Maine Center for Public Health Maine Chapter – American Academy of Pediatrics 1 Maine Youth Overweight Collaborative Improving the Prevention, Identification,

Maine Center for Public HealthMaine Chapter – American Academy of Pediatrics 1

Maine Youth Overweight Collaborative

Improving the Prevention, Identification, and Treatment of Youth Overweight

Maine Center for Public HealthMaine Chapter- American Academy of Pediatrics

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Why Youth Overweight? Why Now?

• Enormous problem!

– Prevalence of youth overweight tripled in past two decades

– Hugely costly• Human costs• Economic costs

• Known gaps in care, opportunities for improvement


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JAMA, April 5, 2006, Vol 295, No. 13, 1549-1555

How many children are overweight?

45

4

67

5

11 11

16 16

18.817.4

0

2

4

6

8

10

12

14

16

18

20

% O

ve

rwe

igh

t

1963-1970

1971-1974

1976-1980

1988-1994

1999-2002

2003-2004

6-11 Years12-19 Years

Since 1963, the number of overweight children in the U.S. has tripled!

Kaiser Permanente RKaiser Permanente REGIONALEGIONAL H HEALTHEALTH E EDUCATIONDUCATION


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Youth Overweight in Maine…

• Nearly one-third youth in Maine at risk for overweight or overweight!

• One in six Maine youth are currently overweight (BMI 95%’ile for age/gender)o 15.3% Maine youth 6-11yoo 15.4% youth 12-19yo

• 36% of Maine kindergarteners at risk for overweight or overweight!


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Do overweight children grow up to be overweight adults?

• The older the overweight child is, the more likely he/she will continue to be overweight as an adult.

• 8 out of 10 overweight teens will continue to be overweight as adults.

% Overweight Children% Overweight Children

who Become Obese Adultswho Become Obese Adults

10

35

50

80

0102030405060708090100

Per

cen

tag

e

Preventive Medicine 1993; Vol. 22:pp. 167-177Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452



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The Bottom Line

ENERGY IN ENERGY OUT!!

EXCEEDS

>>


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Individuals & Families

Who’s Job is it to Promote Healthy Weight?

Schools & Universities

Healthcare Organizations

Public HealthHousing & Community

Clinicians

Family & Home

Business & Employers

Childcare providers


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Informed,ActivatedPatient

ProductiveProductiveInteractionsInteractions

Prepared,Proactive

Practice Team

Improved Outcomes

DeliveryDeliverySystemSystemDesignDesign

DecisionDecisionSupportSupport

ClinicalClinicalInformationInformation

SystemsSystems

Self-Self-Management Management

SupportSupport

Health SystemHealth System

Resources and PoliciesResources and Policies

CommunityCommunity

Health Care OrganizationHealth Care Organization

(Chronic)Care Model


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MYOC2 Key Changes

• Assess BMI % for age/gender on all children (2-18yo) annually; follow recommendations for med assessment of overweight youth

• Educate families & patients about healthy lifestyles (5210 survey!), and risks, complications of overweight; provide compassionate support for change

• Identify care team in practice to promote change, clarify roles for team members

• Use registry to improve care• Partner with community organizations to impact healthy

lifestyles for youth


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For ALL children on annual preventive visit:• Have parents / child complete 5-2-1-0 Survey • Calculate BMI and Plot BMI% for Age

For children determined to be overweight, or at risk of overweight• Perform in-depth medical assessment• Determine weight goals• Order screening lab tests• Provide brief focused advice & goal setting• Arrange for follow-up visit or phone call

Annual Well Child Care Visit

A Practical Approach to Overweight Children



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STEP 1: Assess Weight Using BMI % age

• Measure height & weight

• Calculate BMI % for age/gender on all children 2-18yo at least once annually, on annual preventive health visit


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BMI % for age / gender


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Why do we use BMI?• Consistent with adult standards and

tracks childhood overweight into adulthood

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

• In the absence of sufficient evidence, recognition must precede solutions

• BMI measurement is recommended by the AAP, CDC, IOM, AHA at all well child care visits 2 years & older

Pediatrics Vol. 112 No. 2 Aug 2003 Pediatrics Vol. 116 No. 1 July 2005

8Y

10Y



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Tools for Measuring BMI


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STEP 2: Classify Weight Status

BMI % for age/gender – Underweight < 5% – Healthy weight: 5-84th %– At Risk of Overweight (Overweight) 85-94th%

– Overweight (Obese) 95th %

8Y

10Y

(1) Pediatrics Vol. 101 No. 3 March 1998(2) Pediatrics Vol. 105 No. 5 May 2000

Early Adiposity Rebound (4Y)



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Diagnosing Overweight

• Early Adiposity Rebound–Definition: Adiposity rebound is

the point when the BMI is the lowest for a child before it increases again

–Experiencing early adiposity rebound (rebound before 5-6 years old) is a risk factor for subsequent adiposity in adulthood (1) and is associated with parental obesity (2)

8Y

10Y

(1) Pediatrics Vol. 101 No. 3 March 1998(2) Pediatrics Vol. 105 No. 5 May 2000

Early Adiposity Rebound (4Y)



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STEP 3: Assess & Promote Healthy Behaviors

• Use “5-2-1-0” survey to assess current behaviors and encourage healthy lifestyles (do 5210 survey at least once annually, on annual preventive health visit)


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What behaviors are related to youth overweight?

• Not enough physical activity.

• Too much TV & video games.

• Not enough milk, dairy, fruits and vegetables.

• Too many sweetened drinks (e.g., soda, juice drinks, sports drinks) and too much fast food.

• Skipping meals and breakfast.

Position Paper - Prevention of Childhood Overweight What Should Be Done? Center for Weight and Health - U.C. Berkeley 10/02



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Healthy Lifestyle Behaviors

Five or more fruits or vegetables per day

Two hours or less of total “screen time”

One hour or more of physical activity every day

Limit soda and sugared drinks or whole milk


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5-2-1-0 Preventive Message

5 or more fruits or

vegetables per day

2 hours or less of total

“screen time”

1 hour or more of physical

activity daily

Zero sugared drinks or

whole milk


5-2-1-0 Survey


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Can overweight among children be prevented?

• Breastfeed for the first year.

• Wean from the bottle at 12 months of age.

• Limit juice and other sweetened drinks to 4-6 ounces per day max.

• Limit TV - none before 2 years, 1 hour or less over 2 years of age.

• Avoid using food as a reward for good behavior.

J Pediatr Vol. 141 No. 6 December 2002JAMA Vol. 285 No. 19 May 2001



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STEP 4: Identify Next Steps

• Use Youth Overweight & Medical Evaluation algorithms to determine appropriate next steps based on weight classification, risk factors

• Determine need for further evaluation, management


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Guidelines for Prevention & Management of Overweight in Children 2-18 yrs ALL PATIENTS at ANNUAL Preventive Well-Child Check

1. Measure and plot Ht & Wt2. Calculate BMI and plot BMI% for age/gender classify

weight3. Ask patient / family to complete “Keep ME Healthy 5-2-1-0”

SurveyBMI 5%- 84%’ile for age/genderIdeal wt

BMI 85-94%’ile for age/gender“At Risk for Overweight”

BMI95%’ile for age/gender

“Overweight”

Reinforce healthy eating & physical activity with “5-2-

1-0” messages

Family Hx, Physical Exam

+ FH1 familial hyperlipidemia, early vascular disease2, or type 2 diabetes, OR Phys exam findings c/w overweight comorbidity3, OR rapidly accelerating wt gain4

1. Perform medical evaluation for overweight

2. Assess mental health and readiness to change

• Assess nutritional needs; consider referral for education and support of weight management goals;

• Consider referral to medical and/or mental health specialist(s) as indicated

Re-evaluate annually

• Follow up5 to reinforce behavioral changes in 1-2 mos, then every 1-2 mos X2-3• Recheck BMI q 3-4mos

• Follow up5 to reinforce behavioral changes every 1 month X3 visits; then q3-4 mos• Recheck BMI q3mos

Promote healthy eating & physical activity with “5-2-1-0” messages

Assess family patterns & dynamics, food & phys activity habits, and discuss goal setting; if patient/family ready to

change, discuss goal setting

Normal FH and Phys Exam

Assess family patterns & dynamics, food & phys activity habits, mental health and

readiness to change; if patient/family ready to change, discuss goal setting

Promote healthy eating & physical activity with “5-2-1-0” messages &

tools (e.g. “healthy plate”, pedometer, referral to community physical activity

resource)

Maine Center for Public Health October 2004


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Clinical Guidelines(Medical Evaluation)


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“What should my child weigh?”

• Tell parent what weight would be for BMI 85%• Focus is on making improvements in family

lifestyles– Making better food choices– Being more active, not on weight or weight loss

• Advise that physician / health professional will follow child’s height, weight and BMI, and provide follow up on how family is doing

Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29



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What are recommended weight goals?

Weight loss approx. 1 pound/month

Weight goal: BMI< 85%

Older Adolescents and Adults: 10% weight loss from baseline over 6 months



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STEP 5: Support Appropriate Goal Setting

• Use “brief focused negotiation” and other motivational techniques to…– Identify patient & family’s readiness to

make changes– Set realistic behavior change goals



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The Role of the Physician and Practitioner

All ChildrenGet up and play hardCut back on TV and video gamesEat 5 helpings of fruits and vegetables/dayCut down on sodas & juice drinks

ADVISE

IDENTIFYChildren at Risk or OverweightScreen with BMI starting at age 2 for all childrenFocus on key intervention ages

MOTIVATE Families at Risk to Make Changes Ask permission to discuss weightNegotiate areas of improvementAssess readiness to changeExplore ambivalenceOffer information, referral if indicated and follow-up



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What are more sensitive ways to address overweight?

• Obesity

• Ideal Weight

• Personal Improvement

• Focus on Weight

• Diets or “Bad Foods”

• Exercise

• Overweight

• Healthier Weight

• Family Improvement

• Focus on Lifestyle

• Healthier Food Choices

• Play or ActivityEffective Communication with Families, Kaiser Permanente, © 2004



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Lifestyle Advice (All Families)

To stay healthy and energized,

• Get up and play hard 30-60 minutes each day

• Limit TV / video games to <1 hour each day

• Eat five helpings of fruits and vegetables each day

• Limit soda and juice drinks to <1 small cup each day

Effective Communication with Families, Kaiser Permanente, © 2004



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Brief Focused Advice

Step #1: Engage the Patient / Parent• Can we take a few minutes to discuss your

health and weight?

• How do you feel about your health and weight?




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Step #2: Share Information (optional)• Your current weight puts you at risk for

developing heart disease and diabetes.

• What do you make of this?

• Some ideas for staying healthy include…. (see 5-2-1-0 Survey)

• What are your ideas for working toward a healthy weight?




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Step #3: Make a Key Advice Statement

• I would strongly encourage you to…– Get up and play hard, 30-60 minutes a day.

– Cut back on TV & video games to 60 min/day.

– Eat 5 helpings of fruits of vegetables every day.

– Cut back on sodas & juice drinks to 1 small cup/day.

– Use patient ideas from step #2





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Step #4: Arrange for Follow up• Would you be interested in more information

on ways to reach a healthier weight? AND / OR

• Let’s set up an appointment in 1-4 weeks to talk about this further.


For more info on Brief Focused Advice, see Kaiser Permanente-learning module at http://www.kphealtheducation.org/PWM_Gold/conversation.html




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Who can you ask for help?

• Joan Orr– Maine Center for Public Health - MYOC Project Director– 207.629.9272; [email protected]

• Lisa Letourneau MD– MaineHealth - Senior Director, Clinical Integration– MYOC Physician Advisor– 207.541.7521; [email protected]

• Tory Rogers MD– MMC – Barbara Bush Children's Hospital - Director, Kids COOP– MYOC Quality Improvement Advisor– 207.662.2410; [email protected]

• Susan Levenseler – Maine Medical Partners - Clinical Quality Improvement Manager – 207.523.3246; [email protected]

• Naomi Anderson MPH– MaineHealth – Healthy Weight Program Manager– 207.541.7554; [email protected]


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With Thanks to…

• Maine Center for Public Health

• Maine Chapter American Academy of Pediatrics

• Dr. Scott Gee, Kaiser Permanente Regional Health Education

Documents

Maine Center for Public Health Maine Chapter – American Academy of Pediatrics 1 Maine Youth Overweight Collaborative Improving the Prevention, Identification,