Addressing childhood obesity through partnerships between healthcare and community
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Addressing childhood obesity through partnerships between
healthcare and community
Sarah E. Barlow, MD, MPHBaylor College of Medicine
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IOM report Preventing Childhood Obesity 2005
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Addressing Obesity within the Healthcare System
Benefits of this setting+ Framing the condition in terms of health
rather than appearance+ Care of associated medical problems+ Care of individual and of family
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Addressing Obesity within the Healthcare System
Disadvantages of this setting– Time– Reimbursement– Expertise– Office visit structure– Accessibility for patient
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Office visit model
Symptoms and signs
Diagnosis Treatment
Headaches with nausea
Migraines Medication
Soda, fast food, school food, video games, poverty, unsafe neighbor-hood, single mother, poor parenting, depression
Obesity Education, motivation, parenting skills, social work, screen and address comorbidities
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Pediatricians feel overwhelming sense of futility
“I just feel kind of powerless…what more can I do?”
“Giving them handouts just placates me”
“I can talk until I’m blue in the face…you know at home these kids are just following the [overweight] parents’ footsteps, and there’s not really anything that’s going to change that”
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Hercules carrying the world
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Addressing Obesity within Community Setting
Benefits:+ Accessibility+ Implementation as well as education+ Opportunity for environmental change+ Context of behavioral setting
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Addressing Obesity within Community Setting
Disadvantages:– Low intensity – Limited scope or duration
• Exercise class, nutrition class– Lack of individualization
• Medical• Behavioral
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Community programs Shape Up Somerville
Somerville MA and 2 control communities: grades 1-3Intervention
Before school: breakfast, walk to schoolDuring school: staff development, food service, curriculum, recessAfter school: aftercare curriculum, walk from schoolHome: newsletter, coupons, family eventsCommunity: farmers market, Ethnic-minority group collaborations, city ordinances on walkability, bike-ability
Economos 2007; Obesity 15, 1325
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Shape Up Somerville
Somerville Control 1 Control 2
Girl Boy Girl Boy Girl Boy
Number 190 195 298 263 117 115
Change in BMI z-score (8 mos)
-0.027 -0.036 -0.002 -0.009 0.009 -0.018
Estimated effect on weight over 8 months:
Boys – 0.82 lb Girls – 0.95 lbs
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Integrating Healthcare and Community Resources
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Environment
Family
School
Worksite
Community
Chronic Care Model
Medical System
Information Systems
Decision Support
Delivery System Design
Self Management Support
Family/PatientSelf-Management
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Chronic Care ModelSelf-Management
Patients have a central role in determining their care
Decision Support Health organizations integrates guidelines into day-to-day practice
Delivery System Design Providers have clear roles and tasks; patient information is centralized and up-to-date.
Clinical Information System Information systems can track individual as well as groups of patients.
Organization of Health Care Health care systems can create an environment in which organized efforts to improve chronic illness care flourish.
Community Healthcare forms partnerships with state, local, and private entities.
Wagner EH. Effective Clinical Practice. 1998;1(1):2-4
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Expert Committee Recommendations for Prevention, Assessment and Treatment
of Child and Adolescent Obesity
AssessmentMedical risk
Behaviors
Attitude
BMI Category(calculated yearly from weight and height)
Prevention
Treatment Stages1 Prevention Plus
2 Structured Weight Management
3 Comprehensive Multidisciplinary
4 Tertiary Care Intervention
Barlow SE and Expert Committee, 2007. Pediatrics 120; suppl 4.
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Prevention Plus
Structured Weight Management
Comprehensive Multidisciplinary
Tertiary Care
Intensity
Stages of intervention
Age
BMI
Medical status
Motivation
Who What and How
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1. Prevention Plus
WHAT5+ fruits and vegetables£ 2 hours screen time≥ 1+ hours physical activityReduce sweet drinksEating behaviors (3 meals,
family meals, etc.)Family-based change
HOWOffice-basedTrained office support MD, PNP, PA, RNScheduled follow-up visitsAdvance to next level depending on response and
interest
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2. Structured Weight Management
WHATReduced calorie eating plan≤ 1 hour screen time> 1 hour physical activityMonitoring
HOW RD, MD, RN with training in assessment, counselingOffice-based Support from referrals and outside programsMonthly visitsAdvance if needed
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Goals with community partners: coordinating programs
Programs for physical activity– Fun– Inclusive (rather than select)– Available and affordable/free– Some targeted for overweight children
Programs for better nutrition– Parent education, culturally appropriate– Child education– Access (Farmers markets, supermarkets)
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Healthy Kids-Houston(Project KidFIT)
Partners: Baylor College of Medicine Texas Children’s HospitalHouston Parks and Recreation Dept Houston Metropolitan Authority
6-week after-school physical fitness and nutrition education program – 128 children 6-12 years of age– 61% African American, 39% Hispanic– 54% with BMI > 95th %ile
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Healthy Kids-Houston: Decreased weight and BMI in obese youth
Bush CL et al. J Peds 2007; 151:513
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Viva La Salud Infantil Weight Loss Intervention Pilot Study
Baylor College of Medicine, Children’s Nutrition Research Center, Nancy Butte PhD, principal investigator
Ripley House—Neighborhood Center“Bringing resources, education and connection to underserved neighborhoods”
To compare a 4 month intervention for overweight Hispanic 7-12 year olds and families
– weekly diet behavior modification vs.
– weekly diet behavior modification plus structured aerobic exercise 3x a week
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Viva La Salud Results
24 children enrolled, 21 completed– Weekly sessions: 94% – Exercise sessions: 84%
Weight change both groups -2.2 kg ± 2.7 diet-3.3 kg ± 2.7 diet + ex
Improved Quality of Life (p=0.04)
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Viva La Salud Infantil Weight Loss Intervention Pilot Study
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2 week residential camp
Partners:• Camp Cho-Yeh, Livingston TX• Texas Children’s Hospital / Texas Children’s Pediatric
Associates• Baylor College of Medicine • USDA/ARS Children’s Nutrition Research Center• Harris County Hospital District Foundation
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Kamp K’aana
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Kamp K’aana Program
Lessons
Daily for 1 hour
4 nutrition 6 behavior
Healthy food
1 pass cafeteria lineUnlimited salad1800 kcal per dayTraffic Light labels
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Kamp K’aana Activities
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Kamp K’aana Outcome
• Improved weight: -3.7 ± 1.2 kg-1.6 ± 0.5 kg/m2
• Improved self-esteem
Kamp K’aana 2009www.bcm.edu/kampkaana
Wong w et al. JPGN 2009 in press.
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Adult program: Community referral for promoting physical activity among
primary care patients Kevin O. Hwang, MD, MPH, UT Houston
Partners: YMCA and UT Houston Physicians General Clinic
Prescription for physical activity alone vs. prescription plus referral to YMCA and vouchers
Results: both groups increased physical activity, with no difference between the groups
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Prevention Plus
Structured Weight Management
Comprehensive Multidisciplinary
Tertiary Care
Intensity
Stages of interventionImprove, integrate, and evaluate
Healthcare AllianceTexas Pediatric Society toolkit
Viva La SaludHealthy Kids Houston
Kamp K’aana
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Obesity care is a team activity:Healthcare and community partnerships
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