Good morning and Welcome! What did you have for breakfast? Stage - - PowerPoint PPT Presentation
Good morning and Welcome! What did you have for breakfast? Stage Three Pediatric Obesity Treatment: The Comprehensive, Multidisciplinary Care Model Wendy Slusser, MD, MS, Associate Vice Provost, Healthy Campus Initiative Health Science
The Comprehensive, Multidisciplinary Care Model
Wendy Slusser, MD, MS, Associate Vice Provost, Healthy Campus Initiative Health Science Clinical Professor Danyale McCurdy-McKinnon, PhD Psychologist Miranda Westfall, MPH, RD Dietitian UCLA FIT for Healthy Weight Program Mattel Children’s Hospital UCLA UCLA Schools of Public Health and Medicine Funded by the Unihealth Foundation www.fitprogram.ucla.edu
DISCLOSURE STATEMENT Wendy Slusser
Affiliation / Financial Interest Organization Stock Amgen Stock Bristol-Myers Squibb Stock Merck Stock Novo-Nordisk Honoraria/Scientific Advisor Dannon
Any real or apparent conflicts of interest related to the content of this presentation have been resolved.
Danyale McCurdy-McKinnon, PhD Miranda Westfall, MPH, RD
Have documented no financial relationships to disclose or Conflicts
multidisciplinary pediatric obesity care team
to counseling interactions
in obesity management
0% 5% 10% 15% 20% 25% 1963-65 & 1966-70 1971-74 1988-94 1999-2002 2007-8 2009-10 2011-12
Obese* Children in the U.S. (*BMI≥95th percentile)
6-11 years old 12-19 years old
Source: www.NICHQ.org; Ogden,CL et al., JAMA. 2010;303(3):242-249; JAMA. 2012;307(5):483-490; JAMA 2014;311(8):806-814.
0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% All race Non-Hispanic White Non-Hispanic Black Non-Hispanice Asian Hispanic 2007-8 2009-10 2011-12
From: JAMA. 2010;303(3):242-249; JAMA. 2012;307(5):483-490; JAMA 2014;311(8):806-814.
Obese and Overweight* Children 2-5 years old in the U.S. by race (*BMI≥85th percentile)
Overweight children and adolescents have a:
risk of growing up to be an overweight adult.
Overweight children have higher risk
What are the top three co-morbidities that drive the health care costs for pediatric
asthma
complaints
diabetes, sleep apnea
Management
Multidisciplinary Intervention
From:Barlow, S Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.
diagnosed.
eating and activity habits.
improved habitus (BMI Status).
From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child
and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.
What is the intervention with the strongest evidence for obesity prevention and management
day.
– Minimize Sugar-sweetened beverages with a goal
– Increase meals prepared at home**. – Education and modification of portion sizes** – Reduction of inactive time to < 2 hours/day and if less than 2 years old to 0 time**. – Increasing active time for children and families to >=1 hour each day**. – Involve the whole family in lifestyle changes. – Cultural sensitivity
** = strong evidence
From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent
Overweight and Obesity: Summary Report. Pediatrics, 2007.
– Increasing to 5 fruit and vegetable servings or more per day*. – Reduction of 100% fruit juices*. – Consume a healthy breakfast*. – Reduce foods that are high in energy density *. – Meal frequency and snacking *. – Involve the whole family in lifestyle changes. – Cultural sensitivity
From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and
Obesity: Summary Report. Pediatrics, 2007.
*weaker evidence, but may be important for some individuals
Fasting lipids No risk factors
Fasting lipids, with risk factors Fasting glucose, AST/ALT
Fasting lipids, Fasting glucose, AST/ALT
From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.
support and structure
– Planned diet, structured daily meals and snacks – Supervised physical activity – Monitoring behaviors with logs – Additional reduction in inactive time – Planned reinforcement
From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent
Overweight and Obesity: Summary Report. Pediatrics, 2007.
Management
Multidisciplinary Intervention
From:Barlow, S Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.
Maintain or reduce BMI percentile. Slow down weight gain velocity. Improved co-morbidity measures (ie reduced blood pressure, reduced insulin levels, reduced fasting serum lipids). Reduced medication usage. Increased school attendance.
Educator
Modified from: Barlow, S Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.
team members.
utilization of patient visits for reauthorization as needed.
*Based on the Alliance for a Healthier Generations (Collaboration between the Clinton Foundation, AHA and 5 private health insurers: Aetna, BlueCross MA and NC, Pepsico, Wellpoint).
Dan DeUgarte, MD Yasmin Firouzman, RD Cambria Garell, MD Alma Guerrero, MD, MPH Anna Haddal, MD Dena Herman, PhD, RD Danyale McCurdy-McKinnon, PhD Twyman Owens, MD Wendy Slusser, MD, MS Robert Venick, MD Miranda Wesfall, RD, MPH Ora Yadin, MD Volunteers, Interns and Residents
Organizations & Institutions
Media Law Popular Culture Professional Education Public Education Public Parks
Community/Neighborhood
Home Visitation Child Care Employer Lactation Specialists Hospitals Health Care Providers Insurers
Parent, Infant, Child
Friends/Family
Fathers Friends Family Neighbors Coworkers
From: Frieden, Am J Public Health. 2010;100:590–595
– Follow the ABCs of counseling
– Parenting Skills:
From: Slusser W and Kroeger M (1992) in Woodward-Lopez G and Creer AE lactation Management Curriculum: A Faculty Guide for Schools of Medicine, Nursing, and Nutrition. Third edition, 1995 UCSD and Wellstart International.
Fruit comes from flowers Fruit is very good to eat I like to eat fruit
Danyale McCurdy-McKinnon, PhD Clinical Psychology Director UCLA Fit for Healthy Weight Program
people to do what they don’t want to do; rather, it is a fundamental way of being with and for people - a facilitative approach to communication that evokes change.”
Miller & Rollnick 2002
Motivation – it’s complicated!
treating pediatric obesity 1
providing obesity interventions to children 1
regarding outcome is that practitioners perceive low patient motivation and poor behavioral adherence 2,3
1) Jelalian, Boergers, Alday, & Frank (2003) 2) Kolagotla & Adams (2004) 3) Story, Neumark-Stzainer, Sherwood, Holt, Sofka, et al. (2002)
field 1
addictive behaviors 2
activity in adults with overweight and obesity 3
1) Miller (1983) 2) Burke, Arkowitz, & Menchola (2003) 3) Armstrong, Mottershead, Ronksley, Sigal, Campbell, & Hemmelgarn (2011)
adolescents 1
autonomy support from medical staff at the end of the program, greater increase in integrated and identified regulations, and a decrease in amotivation
for healthy life‐styles during a weight feedback session to parents in recruitment to a family-based weight loss study 2
participate in a family‐based intervention; with MI only increasing autonomy
1) Gourlan, Sarrazin, & Trouilloud (2013) 2) Dawson, Brown, Cox, Williams, Treacy, et al. (2014)
they talk) influences outcomes 1
express verbal commitments to change, they have better treatment outcomes 2
1) Miller & Rollnick 2002 2) Armhein et al 2004
Motivational interviewing is a person- centered, directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence.
wants to do
change
not push it in order to maintain patient/professional alliance
change is within the realm of the patient
health provider)
effective (not to be confused with giving information)
ambivalence before moving towards change
What are the advantages
the way they are now? What are the advantages
What are the disadvantages
What are the disadvantages
the way they are now?
the patient
walking to the grocery store or cutting down
program?
How important would you say it is for you to _________? On a scale of 0-10, where 0 is not at all important and 10 is extremely important, where would say you are? Follow-up: And why are you at __ and not zero? How confident would you say it is for you to _________? On a scale of 0-10, where 0 is not at all confident and 10 is extremely confident, where would say you are? Follow-up: And why are you at __ and not zero?
dilemma, but give no advice. Ask these three open questions, and listen: 1) What is there about you (strengths, abilities, talents) that will help you do this? 2) How might you go about it in order to succeed? 3) What have you done successfully in the past that was like this in some way?
57
questions!”
saying..."
down at the end.
than asking)
and how you would like to get outdoors more.”
discussed earlier
important it is to you to be a good soccer player.”
to a new task
you've told me so far, and see if I've missed anything
don't have as much energy as you would like, and it bums you out...”
patient and their family to identify behaviors that contribute to the child's weight
each behavior can be implemented
Come up with something about yourself that you...
...but you haven't changed yet (i.e., – something you're ambivalent about)
dilemma
– Why would you want to make this change? – How might you go about it, in order to succeed? – What are the three best reasons to do it?
closed-ended questions the provider asks
(15 minutes)
UCLA Fit for Healthy Weight Clinic
n Mean (SD) or % Clinic visits 309 3.13 (2.85) Time between clinic visits (months)
Age (years) 115 13.10 (3.81) <2 0% 2<x<9 19 16.52% 9<x<13 45 39.13% 13<x<16 22 19.13% 16<x<19 24 20.87% >19 5 4.35% Sex Male 57 49.57% Female 58 50.43%
UCLA Fit for Healthy Weight Clinic
n Mean (SD) Height (cm) 115 157.09 (17.26) Weight (kg) 115 88.59 (33.29) BMI (kg/m2) 115 34.68 (9.14) BMI percentile 115 97.8 (1.66)
UCLA Fit for Healthy Weight Clinic
n Mean (SD) or % BMI Category Overweight 3 2.61% Obese 112 97.39% Blood Pressure Systolic BP (mm Hg) 113 117.92 (9.80) Systolic BP percentile 113 74.0 (24.2) Normotensive 79 69.91% Prehypertensive 11 9.73% Stage 1 hypertensive 17 15.04% Stage 2 hypertensive 6 5.31%
5 10 15 20 25 30 35 40 45 50 Percent of Patients Barriers Selected
Barriers to Physical Activity
10 20 30 40 50 60 70
Percent of Patients
Barriers Selected
Barriers to Healthy Diet
Change in BMI Values across Clinic Visits
Figure 3. Change in BMI values across number of visits. Number of patients with an increase, decrease, or no change in BMI values over clinic
change in BMI.
Prevalence of elevated blood pressure categories
Table 3. Identified comorbidities at the first visit of Fit Clinic patients (N=115)
Present Not Present Not Reporteda % with Identified Comorbidity Constitutional 112 3 97 Skin 90 21 4 79 Endocrine 80 31 4 70 Cardiovascular 60 52 3 52 Ears, Nose, Mouth, Throat 58 55 2 50 Psychiatric 48 66 1 41 Respiratory 42 71 2 36 Gastrointestinal 37 76 2 32 Neurological 33 80 2 28 Musculoskeletal 32 81 2 26 Female Specific 15 52 48 21 Eyes 20 92 3 17 Immunological 19 92 4 17 Genitourinary 16 97 2 14 Male Specific 9 54 52 14 Chest 13 100 2 11 Heme/Lymph 6 107 2 5 Average 5.8 identified comorbid systems at first clinic visit.
aMissing data included in percentage calculations
Source: ars.usda.gov
sweetened beverages
consumption
particularly fast food restaurants
with goal of 60 minutes per day
2 hours per day
– Ability to purchase healthy foods – Access to safe spaces for exercise
patient and family determine
– 2 to 3 nutrition goals – 1 to 2 physical activity goals
related to comorbidities
Dairy Fruits Protein Veggies Grains Dairy Dairy Fruits
My Plate My Snack
key psychiatric symptoms
Adapted from case study presented by Marc S Jacobson on 12/12/2008
her pediatrician because she had gained 20lb’s in the past year and had high cholesterol and triglycerides. She had been trying to lose weight using Weight Watchers and by joining a gym with no effect.
none, Medications: none, Allergies: none
Neuro nl, Musculoskeletal nl, Endocrine and growth: Menarche was at age 12.5
not skipped more than a few weeks prior to 3months ago when she had her last normal period.
CABG at age 54), obesity, hypertension, type 2 diabetes and hypercholesterolemia.
She does not smoke.
spends most of her free time on movies and shopping with
takes the bus most days. She lives ~1 mile away from her high school but takes the bus most days.
computer).
bpm,
present in all 4 extremities.
noted.
Wendy Slusser, MD, MS, Debra Lotstein, MD, MPH, Heidi Fischer, MPH, Margaret Whitley, Alma Guerrero, MD, MPH
how it is helping to prevent and treat childhood
addressed using the Chronic Care Model.
Collaborating with residency programs we aimed to improve the knowledge, attitude and practices of the future primary care workforce in:
– Prevention and Early Identification – Management and Referral – Advocacy
In order to reduce the rates of pediatric obesity and its complications in racially and ethnically diverse populations.
experiencing large health disparities traditionally served by residency programs.
developing and launching the Breastfeeding Residency Curriculum.
Pediatrics, American Academy of Family Practice and committee membership representing the CDC, AAP resident training and national leaders in childhood obesity.
curriculum and identify educational and clinical tools.
care residency programs piloted the FIT curriculum and clinic changes (with comparison sites): – Childrens’ Hospital Oakland – Contra Costa Family Practice – White Memorial Pediatrics and Family Medicine – Harbor UCLA Pediatrics – Scripps Family Practice
primary care residents in:
– Prevention – Management and referral – Advocacy
– Knowledge objectives and measures – Clinical change objectives and measures
expert based guidelines – 2007 Expert Committee Recommendations – 2005 AAP Breastfeeding Statement
needed to put these guidelines into practice effectively
Ref: http://www.ama-assn.org/ama1/pub/upload/mm/433/ped_obesity_recs.pdf; http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496#SEC10
Helping physicians do the right thing every time
Patient registries and performance feedback
Assigning provider team roles, planned visits, and follow-up care
Active patient/family role; written plans with patient-directed goals
Develop relationships with community resources; advocate for policy changes
Engagement of senior leadership in quality improvement; policies to support care coordination
– Twice: at beginning and end of year
– Includes feedback measures and additional measures of quality of care
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 Percent change
Knowledge Results
Percent Change at One Year*
Pilot Control
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 Percent change
Attitudes Results
Percent Change at One Year
Pilot Control
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Sep-09 Dec-09 Mar-10 Jun-10
Percent BMI Calculated
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 Sep-09 Dec-09 Mar-10 Jun-10
Percent BMI Calculated Correctly
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Sep-09 Dec-09 Mar-10 Jun-10
Percent BMI Plotted
0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Sep-09 Dec-09 Mar-10 Jun-10
Percent BMI Classified
0.2 0.4 0.6 0.8 1 Sep-09 Dec-09 Mar-10 Jun-10
Percent Blood Pressure Classified Correctly
0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Sep-09 Dec-09 Mar-10 Jun-10
Percent Blood Pressure Classified
Outcomes Measured
confidence related to pediatric obesity prevention and management
prior
mentorship
and follow-up
patients seen in project year 1 and 2 at different time periods
retrospectively
Domain Change from Pre to Post P-value *Significant at alpha = .05 General Knowledge (Maximum=39) + 2 0.009* Attitudes (Maximum= 95) + 9.5 <.001* Confidence Subdomain (Maximum=60) + 9 <.001* QI Knowledge (Maximum= 40) + 3.5 0.0645
Percent of appointments where BMI percentile decreased or stabilized 12 months prior 6 months prior2 Year One 71% (n=31) 62.5% (n=8) All 6 mo: 69.4% (n=36) Year Two 56.8% (n=118) 48.7% (n=39) All 6 mo: 54.0% (n=113)
Sharing in upcoming book edited by Sandra Hassink and Sarah Hampl
Danyale McCurdy-McKinnon, PhD
Fit Clinic experience is offered as an elective to clinical psychology interns
– Monthly supervision meeting with relevant topics
– depression, anxiety, trauma, eating disorders, and behavioral issues
– MI, exposure therapy, CBT , DBT , social skills training, bullying interventions
– Recent publications are selected, reviewed, and discussed
– Interns shadow psychologist in the clinic initially for in vivo training experience – Trainees take over in the role of junior colleague and psychologist for the duration
– Intern’s Role:
Exploring Reimbursement for Pediatric Weight Management Services A Pilot Project
In 2004: – privately insured obese children annual health care costs: $3,743 (all children $1,108) – Medicaid insured obese children annual health care costs: $6,730 (all children, $2,446)
From:William MD, Chang S, (2005). Childhood Obesity: Costs, Treatment Patterns, Disparities in Care, and Prevalent Medical Conditions. Ann Arbor, Mich: THOMSON MEDSTAT RESEARCH BRIEF accessed, January 26, 2010. http://www.medstat.com/pdfs/childhood_obesity.pdf
Overweight children have higher risk
adequately reimburse a multidisciplinary care model
covered
sources of funding
From: Slusser W, Staten K, Stephens K et al. (2011). Payment for Obesity Services: Examples and Recommendations for Stage 3 Comprehensive Multidisciplinary Intervention Programs for Children and Adolescents. Pediatrics. 2011;128;S78
Reported Challenges Facing Obesity Programs Lack of Reimbursement 29 85% High operating costs 24 71% Inadequate space 19 56% Not financially viable 14 41% Lack of demonstrable
12 35% Personnel problems 5 15% Poor patient recruitment 5 15% Inadequate expertise 2 6% Lack of leadership 1 3%
From: FOCUS on a Fitter Future Outcomes Presentation. Presented at: Creating Connections Conference; March 2010
From: Slusser W, Staten K, Stephens K et al. (2011). Payment for Obesity Services: Examples and Recommendations for Stage 3 Comprehensive Multidisciplinary Intervention Programs for Children and Adolescents. Pediatrics. 2011;128;S78
House Task Force on Childhood Obesity “Federally funded and private insurance plans should cover services necessary to prevent, assess, and provide care to
2 year period Obese + ≥1 Comorbidity Morbidly Obese + ≥1 comorbidity # Patients # # Total Cost $ $ Cost per Patient $ $ % Cost attributed to: Inpatient % % Outpatient % % ER % % Rx % %
– Obese and/or morbidly obese
– Inpatient – Outpatient – Medications
Morbid Obesity
Comorbidity
Hypercholesterolemia
Two year pilot program
Recruitment & Enrollment (Jul - Dec 2015) Treatment and Data Collection (Aug 2015 - Dec 2016) Data Analysis (Jan - Jun 2017)
the pilot and their geographic location
groups about the pilot and the obesity care carve out
medical groups based on volume of referrals
Visit MD RD Psych Medi-Cal Fee Schedule # visits Total Initial $ 1 $ Follow-Up $ 11 $ 1-Year Family Membership to YMCA $ Total Case Rate $
complications of obesity. For example:
– Imaging studies (e.g. liver ultrasound) – Sleep studies
– ED visit for stitches
– Lower the cost per patient – Decrease number of hospitalizations – Fewer ER visits
With realization of one’s own potential and self confidence in one’s ability, one can build a better