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

Pediatric Obesity: Provider Skill Sets for

Improved CareScott Gee, MD

Kaiser Permanente

February 18, 2010French Camp, CA

Disclosure

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.”

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

Workshop Objectives

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

Review Provider Role and Practice Pediatric Obesity Provider Skills:

1. BMI Screening2. Preventive Counseling3. Clinical Follow-up & Resources

Tips for Obesity Training 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

5

Obesity Training – Overcoming ChallengesObesity Training – Overcoming Challenges

6

Brief Focused Advice Motivational Interviewing

Office Systems and Tools Team Based Care

Coding Strategies Advocacy

Lack of Patient Motivation & Provider Skills

Not Enough Time

No Reimbursement

Obesity Training – Keeping It SimpleObesity 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

7

Recommended Lab ScreeningRecommended Lab Screening

8

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

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.

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

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)

NICHQ

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)

Obesity Algorithm

BMI ScreeningModule 1

See Pages 8-11 of the Training Guide

Scott Gee, MD, FAAP

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

8Y

10Y

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

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

Expert Committee - Assessment OverviewMedical Risks• Height, Weight, BMI, Blood Pressure, Pulse• Family History• Review of Systems• Physical Examination• Laboratory Tests

Behaviors and Attitudes• Diet Behaviors• Physical Activity Behaviors• Attitudes

Measure BMI Annually Measure BMI annually for children 2-18 years

1. Obtain an accurate height and weight

2. Calculate BMI

3. Plot BMI on BMI for age growth chart

4. Make a weight diagnosis

5. Communicate weight status to family

6. 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

Accurate Height and WeightObtain 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

Calculate BMI & Make a Weight Diagnosis Calculate BMI• BMI (English):[ weight (lb) ÷ height (in) ÷ height (in) ] x 703• BMI (metric):[ weight (kg) ÷ height (cm) ÷ height (cm) ] x 10,000Make a weight diagnosis using BMI %tile for age• < 5%ileUnderweight• 5-84%ile Healthy Weight• 85-94%ile Overweight• 95-98%ile Obesity• >=99%ile

8Y

10Y

Early Adiposity Rebound (4Y)

Practice Tools Make it Easier!!!

• Accurate Scale &

Stadiometer

• CDC BMI for Age

growth Chart

• BMI Wheel

Calculator

Boys: 2 to 20 years

BMI BMI

BMIBMI

BMI

What are more sensitive ways to address obesity and overweight?

Obesity Overweight

Fat or Chubby

Weight or Extra Weight

Body Mass Index (BMI)

Increased Risk for Diabetes

Weight is a very sensitive issue for children and adults.

Clinical Follow-up & ResourcesModule 3

See Pages 15-20 of the Training Guide

Scott Gee, MD, FAAP

The

Prevention

Plus Visit

The Prevention Plus Visit (NICHQ)

Review Labs Discuss Treatment Options and Referrals Motivational Interviewing or Brief Negotiation Cognitive Behavior Skills Arrange for Follow-Up as Necessary

Who needs a Prevention Plus Visit?

All obese children Overweight children with other risk factors or

co-morbid conditions Acanthosis nigricans Elevated blood pressure Suspected sleep apnea Other…

How often should visits occur? 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

Treatment Goals - Health Behaviors 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

Treatment Goals - BMI 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

Prevention Plus Visit Challenges

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

Improve compliance with the follow-up visit…

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?

Using Resources & MaterialsPresenter:

David Bodick, MPH Health Educator

Office of Multicultural Health (OMH)

Disclosure

Using Resources for Pediatric Skill Sets for Improved Care

Nothing to disclose as to financial relationships or commercial interests

CHDP Community Program Resources 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

San Joaquin CHDP Resource GuideSample-available upon request

Community Program Resources

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

Community ResourcesAvailable 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

WIC Healthy Habits Every DayOffered by all local WIC programs

CHDP Provider Toolswww.dhcs.ca.gov/services/chdp

Available by downloading from the CHDP websiteProvider 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.)

Medi-Cal Managed Care Health PlansPediatric Obesity & Patient Education Pediatric Obesity & Patient Education

Resource Guide-Resource Guide-at your tableat 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

Resource Guideof Health Education Materials

• Title of material• Material type (brochure, poster, etc.) • Topic (nutrition, physical activity or both)• Target Audience & Grade Level• Reading Level• Languages

Resource Guide

• 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]

Workshop Post Evaluation

• 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!

“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