PRACTICAL OBESITY CARE:
LESSONS FROM PRACTICE
Christopher F. Bolling, MD
National Program Chair, AAP Provisional Section on Obesity Obesity Chair, Kentucky Chapter, AAP
There is no time
like the present
GUIDELINES EXIST
American Academy of Pediatrics 2007 recommendations
AND MORE
SUPPORT TOO…
NICHQ and the Childhood Obesity Action Network www.nichq.org/childhood_obesity
THE PROVISIONAL
ACKNOWLEDGMENT TO DO THE RIGHT THING
AND NOT JUST
ACKNOWLEDGED, BUT MANDATED…
HEDIS measure from NCQA
Healthcare providers should document BMI percentile for age and gender annually in every patient’s chart between the ages of two and seventeen years.
Healthcare providers should document evidence of counseling for good nutrition and activity annually in every patient’s chart between the ages of two and seventeen years.
SOME POWERFUL
PARTNERS
The Clinton Foundation & The American Heart Association
WITH GREAT
RESOURCES
SUPPORT AT THE
HIGHEST LEVELS
SOME GOOD
TEAMWORK
• Physicians should screen
for BMI percentile
• Physicians should give a
prescription for good nutrition and increased activity
MY STATE (KENTUCKY) IS REPRESENTATIVE…
www.ncsl.org/.../programs/health/ObesityMap.jpg
The National Survey of Children's Health, Overweight and Physical Activity Among Children: A Portrait of States and the Nation 2005; HRSA,Health, United States, U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National Center for Health Statistics, 2007.
THE NEED IS STILL VERY HIGH
Take Credit for
What You Are
Already Doing!
KEEP SCREENING
BMI PERCENTILE!
BMI Percentile for age and gender
And the less savory alternatives:
• Abdominal circumference • Body fat analysis
PRACTICE BASIC
PREVENTION
• Promote breastfeeding
• Encourage on demand feeding • Limit juice starting early on
• Talk about feeding cues
• Prepare parents for “neophobia”
Know your
community
LIVE THE
SOCIO-ECOLOGICAL MODEL
• Boy’s and Girls Clubs • Weight Watchers • TOPS • YMCA • JCC • Health Clubs
• Physical Therapy sites • Dietitians
• Personal trainers • Health Clubs
• Parks and Recreation • School systems
• Libraries
• Child care providers
• Churches • Neighborhood groups • Hospitals • Community Centers • Colleges • Culinary Schools • Professional schools • Nurse organizations • Chambers of Commerce • Children and Nature • Dairy Council
• Professional Sports
Teams
• City Council members
• Military recruiters • State legislators • Members of congress • Interested parents • United Way • Wellness committees • Media • Various non-profits • Boy Scouts • Girl Scouts • Extension Services • 4 H
• And so many more…
AND KNOW YOUR
LOCAL RESOURCES
Obesity Care in
your office is
completely
scalable
•
Severity
•
Timing
•
Complexity
AND SCALABLE IN DIFFERENT WAYS
Pay attention to
readiness
• Our Internal Medicine/Family Medicine brethren get this because of dealing with substance abuse
• Our patients’ behavior is their behavior • Pediatrics is very prescriptive
• “Cold turkey” is never an option
• We can’t let challenges with behavior change cause us to blame our patients
• Provides us with a great opportunity to be
more effective
• Fits well into practice
• Allows a lot (or a little) for you to do
• Increasing numbers of training opportunities • Helps you overcome the “I don’t have time for
that!” hurdle And lastly…
• It’s fun!
Set a good
example
• Does not mean you need to be
perfect, just trying your best
• The value of advocacy • Office wellness
• Let your patients and parents see
you out there!
SO, WHAT DOES
THINKING GLOBALLY
AND ACTING LOCALLY
EVERYBODY
Make it your own
BASE YOUR LEVEL OF
INTERVENTION ON
• Your motivation
• Your level of comfort • Your resources
• Your community
• Basic Training
• 14 MD’s, 3 NP’s, 2 PA’s
• Open to other patients, but all have been our own
• All providers trained in screening and basic adapted MI • Patients referred after screening and readiness addressed • Referring provider orders basic labs
• I do the initial visits (at least currently)
• Follow-up with either me, our NP Amber (Nutrition Guru) or
PA Rachell (Activity Guru)
• Use CBT basic goal setting with MI counseling techniques • Patients pick goals and follow-up schedule
• Frequently use local resources
Handed out to interested families
BASIC TRAINING
INFO SHEET
OUR LAB SHEET
GOAL
SHEET
SPECIALIZED BEHAVIOR SHEETS FROM CDC, USDA ETC…
Pick some good
workhorses
A GOOD PREVENTION STRATEGY
Pay attention to
outcomes, but
keep them in
perspective
• Very important for many reasons
• Keep your improvement cycles going • Weight management programs are
notoriously difficult to gauge as successful
• Hard to move the BMI needle, so look
at proven intermediate steps
• Measure absolutely, but don’t let it
paralyze you from acting
Organize your
referral strategy
Prevention & Healthy Lifestyle Promotion
Identi-
fication Intervention Practice Referral Midlevel Level High Referral
Surgical
Intervention Treatment Failure
Various Medical Providers Environment
Schools
Community Interventions
Hospital Based Programs
KNOW YOUR
TERTIARY CENTER
• Diverse and effective centers
• Obesity is a chronic disease: think ADHD,
asthma
• Stay engaged
• Know your other resources, especially
– Co-morbidities may need more than you can give, but address them as your
comfort level increases
– Severe obesity-these patients can really derail you if you aren’t careful
• The social services dilemma
• Easy to forget that readiness is still a factor
A FEW OTHER THOUGHTS ON REFERRALS
1) No time like the present
2)Take credit for what you are already doing 3)Know your community
4)It’s scalable
5)Pay attention to readiness 6)Set a good example
7)Make it your own
8)Pick some good workhorses 9)Be practical about outcomes
10)Organize your referral strategy
Please feel free to contact me Christopher F. Bolling, MD [email protected] 859-341-5400 office 859-630-8403 cell 859-578-3172 fax
