Approaches to Obesity Prevention and Treatment at School-Based Health Centers

1. Approaches to Obesity Prevention and Treatment at School-Based Health Centers Matt Haemer MD Assistant Professor in Pediatrics Section of Nutrition CU School of Medicine Medical Director LIFEStyle Medicine Weight Management Children’s Hospital Colorado matthew.haemer@childrenscolorado.org

2. Faculty Disclosure • Dr Haemer has no relevant financial or other conflicts to disclose.

3. Objectives • to describe effective strategies to discuss weight status • to understand tools to support lifestyle screening and counseling and the potential benefit • to describe effective strategies to deliver clinical obesity prevention and treatment services through SBHCs

4. Please Raise Your Hands if you: Audience Survey: • Think changing a family’s behavior for a child’s weight can be hard? • Discuss Body Mass Index at every checkup >2yrs? • Get a BMI (Ht/Wt) at sick visits? • Had difficulty describing weight status with a patient’s family? • Have a referral resource to send obese children for treatment?

5. #1. Range of Visit Goals • Raising Awareness of a weight issue • Enhancing Motivation to change • Changing or Maintaining Healthy Behaviors with Specific Goals

6. Objective 1: Strategies to Discuss Weight Status • A range of goals for the visit • Definitions of weight status • Awareness of weight status • Ideal language: motivating and non-stigmatizing

7. Awareness BMI / Weight Status>2y Percentile Ranges: • <5th underweight • 5-85th healthy weight • 85-95th overweight* • >95th obese • excess adiposity • >99th severe • Comorbidities • ~4% population *<2yrs wt/length >95% is ‘overweight’

8. 3yo Girl: BMI 90th%= Overweight Which Plot is Concerning?

9. Awareness: BMI vs. Visual 18mo 3yo 4 yo 3yo 85-95th % 95th % > 99th % healthy

10. It is OK to devote a visit to raising awareness without setting specific goals. • The first step is Awareness of : -BMI status -healthy behaviors • Raising awareness tactfully may be all you can accomplish in a visit. • Resistant patients may be more willing to talk about making changes…at next visit.

11. Awareness – Language • Communicating with children and families • Use ‘obesity’ for documentation • English: ‘overweight’ or ‘unhealthy weight’ are more acceptable (Puhl PEDIATRICS 9.26.11) • Spanish: ‘demasiado peso porsusalud’ is most motivating and nonstigmatizing (Knierim PAS 2014) • Focus groups followed by survey of 525 parents in Denver Health Krebs PEDIATRICS 2007 SeidellJC Arch Int Med 1996 Cameron AJ Med J Aust2009

12. Language - English

13. Language - Spanish

14. Awareness – Language • Ask if families are aware? • Motivators for Children • Peer acceptance, confidence, athletic performance, feeling comfortable in clothes • Motivators for Parents: consequences of Obesity in adulthood – FamHx • DM, CVD, Cancer, Arthritis, Liver Disease • Avoidance of Health Risk may not be a sufficient motivator Krebs PEDIATRICS 2007 SeidellJC Arch Int Med 1996 Cameron AJ Med J Aust2009

15. Questions on Raising Awareness?

16. Objective 2:Screening and Counseling for Healthy Lifestyles • Tools for Lifestyle Screening • Skills for effective counseling • Results – universal screening and MI counseling in SBHCs and community health centers • HEDIS measures: document weight status with BMI, discuss nutr/phys activity

17. Generic Lifestyle Advice (5210) <1 minute

18. Health Team Works

19. Page 1 Example Screening form • 1. Do you eat 5 or more fruits and vegetables per day? YES 􀀍 NO 􀀍 • 2. Do you eat breakfast everyday? YES 􀀍 NO 􀀍 • 3. Do you watch TV, videos or play computer games for no more than 2 hours per day? YES 􀀍 NO 􀀍 • 4. Do you take gym class or participate in sports or dance in or outside of school 5 or more times per week? YES 􀀍 NO 􀀍 • 5. Do you have a favorite sport or physical activity that you love to do? YES 􀀍 NO 􀀍 • 6. Do you eat dinner at the table with your family at least once a week? YES 􀀍 NO 􀀍 • 7. Do you have a TV in your bedroom? YES 􀀍 NO 􀀍 • 8. Do you eat in front of the TV? YES 􀀍 NO 􀀍 • 9. Do you drink soda, juice, or other sugar sweetened drinks one or more times a day? YES 􀀍 NO 􀀍 • 10. Would you like to talk to your doctor about making changes to improve your health? YES 􀀍 NO 􀀍 • (if yes, continue to page 2)

20. (Page 2)“Menu for Action”Counseling ToolAdapted from the Jump Up &Go! Physical Activity and Nutrition Survey and theMaine Center for Public Health Keep Me Healthy Goal Setting Worksheet

21. Where to find tools? 1. AAP “Let’s Go” Initiative https://www2.aap.org/obesity/ 2. NICHQ – COAN Childhood Obesity Action Network • http://www.nichq.org/childhood_obesity/childhood_obesity_toolkit.html 3. Health Team Works – Colorado Toolkit http://www.healthteamworks.org/guidelines/childhood-obesity.html

22. Counseling – General Styles Collaborative Goal Setting • Generic Lifestyle Advice (5210) <1min • Suggested minimum for every visit • Brief Focused Advice <3 minutes • Engage-Advise-Elicit-Assist • Collaborative Goal Setting • Brief Negotiation 5 minutes • Motivation Interviewing for a short clinic encounter • Uncover the family’s motivation • Elicit Change Talk • Collaborative Goal Setting • Set Specific Goals to Monitor if possilble

23. Why do providers worry their counseling is not effective? Acute Care Counseling Model: I tell patient what to do and why  then they do it • What if someone “knows” about the health risks of obesity, but doesn’t change? • Perhaps “Health” is not is their top priority • People act in ways they see as consistent with Core Values

24. Values and Behavior Change - How Many Providers Think Health Behavior Core Value: Maintaining Good Health Dan Bessesen MD Endocrinology UC Denver Health

25. Core values for most men Resnikow Quantum Change Study 1. Wealth 2. Adventure 3. Achievement 4. Pleasure 5. Be respected 6. Family 7. Fun 8. Self Esteem 9. Freedom 10. Attractiveness 11. Popularity Health didn’t make the top 11 !!! Resnikow K, International Journal of Behavioral Nutrition and Physical Activity; 2006; 3: 25

26. Core values for women Resnikow Quantum Change Study 1. Family 2. Independence 3. Career 4. Fitting in 5. Attractiveness 6. Knowledge 7. Self control 8. Be loved 9. Happiness 10. Wealth 11. Faithfulness Health didn’t make the top 11 !!!

27. Core values for Teens and Tweens??? • Peer Acceptance • Acceptance • Acceptance • Attractiveness • Being cool • Sports performance • ?Safety • ?Academics • ?Environmental health • ? Family Long term health #999 or higher for some?

28. Values and Behavior Change What Core Values do Mom, Dad, Child, Grandparents follow: Family? Being a success? Fun? Respect? Feeling accepted? Wearing ‘cute’ clothes? Health? Health Behavior VALUE??? • How do we align healthy diet and activity with the family/ child’s core values? • Understand we can’t “make” them • Figure out what is important to them • Help them see how healthy behavior fits in • Changing behaviors may be easier than changing someone else’s values • Self preservation technique for providers

29. Treatment – Counseling Techniques • Motivational Interviewing (MI) or • “Brief Negotiation” in 5 minutes • Critical for ambivalentpatients: • Motivation to change comes from within • Not from Provider • Allows the person to see Healthy Change as consistent with values • GOAL = CHANGE TALK • We are more likely to do things that we say we will do = “I could…” “I can…” “I will…” “because…”

30. Motivational Interviewing for Childhood Obesity OARrrrS • Open-ended questions • “tell me about what makes eating healthier hard for you…” • Affirmations • “you feel like being more athletic is important…” • Reflections: make them think again • “so… you eat less healthy snacks because the vending machine and the corner store are convenient…” OR “you aren’t concerned about your weight right now…”

31. Motivational Interviewing for Childhood Obesity OARrrrS • Roll with Resistance – • Resist the urge to tell them what to do • Reframing • Instead of patient: “I do nothing 5 days a week” • “You are able to exercise 2 days a week, what allows you to succeed in that?” • Summaries • “So, being athletic is important to you, so you plan to start packing a healthy snack for after school instead of buying from the vending machine, and you are willing to keep track of what you eat daily. We’ll talk again in 2 months.”

32. Treatment – Counseling Techniques • Motivational Interviewing (MI) or “Brief Negotiation” 5 minutes • Visit Outline • Negotiate Agenda • Assess Readiness • Explore Ambivalence • Tailor Goals to Readiness • Collaborative Goal setting • Summarize the Visit, Goals, and Follow-up plan Read this book to learn and practice: Motivational Interviewing in Health Care: Helping Patients Change Behavior Rollnick 2008

33. Interactive Online Training 1. Kaiser Permanente’s MI for Pediatric Weight Management Online Tutorial http://www.kphealtheducation.org/pwm/ 2. “Change Talk” interactive training simulation Internet or Mobile App: http://www.kognito.com/changetalk/

34. Collaborative Goal Setting • Use a menu of changes • Choose targets together • Use a nonjudgmental style • Elicit Confidence in the Change • Uncover barriers and strengths/motivators • Make the change realistic • Environment • Social Support

35. When a general goal is chosen, make it Specific… • Cognitive Behavioral techniques • For motivated child / family • Self Monitoring  successful change • Specific • Measurable – daily weekly, learn cues • Accountability – parent, other support • Reward – for new healthy routine • Time limited – report back, troubleshoot Spear BA PEDIATRICS 2007

36. Goal Setting Form - Example My Health GOALS I want do this:_____________________________________ It is important to me because:__________________________________ My Specific goal is to:_____________this much:________ each: day – or - week Someone to help me:________________________My reward for good work:_____________________ Make a mark each day when you do it. You can write how many times you did your goal each day and each week. Goal Mon Tues Wed Thurs Fri Sat Sun TOTAL 1. 2. Buddy/Parent sign here at end of week:___________________ Reward: Yes /No

37. Results – • What BMI outcomes are possible with • universal screening • MI counseling in SBHCs and community health centers • Connections to community resources

38. The S.T.O.P – I.T. TrialSchool&community-health centers Prevent & Treat ChildhoodObesity through Community Partnership and Information Technology • Funding: Grant #3109: “A University-Clinic-Community Collaborative to Prevent and Treat Childhood Obesity in Commerce City, CO” The Colorado Health Foundation

39. STOP-IT Overview of Strategy Goal: to test Feasibility and Effectiveness • Enhanced Primary Care for Obesity • Training in clinical obesity care (comorbidities) • Training in counseling – MI • Technology-support for screening, counseling, and community resource referral • Community-Based Treatment • Multidisciplinary • Delivered by trained local staff • At a School or Recreation Center

40. ?

41. Intervention Overview • Clinical information system • HeartSmartscreening/counseling system • Decision support • Training: Comorbidity Management and Referral laboratory protocols, counseling prompts • Redesigned Delivery System • New local community-based treatment • Patient Self-Management Support • Trained for MI counseling, collaborative goal setting • Community resources supporting health • Advertised during well-child visits using HeartSmart

42. Setting - Population

43. Training: Motivational Interviewing

45. Intervention: Electronic Support • Parent or Teen enters: • Family History • 12 Lifestyle factors • Readiness Assessment • Waiting area • Touch-screen • Kiosk or Tablet • Medical Assistant enters: • Weight • Height • Blood Pressure

46. Items Surveyed * associated with baseline weight status – Haemer PAS 2012

47. Methods

50. Results: Feasibility • Completed Screenings 12 month study: • 768 of 776 total = 98.9% of well-child exams • Time to Complete – electronic time stamp • Mean 3.5 minutes • 12 Lifestyle ?’s, family history, readiness to change • While waiting or being checked into clinic