Addressing childhood obesity through partnerships between

healthcare and community

Sarah E. Barlow, MD, MPHBaylor College of Medicine

IOM report Preventing Childhood Obesity 2005

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

Addressing Obesity within the Healthcare System

Disadvantages of this setting– Time– Reimbursement– Expertise– Office visit structure– Accessibility for patient

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

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”

Hercules carrying the world

Addressing Obesity within Community Setting

Benefits:+ Accessibility+ Implementation as well as education+ Opportunity for environmental change+ Context of behavioral setting

Addressing Obesity within Community Setting

Disadvantages:– Low intensity – Limited scope or duration

• Exercise class, nutrition class– Lack of individualization

• Medical• Behavioral

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

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

Integrating Healthcare and Community Resources

Environment

Family

School

Worksite

Community

Chronic Care Model

Medical System

Information Systems

Decision Support

Delivery System Design

Self Management Support

Family/PatientSelf-Management

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

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.

Prevention Plus

Structured Weight Management

Comprehensive Multidisciplinary

Tertiary Care

Intensity

Stages of intervention

Age

BMI

Medical status

Motivation

Who What and How

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

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

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)

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

Healthy Kids-Houston: Decreased weight and BMI in obese youth

Bush CL et al. J Peds 2007; 151:513

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

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)

Viva La Salud Infantil Weight Loss Intervention Pilot Study

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

Kamp K’aana

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

Kamp K’aana Activities

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.

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

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

Obesity care is a team activity:Healthcare and community partnerships