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Pediatric Obesity: Provider Skill Sets for Improved Care. Scott Gee, MD Kaiser Permanente February 18, 2010 French Camp, CA . Disclosure. Pediatric Skill Sets for Improved Care

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Pediatric Obesity:

Provider Skill Sets for Improved Care

Scott Gee, MD

Kaiser Permanente

February 18, 2010

French Camp, CA

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Pediatric Skill Sets for Improved Care

  • I have no relevant financial relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.”

  • “I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.”

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Workshop Objectives

  • Provide the Vision for this Toolkit Plus Training

  • Provide tips for setting up your provider trainings

  • Review Toolkit Plus Training Materials

    • CMAF Child & Adolescent Obesity Provider Toolkit

    • Health Net/CMAF companion flip chart

    • Quick & Basic Training Guide & health education tools

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Workshop Objectives

  • Explain why AMA Expert Committee & NICHQ pediatric obesity guidelines & recommendations support skill sets

  • Review Provider Role and Practice Pediatric Obesity Provider Skills:

    • BMI Screening

    • Preventive Counseling

    • Clinical Follow-up & Resources

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Tips for Obesity Training

  • Regional or Community Wide CME Event

    • Weekday breakfast, lunch or dinner, Saturday morning

    • Good food more important than CME

    • Usually 1-2 hours long

    • Physicians, Nurses and Dieticians

  • Office Training

    • Lunch or dinner

    • Good food more important than CME

    • Usually 45 – 60 minutes long

    • Physicians, Nurses, and Medical Assistants

    • More effective with academic detailing

    • May be hard to set up a LCD projector


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Obesity Training – Overcoming Challenges

Lack of Patient Motivation & Provider Skills

Not Enough Time

No Reimbursement

  • Brief Focused Advice

  • Motivational Interviewing

  • Office Systems and Tools

  • Team Based Care

  • Coding Strategies

  • Advocacy


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Obesity Training – Keeping It Simple

  • For All Children over 2 Years…

    • Measure BMI Annually

    • Provide Counseling Annually

  • For Overweight or Obese Children…

    • Order Lab Tests

    • Arrange for Treatment & Follow-Up

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Recommended Lab Screening

  • BMI 85-94%ile Without Risk Factors-

    2 Years and Older

    • Fasting Lipid Profile

  • BMI 85-94%ile Age 10 Years & Older With Risk Factors

    • Fasting Lipid Profile

    • ALT and AST

    • Fasting Glucose

  • BMI >= 95%ile Age 10 Years & Older

    • Fasting Lipid Profile

    • ALT and AST

    • Fasting Glucose

    • Other Tests as Indicated by Health Risks

The AHA & AAP recommend screening at 2 years of age if there is a family history of lipid abnormalities or if risk factors are present in the absence of a positive family history

Every 2 Years

Every 2 Years


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Treatment & Follow-Up Overview

Treatment Goals

Behavioral Goals and Parenting Skills

Self Esteem and Self Efficacy

BMI Velocity, Weight Loss Targets and BMI % ile

A Staged Approach from the AMA Expert Committee - promotes brief, office-based intervention then a systematic intensification of efforts, tailored to the capacity of the clinical office, the motivation of the family, the presence of risk factors and the degree of obesity.

Prevention Plus

Structured Weight Management

Comprehensive, Multidisciplinary Intervention

Tertiary Care Intervention

Families progress to the next stage if there has been no improvement in BMI/weight or velocity after 3-6 months and if the family is willing and ready.

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A Staged Approach - Overview

Stage 1 - Prevention Plus

Family visits with physician or health professional

Frequency individualized to family needs and risk factors

Stage 2 - Structured Weight Management

Family visits with physician or health professional with training in childhood weight management. Visits can be individual or group.

May include visits with a dietitian, exercise therapist or counselor

May include self-monitoring, goal setting and rewards

Frequency monthly or individualized to family needs and risk factors

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A Staged Approach - Overview

Stage 3 - Comprehensive, Multidisciplinary Intervention

Multidisciplinary team with experience in childhood obesity

Frequency often weekly group sessions for 8-12 weeks with follow up

Stage 4 - Tertiary Care Intervention (for select children only when provided by experienced programs with established clinical or research protocols)

Medications - sibutramine, orlistat

Very-low-calorie diets

Weight control surgery - gastric bypass or banding (not FDA approved for children but in clinical trials)

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National Initiative for Children’s Healthcare

Quality refined the AMA Expert Committee

Recommendations into:

Step 1: Obesity Prevention at Well Care Visits (Assessment and Prevention)

Step 2: Prevention Plus Visits (Treatment)

Step 3: Going Beyond Your Practice (Prevention and Treatment)

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BMI Screening

Module 1

See Pages 8-11 of the

Training Guide

Scott Gee, MD, FAAP

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Why do we use BMI?

Consistent with adult standards and tracks childhood obesity into adulthood

BMI for age relates to health risks including cardiovascular disease, hypertension and type 2 diabetes

BMI measurement is recommended by the AAP, CDC, IOM, AHA and USPSTF annually beginning at 2 years and older

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What are the challenges of BMI?

  • Small errors in height measurement lead to large errors in BMI

  • BMI cannot distinguish between increased fat mass and increased fat-free mass (e.g., muscle mass)

  • Waist circumference may add greater specificity but there are not nationally accepted standards for children

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BMI percentile during the measurement year as identified by administrative data or medical record review.

ICD-9-CM Diagnosis - V85.5

Medical Record Review: Documentation must include a note indicating the date on which the BMI percentile was documented and evidence of either of the following.

BMI percentile, or

BMI percentile plotted on age-growth chart

For adolescents 16–17 years, documentation of a BMI value expressed as kg/m2 is acceptable.

HEDIS 2009… Weight Assessment

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Expert Committee - Assessment Overview administrative data or medical record review.

Medical Risks

Height, Weight, BMI, Blood Pressure, Pulse

Family History

Review of Systems

Physical Examination

Laboratory Tests

Behaviors and Attitudes

Diet Behaviors

Physical Activity Behaviors


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Measure BMI Annually administrative data or medical record review.

Measure BMI annually for children 2-18 years

Obtain an accurate height and weight

Calculate BMI

Plot BMI on BMI for age growth chart

Make a weight diagnosis

Communicate weight status to family

Document the BMI

Code weight status as a visit diagnosis (for Health Plans) ICD-9-CM Diagnosis - V85.5

For CHDP, use the CHDP Screening/Billing Report form, PM 160 to document BMI

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Accurate Height and Weight administrative data or medical record review.

Obtain an Accurate Height

Measure to the quarter inch

Shoulder blades, buttocks and heels all touching the measurement surface

Child looking straight ahead, arms at side, toes straight and knees together

Shoes off, feet flat and heels almost together

Obtain an Accurate Weight

Balance scale to zero

Weigh in pounds to the nearest ounce

Weigh in undergarments/gown/lightweight clothing

Socks/bare feet

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Calculate BMI & Make a Weight Diagnosis administrative data or medical record review.

Calculate BMI

BMI (English):[ weight (lb) ÷ height (in) ÷ height (in) ] x 703

BMI (metric):[ weight (kg) ÷ height (cm) ÷ height (cm) ] x 10,000

Make a weight diagnosis using BMI %tile for age

< 5%ile Underweight

5-84%ile Healthy Weight

85-94%ile Overweight

95-98%ile Obesity


Early Adiposity Rebound (4Y)

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Practice Tools Make it Easier!!! administrative data or medical record review.

Accurate Scale & Stadiometer

CDC BMI for Age growth Chart

BMI Wheel Calculator

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What are more sensitive ways to address obesity and overweight?



Fat or Chubby

Weight is a very sensitive issue for children and adults.

Weight or Extra Weight

Body Mass Index (BMI)

Increased Risk for Diabetes

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Clinical Follow-up & Resources overweight?

Module 3

See Pages 15-20 of the

Training Guide

Scott Gee, MD, FAAP

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The Prevention Plus Visit (NICHQ) overweight?

Review Labs

Discuss Treatment Options and Referrals

Motivational Interviewing or Brief Negotiation

Cognitive Behavior Skills

Arrange for Follow-Up as Necessary

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Who needs a Prevention Plus Visit? overweight?

All obese children

Overweight children with other risk factors or co-morbid conditions

Acanthosis nigricans

Elevated blood pressure

Suspected sleep apnea


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How often should visits occur? overweight?

First Follow-Up Visit

When lab results back and in-depth survey completed usually 1-8 weeks

Format: in-person, sometimes by phone

Subsequent Visits

As needed based on risk factors conditions & readiness to change

Frequency Range – 1 week to 2-3 months

BMI checks – every 3-6 months (Z-Score if able)

Format: in-person, phone, group, e mail (MD, NP, RD, HE)

Families progress to structured weight management if there has been no improvement in BMI/weight or velocity after 3-6 months and if the family is willing and ready

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Treatment Goals - Health Behaviors overweight?

Lifelong healthy behaviors such as physical activity will improve health outcomes regardless of weight change

Improving self esteem and self efficacy can also improve health outcomes

Small consistent changes over time can make a big difference!

Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap which leads to excess weight gain in some children.

Changes in excess dietary intake (eg, eliminating one sugar-sweetened beverage at 150 kcal/can) may be easier to attain than increases in physical activity levels (1.9 hours walking for an extra 150 kcal).

Pediatrics Vol. 118 No. 6 December 2006 pp. e1721-1733

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Treatment Goals - BMI overweight?

The long term BMI goal will need to be individualized based on risk factors and genetics

BMI < 85%ile - Ideal long term goal

BMI 85-94%ile - Some children can be healthy in this range

Short term BMI goals will need to be individualized based on genetics, risk factors and the intensity of the intervention

Decrease in BMI velocity

Weight maintenance

Weight loss

Younger and more mildly obese children should change weight more gradually than older, more severely obese youth

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Prevention Plus Visit Challenges overweight?

Non-compliance with lab tests

Non-compliance with follow-up visits

Family readiness to change

Perception by providers that the follow-up visit does not have enough content/substance to justify the cost

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Improve compliance with the follow-up visit… overweight?

Ask only high-risk patients to return. “I am very concerned about your blood pressure, can we re-check it in 2 weeks?”

Ask about interest in returning. “Would be interested in returning in 1-2 weeks to discuss your lab results, treatment options and any issues you would like to work on?”

Make a strong advice statement. “I am really concerned about your health and would like you to return in 2 weeks so we can discuss this further.”

Ask about follow-up preferences. “Would you be interested in coming back for a follow visit or would a phone call be more convenient?

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Using Resources & Materials overweight?


David Bodick, MPH

Health Educator

Office of Multicultural Health (OMH)

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Disclosure overweight?

Using Resources for Pediatric Skill Sets for Improved Care

Nothing to disclose as to financial relationships or commercial interests

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CHDP Community Program Resources overweight?

Resource List for Prevention and Treatment of Child and Adolescent Overweight and Obesity

The list identifies programs according to the type of service:

Medical, Nutrition, Physical Activity and Behavioral Program

Details of the program: age served, language(s) & cost

Larger county programs update their lists quarterly

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San Joaquin CHDP Resource Guide overweight?Sample-available upon request

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Community Program Resources overweight?

Goal – Refer to community resources to extend provider counseling and improve outcomes

Lifestyle support important for behavior change

Link between clinical recommendations for wellness and community resources

Motivates families and provides peer interaction/support

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Community Resources overweight?Available in most communities

WIC: New Healthy Habits Campaign

Nutrition Network Programs

Youth Programs: YMCA & YWCA

Parks and Recreation Programs

School and After-School Programs

School Lunch

University Cooperative Extension

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WIC Healthy Habits Every Day overweight?Offered by all local WIC programs

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CHDP Provider Tools overweight?

Available by downloading from the CHDP website

Provider Office Training(supplement to training)

Body Mass Index (BMI) Training

How to Accurately Weigh and Measure Children for the CHDP Well Child Exam

Counseling the Overweight Child

Cholesterol and Glucose Screening (coming soon)

Educational Tools(see handout section of Training Guide)

BMI Job Aid: Body Mass Index for Age Percentile

Counseling Flow Sheet: Counseling the Overweight Child

Tips for Encouraging Behavior Change

My Healthy Lifestyle Goal Tracker (Eng. & Sp.)

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Medi-Cal Managed Care Health Plans overweight?Pediatric Obesity & Patient Education Resource Guide-at your table

Collection of contributed patient education materials from the health plans

Multilingual patient education materials supplement the California Medical Association Foundation's Child and Adolescent Obesity Provider Tool Kit

Please contact the health plan representative listed for each material regarding approval to use and/or modify the materials

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Resource Guide overweight?of Health Education Materials

Title of material

Material type (brochure, poster, etc.)

Topic (nutrition, physical activity or both)

Target Audience & Grade Level

Reading Level


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Resource Guide overweight?

Brief Description & Format

Full Color or Black & White

Link to website or other ordering information (if available)

Regularly updated

Available on CHDP and Medi-Cal Managed Care Division’s websites in March 2010

Please contact Irene Reveles-Chase, MPH for more information: [email protected]

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Workshop Post Evaluation overweight?

In the next 4-6 months workshop participants will get an e-mail (Survey Monkey Link).

Survey will include questions about:

How you used your new training skills and materials

Recommendations for future workshops.

Evaluation information will provide us with valuable information about the usefulness of the training and to what extent the training was used by participants.

Please submit your responses to Survey Monkey as soon as you receive it!

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“Childhood obesity is no one’s fault, but it is everyone’s responsibility.”

Dr. Phil McGraw

Governor’s Summit on Health, Nutrition and Obesity – September 15, 2005