Changes for Life: A Primary Care Based Multidisciplinary Program for Obesity in Children and Families

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Changes for Life A Primary Care Based
Multidisciplinary Program for Obesity in Children
and Families
Session C5 October 29, 2011130 pM

• Tom Bishop, Psy.D.
• Behavioral Health Consultant
• Cherokee Health Systems
• Jena Saporito, Ph.D.
• Behavioral Health Consultant
• Cherokee Health Systems

• Parinda Khatri, Ph.D.
• Director of Integrated Care
• Cherokee Health Systems
• Hollie Raynor, Ph.D.
• Associate Professor
• Department of Nutrition
• University of Tennessee

Collaborative Family Healthcare Association 13th
Annual Conference October 27-29, 2011
Philadelphia, Pennsylvania U.S.A.
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Faculty Disclosure

• I/We have not had any relevant financial
  relationships during the past 12 months.

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Need/Practice Gap Supporting Resources

• Surveys from 60 parents of children aged 2 to 12
  years with a BMI gt 85th ile
• Eating behaviors
• 83.3 consumed fast-food gt 1/week (limit)
• Mean sweetened drink intake 2.1 2.6
  servings/day (limit)
• 28 and 18.3 consumed sweet and salty snack
  foods at least once per day, respectively (limit)
• Mean low-fat dairy intake 1.8 .4 servings/day
  (2 servings per day)
• Mean fruit vegetable intake was 1.9 .2 and
  1.4 .1 servings per day, respectively (1.5 c
  fruits 2.5 c vegetables/day)
• Leisure-time behaviors
• 53.3 played or exercised hard enough to sweat 4
  or fewer days/week (60 minutes per day)
• Mean TV viewing time was 2.5 1.6 and 2.9 1.6
  hours on weekdays and weekend days, respectively
  (lt 2 hrs/day)
• Raynor, H. A., Jelalian, E., Vivier, P., Hart,
  C., Wing, R. R. (2009). Parent-reported
  eating and leisure-time activity selection
  patterns related to energy balance in preschool-
  and school-aged children. Journal of Nutrition
  Education and Behavior, 41, 19-26.

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• Pediatric weight management
• Using behavioral counseling as part of a
  multi-component pediatric weight management (PWM)
  program to treat overweight results in
  significant reductions in weight status and
  adiposity in children and adolescents.
• PWM family participation in treating pediatric
  obesity in children and adolescent obesity
  treatment
• Family participation Children (6-12 yrs)
• Rating Strong (Imperative)
• Family participation Adolescents
• Rating Fair (conditional)
• What is the effectiveness of family-based
  counseling as part of an intervention program for
  PWM?
• Ages 6-12 yrs good
• Ages 13-18 yrs limited
• Is counseling for weight loss in the absence of
  parents effective?
• Ages 6-12 yrs expert opinion
• Evidence suggests that child-only interventions
  are not effective for children ages 6 to 12 yrs
• Ages 13-18 yrs Fair

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Objectives

• Describe background, structure, and outcome data
  for program targeting obesity in children and
  their families
• Provide the nutritional and behavioral content of
  prevention and intervention components of program
  targeting obesity in children and their families
• Describe challenges and lessons learned in
  targeting obesity in a multidisciplinary primary
  care setting
• Provide strategies for implementing
  multidisciplinary program for obesity in primary
  care.

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Expected Outcome

• What do you plan for this talk to change in the
  participants practice?
• Improved identification of obesity and risk for
  diabetes
• Increased knowledge of evidence based prevention
  and intervention strategies for obesity and
  diabetes risk
• Enhanced application strategies for primary care
  based obesity management and diabetes risk
  programs

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Our Mission To improve the quality of life
for our patients through the integration of
primary care, behavioral health and substance
abuse treatment and prevention
programs. TogetherEnhancing Life
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Cherokee Health Systems A Federally Qualified
Health Center and Community Mental Health Center
Corporate Profile Founded 1960 Services
Primary Care - Community Mental Health -
Dental - Corporate Health Strategies Locations
21 clinical locations in 14 Tennessee
Counties Behavioral health outreach at numerous
other sites including primary care clinics,
schools and Head Start Centers Number of
Clients 57,175 unduplicated individuals served
- 22,119 Medicaid (TennCare) New Patients
16,440 Patient Services 452,906
Number of Employees 540 Provider Staff
Psychologists 43 Masters
level Clinicians - 59 Case Managers - 32
Primary Care Physicians 30
Psychiatrists - 12 Pharmacists - 9
NP/PA (Primary Care) - 19 NP
(Psych) - 7 Dentists - 2
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Cherokees Blended Behavioral Health and Primary
Care Clinical Model

• Embedded Behavioral Health Consultant on the
  Primary Care Team
• Real time behavioral and psychiatric consultation
  available to PCP
• Focused behavioral intervention in primary care
• Changes for Life A Primary Care Based
  Multidisciplinary Program for Obesity in Children
  and Families.
• Behavioral medicine scope of practice
• Encourage patient responsibility for healthful
  living
• A behaviorally enhanced Healthcare Home

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Obesity and Risk for Diabetes

• 21 million Americans have Diabetes
• 54 million Americans at risk
• Tennessee highest rate of Diabetes ages 45-64
• 39 school children overweight/obese
• 64 adults overweight/obese
• Rates of physical activity declining each year
• Escalating medical cost due to Diabetes

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Changes for Life Program

• Integrated Primary Care Based Prevention and
  Intervention Program
• Target population is underserved children and
  adolescents who are overweight/obese
• Goal is to reduce risk for diabetes through
  positive health behaviors

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Multidisciplinary Approach

• Primary Care Providers
• Behavioral Health Consultants
• Nutritionist
• Nurses
• Fitness Instructor
• Partners - University of Tennessee

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Overview of Recommendations for Primary care

• Hollie Raynor, Ph.D.

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Recommendations for Treatment in a Primary Care
Setting

• Step or staged approach for weight management is
  recommended
• Evidence supports the components of these stages,
  but the staged approach itself has not been
  evaluated
• Four recommended stages, with each stage
  increasing in intensity of intervention
• Initial stage for treatment is what is encouraged
  for prevention

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Recommendations for Treatment in a Primary Care
Setting

• Once child is gt 85thile body mass index (BMI),
  recommendation to begin treatment starting at the
  age of 2 years
• Encouraged to always start at the first stage,
  except when a child has reached the age of 12
  years and is gt 99thile BMI then Stage 1, 2, or
  3 should be initiated depending on family
  motivation level

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Stage 1 Prevention plus

• Energy balance targets assess motivation to
  change and set goals related to the following
  areas
• Consumption of 5 servings of fruits and
  vegetables per day (mixed evidence)
• Minimization or elimination of sugar-sweetened
  beverages (mixed evidence)
• Limit of 2 hours of screen time per day, no
  television in the room where the child sleeps,
  and no television viewing if the child is 2 years
  of age (consistent evidence)
• 1 hour of physical activity per day (mixed
  evidence)

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Stage 1 Prevention plus

• Family-focused behaviors include
• Eating breakfast daily (mixed evidence)
• Limiting meals outside the home, including at
  fast food venues and other restaurants (mixed
  evidence)
• Eating family meals at least 5 or 6 times per
  week (mixed evidence)
• Frequency of follow-up depends on readiness to
  change
• Progress to next stage if no anthropometric
  change in 3-6 months

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Stage 2 Structured Weight Management

• Closer follow-up with families (monthly)
• More focus on behavioral monitoring and
  reinforcement of achieving behavioral goals
• More structured overall dietary intervention
• Development of a plan for use of a
  balanced-macronutrient diet, emphasizing small
  amounts of energy-dense foods (suggested)
• Provision of structured daily meals and snacks
  (breakfast, lunch, dinner, and 1 or 2 snacks per
  day) (suggested)

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Stage 3 Comprehensive Multidisciplinary
Intervention

• Increasing intensity of behavioral strategies
  much more focus on the family and use of
  psychologist
• More frequent contact (weekly)
• Dietary
• Planned negative energy balance achieved through
  structured diet (may include calorie goals) and
  increased physical activity

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Stage 4 Tertiary Care Intervention

• Referral to a pediatric tertiary weight
  management center that has access to a
  multidisciplinary team with expertise in
  childhood obesity and that operates with a
  designed protocol

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Changes for Life Overview of Phase I and
Phase II

• Tom Bishop, Psy.D.

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Changes for Life Overview

• Training to behavioral and primary care team
  members
• Identify children at risk for diabetes
• Interventions to prevent or impact obesity
• BMI at every office visit/red flag for additional
  interventions
• BMI gt 85 psycho-education and guidance
• At WCCs, BHCs provide info. on nutrition,
  activity, behavior changes
• At Risk clients will be offered specialized
  guidance by the health care team

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• Goals fo0r Participants
• Reduction in BMI
• Increased daily fruit intake
• Increased daily vegetable intake
• Advanced step in readiness for change
• Documented self-management goal
• Increase in physical activity
• Decreased television time
• Maintain healthy changes

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Individual and Group Consultations

• 3 age groups 2-6, 7-12, 13-18
• Family Focus
• Individual consultations last 15-30 min
• Each consultation included
• Healthy lifestyle education/information
• Nutritional ideas/tips and snacks
• Physical activity interventions

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Flow
Return for F/U Medical Visit
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Focus of Interventions

• Healthy Eating
• Choosing healthy foods, healthier recipes, better
  fast food choices, shopping on a budget
• Physical Activity
• Increasing physical activity daily, decreasing TV
  and screen time
• Behavioral changes
• Goal setting, self-management, stress management,
  maintaining positive changes

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Assessment Measures Youth Risk Behavior
Surveillance System and Childrens Eating
Behavior Inventory

• During the past 7 days, how many times did the pt
  eat fruit?
• During the past 7 days, how many times did the pt
  eat vegetables?
• During the past 7 days, how many days was the pt
  physically active for a total of at least 30
  minutes per day?
• On an average school day, how many hours does the
  pt watch TV?
• At what stage of change would the pt believe that
  they are currently functioning at in regards to
  eating healthy and being active?

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Quick Goals

• Limiting sugared drinks.
• Limiting screen time.
• Eating more fruits and vegetables.
• Increasing physical activity.
• Other.
• This step would also include the creation of a
  plan in achieving goals with some anticipation of
  challenges.

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Changes for Life Outcomes and Lessons
learned

• Jena Saporito, Ph.D.

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2010 Phase I
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2011 Phase I
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2009 Phase II Outcomes

• 69 had a decrease in zBMI
• 53 ate more fruit
• 30 ate more vegetables
• 29 increased at least one step in readiness to
  change
• 35 increased physical activity
• 39 decreased time spent watching television on
  school days

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2010 Phase II Outcomes

• 75 had a decrease in zBMI
• 43 ate more fruit
• 21 ate more vegetables
• 36 increased at least one step in readiness to
  change
• 25 increased physical activity
• 46 decreased time spent watching television on
  school days

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2011 Phase II Outcomes

• 49 had a decrease in BMI
• 62 ate more fruit
• 42 ate more vegetables
• 42 increase at least one step in readiness to
  change
• 49 increased physical activity
• 44 decreased time spent watching television on
  school days

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Things we Learned along the Way

• Attendance
• Groups vs. Individual
• Handoffs vs. Scheduled
• Follow-up Visits with PCP appointments
• Use of Incentives
• Cultural
• Fresh Water

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Changes for Life Promoting a Behaviorally
Enhanced Health Care Home
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Session Evaluation
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session. Thank you!