoring or pauses in breathing while sleeping? Yes No -had any effect on school performance? Yes No How many hours of moderate physical activity per day does your child complete? hours How many servings of fruits and vegetables per day? servings/day
Program Design Referral to ProHealth PT and Physical Therapy Sports Medicine Centers for exercise intervention Dietitian only counseling Utilization of dietitians for real time curbside consults Lactation Support New Horizons: behavioral health and ACE study
Healthy Me - Summary Healthy Me: a PRIMARY CARE based counseling program designed to create a TEAM approach to diet and behavior change. Dietitian is embedded within the FAMILY S practice, scheduled on a weekly or monthly basis (depending on the size of the practice). Staff and providers have established relationship This increases accountability of all involved (family, provider, staff and RD), improves compliance, allows for UNLIMITED touchpoints
Why is the PCP involved? Why not?!? Studies show that provider involvement in weight management has improved patient outcomes.¹ This has also been demonstrated in the Healthy Me program. PCP vs. no PCP involvement: 18 month follow up: Practice X: 59% of patients with > 1 visit decreased BMI z score by 11.4% Practice Y: 28% decreased BMI z score, decrease was by 3.7%. 16% had no change. 1. Satisfaction with primary care provider involvement is associated with greater weight loss: Results from the practice-based POWER trial. W Bennett W, et al. PEC. 2015;98(9): 1099-1105.
The Provider s Changing Role
Program Design Motivational Interviewing is utilized by dietitians and providers to help families find ways to make healthy behavior change. Weight loss goals are not the focus Healthy goals: Walk for 2o minutes per day Try a new vegetable each week for the next month. Drink more water and reduce juice intake. Add a fruit to your breakfast.
Healthy Me Why MI? Motivational Interviewing is a key part of the discussion when looking to recruit families who are ready to make changes and be a part of the Healthy Me program. -Use to inquire if patients are interested in and ready for the program -Use to discuss progress towards goals and assess barriers
Change in dynamic needed: Provider as Speaker, patient as Listener Asks patient a lot of questions to complete note fields, guides the visits, provide solutions and marching orders What is your child s diet? Your child s BMI is above the 95 th %, so she is considered obese. You should stop providing juice and soda. You should encourage her to go outside more. You should. You need to make a visit to see our dietitian Here is a handout on how to decrease juice
Change in dynamic Patient as Speaker, provider as Listener Provider asks open-ended questions and allows patient to guide conversation. Reflects back instead of asking more questions. Patient: It d like to eat healthy, but it s just too hard to find the time Provider: You are struggling to find quick but healthy options If offering advice, ask permission first, and then offer patient specific advice. You say you are interested in making some changes, but time is an issue. Can I offer you some ideas for quick options for healthy snacks? If yes, then offer ideas. Then ask Does this seem relevant to you? If no If you decide you would like further information, we are here to help Provider: We now have a dietitian right here in our office. Would you like to set up an appointment with her, to work together to find more ways to make healthy eating easier for your family?
Are they ready? 5 stages of change: Precontemplation: not even thinking about changing. Pushing these patients often leads to further set backs. Contemplation: starting to think about making a change, sometime in the future. Preparation: starting to get ready to make a change in the near future Action: ready to make a change now (not necessarily change everything!) Maintenance: working on sticking to the changes made, sometimes slipping back into old habits Patients in Preparation, Action and Maintenance are best suited for Healthy Me.
Methods To Avoid Scare tactics: You will have diabetes by the time you re 30. Your parents will bury you. You re going to be 300 pounds. Forced visits You have to see the dietitian to make changes. Judgments Why are you wasting everyone s time if you re not going to change? Sets judgment up as part of the relationship and makes the relationship unsafe. Too high expectations You didn t lose any weight since the last visit. Are you even doing what the RD recommended?? If patient has been gaining weight, gaining slower or maintaining may be the goal.
Changing our perspective of weight and weight loss. Diets don t work. We need to change our objectives for our patients. Behavior change takes time. There is no quick fix for obesity. If you don t have time to do it right, apparently you have time to do it twice
Program Details 7 Dietitians are currently providing nutrition/behavior counseling at: 31 participating ProHealth practice sites 23 Pediatric Practices 7 family practices 1 pediatric GI practice 3 dietitians are also now providing counseling to adult patients at the 7 participating family practices (since Jan 2016)
Preliminary Results Pilot results Total Patients with > 1 visit: 30 (17 Sims Peds, 13 Som Peds) Total Decrease BMI z score: 43% (Decreased by 4.4% avg) Unchanged/maintained: 7% Increased BMI z score: 50% (Increase by 2.8% avg, control increased by 9.5%)
Preliminary Results In 2015, ProHealth provided 3104 Healthy Me visits to our patients. Program Early Results (n=399) 59% decreased their BMI z scores by an average of 4.8% 5.3% maintained their BMI z score 35% increased BUT did so by only 3.5% (controls demonstrated a 9.5% increase). Pilot office also found 50% of patients with only one visit showed a decrease in BMI z-score! We are working with CCPC to further analyze the BMI data Patient Satisfaction
Barriers to program success Referral of patients not ready to make changes Provider/staff perception of success not matching family s Cost of RD time No-show/cancellation rate (? due to readiness) Perception that obesity treatment is pointless Lack of funding for program incentives and initiatives
Prevention: Microculture Infrastructure Website (prohealthmd.com/healthyme), handouts, recipes, and community resources. Education Provided to all providers and staff Changing the Culture/Resetting the Default Within the Exam Room, Office and Community Prevention Toolkit
Prevention Infrastructure This part is flexible, based on office interests and feasibility We suggested: Familiarization w/ handouts, recipes, website Developing a schtick and using it at EVERY visit, no matter the BMI! If time, going over a handout with the family Printing out helpful handouts/recipes, referring families to the website Developing an office culture
Prevention Toolkit Office Culture: Healthy snacks at checkout. In the fall some practices put out a basket of apples. This offers a chance at partnership with local farms/markets. Utilize the handouts as best you can, such as seasonally put out a new recipe. Also think about using them in a targeted way, for example around the holidays, put out the Holiday handout. In the Exam Room: Use those handouts!! Familiarize yourself with what is available, have some of your favorites printed out, refer families to the website for others. Get to know the website (prohealthmd.com/healthyme) and refer families to it. There are recipes, community specific resources, all the handouts, and more to come! Community: Engage with the local library. Most libraries have a resource room set aside for talks/programs.
Prevention Plan: Compensation Metric Daily Healthy Me handout given at every well visit-age appropriate plan Offer the RD services to ALL families that come through Identify patients crossing percentiles or increasing faster than recommended Monthly Seasonal recipe at reception Bulletin board update New mom class Community outreach (ex: provide pregnancy/bf handouts to local OB)
Prevention Strategies
Prevention Strategies
Future prevention support Dietitians are now trained in lactation counseling. Lactation counseling is a great opportunity for obesity prevention The first 6 months of life are considered a key period for preventing obesity Dietitian-only visits for: failure to thrive, picky eating, high cholesterol. These visits can help create healthy eating behaviors for the future. We encourage providers to utilize the dietitians to discuss: starting solid foods, hunger cues, transitioning to milk
Obesity Prevention Prevention data: Recent data compiled by the Healthy Me team demonstrates that the percent of overweight pediatric patients is continuing to increase in our ProHealth population, by 1-5% at each practice site (not providing a specific prevention plan) over the past ~18 months. One pediatric practice with a comprehensive obesity prevention plan managed to stabilize their patient panel s overweight BMI percentage for two years running (remained stable at 21.3% of the population). Over a similar time period, a practice with little action in prevention increased by 2.7%. Rolling out a specific and actionable prevention plan is our only hope to seeing a decline in incidence of obesity.
Patient and Provider Perspectives Healthy Me parent: I wanted to tell you that you really made an impression on my child. I appreciate the way you talked to us, and gently recommended changes to improve her diet. Healthy Me provider: To me, the biggest advantage of the Healthy Me Program is having the RD in our office. I point out to the family that this encourages direct communication between the provider and the dietitian, allowing the patient, family, RD and provider to work together as a team, toward a common goal.
Questions??