FLAIRFLAIRFamily Lifestyle Family Lifestyle

Assessment Assessment of Initial Riskof Initial Risk

New York City Research and New York City Research and Improvement Group (NYC RING)Improvement Group (NYC RING)

Darwin Deen, MDDarwin Deen, MDProfessor, Family and Social MedicineProfessor, Family and Social Medicine

Albert Einstein College of MedicineAlbert Einstein College of Medicine

Bronx, NYBronx, NY

deen@aecom.yu.edudeen@aecom.yu.edu

Pediatric Obesity in the Pediatric Obesity in the BronxBronx

1.3 million people reside in the Bronx1.3 million people reside in the Bronx 7% below the age of 57% below the age of 5 32% African-American, 34% Hispanic32% African-American, 34% Hispanic 80% sedentary; 75% eat few fruits and vegetables, 80% sedentary; 75% eat few fruits and vegetables,

29% are obese 29% are obese

In NYC 43% of elementary public school In NYC 43% of elementary public school children are obese (24%) or overweight (19%)children are obese (24%) or overweight (19%)

Thorpe Am J Public Health 2004

RWJ Prescription for RWJ Prescription for HealthHealth

5-year initiative of the RWJ Foundation5-year initiative of the RWJ Foundation 10 PBRN’s funded in Round II10 PBRN’s funded in Round II

Aims: Develop practical strategies for promoting Aims: Develop practical strategies for promoting healthy behaviors among primary care patients, healthy behaviors among primary care patients, targeting:targeting: Lack of physical activityLack of physical activity Unhealthy dietUnhealthy diet Tobacco useTobacco use Risky alcohol useRisky alcohol use

NYC RING MissionNYC RING Mission To address health and health care of underserved To address health and health care of underserved

urban communities through quality improvement urban communities through quality improvement projects and research initiatives.projects and research initiatives.

25 practices25 practices

450,000+ primary care visits/yr450,000+ primary care visits/yr

60% Latino, 35% AA60% Latino, 35% AA

Primarily low income and wc Primarily low income and wc

Most sites with partial EMRMost sites with partial EMR

and ability to access CISand ability to access CIS

FLAIR TeamFLAIR Team

M. Diane McKee, MD, MSM. Diane McKee, MD, MS Darwin Deen, MD,MSDarwin Deen, MD,MS Alice Fornari, RD,PhDAlice Fornari, RD,PhD Arthur Blank, PhDArthur Blank, PhD Stacia Maher, MPHStacia Maher, MPH Irina Polanco, MAIrina Polanco, MA Patricia Lopez, MAPatricia Lopez, MA Adelyn Alvarez, MAAdelyn Alvarez, MA Jason Fletcher, MAJason Fletcher, MA Jennifer Klein, RDJennifer Klein, RD

Jean Burg, MDJean Burg, MD Robert Clarick, MDRobert Clarick, MD Frank Silagy, MDFrank Silagy, MD Claudine Smith, MDClaudine Smith, MD Staff and clinicians at our Staff and clinicians at our

3 intervention sites3 intervention sites

FLAIR Primary Research QuestionsFLAIR Primary Research Questions Can 2-4 y.o. well visits be successfully reframed to Can 2-4 y.o. well visits be successfully reframed to

assess risk and initiate counseling for behavior change? assess risk and initiate counseling for behavior change?

Can an intervention based on family lifestyle risk Can an intervention based on family lifestyle risk assessment change behaviors (of adults and children)?assessment change behaviors (of adults and children)?

FLAIR Secondary Research QuestionsFLAIR Secondary Research Questions What is a reasonable estimate of effect size for changing What is a reasonable estimate of effect size for changing

family diet and exercise behaviors? Children’s BMI?family diet and exercise behaviors? Children’s BMI?

Can home visits be used to advance family nutrition Can home visits be used to advance family nutrition assessment?assessment?

Montefiore Medical Center Montefiore Medical Center InitiativesInitiatives

Childhood obesity management programsChildhood obesity management programs B’N Fit B’N Fit CHCC Fun & FitCHCC Fun & Fit Starting RightStarting Right

ConsultsConsults Endocrine Clinic Endocrine Clinic Hyperlipidemia ClinicHyperlipidemia Clinic Hypertension ProgramHypertension Program

Sources of tools/trainingSources of tools/training FLAIRFLAIR School Health Obesity InitiativeSchool Health Obesity Initiative

Practical Approaches to Practical Approaches to Child and Adolescent Child and Adolescent Obesity in the BronxObesity in the Bronx

The Montefiore Pediatric Obesity The Montefiore Pediatric Obesity Prevention Prevention (MPOP)(MPOP) Workgroup Workgroup

D Appel, MD Director, Montefiore School Health ProgramD Appel, MD Director, Montefiore School Health Program K Ayoob, EdD, RD, Nutrition Clinic, Rose F. Kennedy CenterK Ayoob, EdD, RD, Nutrition Clinic, Rose F. Kennedy Center P Belamarich, MD Medical Director, PASSP Belamarich, MD Medical Director, PASS S Braganza, MD Division of Social PediatricsS Braganza, MD Division of Social Pediatrics M Charlop, MD, MPH Director, Community Health Division, MSHPM Charlop, MD, MPH Director, Community Health Division, MSHP D Deen, MD, MS Professor of Epidemiology and Population HealthD Deen, MD, MS Professor of Epidemiology and Population Health J Flynn, MD, MS Director, Pediatric Hypertension ProgramJ Flynn, MD, MS Director, Pediatric Hypertension Program C Isasi, MD, PhD Division of Health Behavior and NutritionC Isasi, MD, PhD Division of Health Behavior and Nutrition U Khan, MD B’N Fit Division of Adolescent MedicineU Khan, MD B’N Fit Division of Adolescent Medicine M Larkin, MD, Co-Director, Starting Right, SBHCCFM Larkin, MD, Co-Director, Starting Right, SBHCCF E Larrier, Executive Director, Bronx Community Health Network (BCHN)E Larrier, Executive Director, Bronx Community Health Network (BCHN) J Leo, MD, Montefiore School Health ProgramJ Leo, MD, Montefiore School Health Program J Leuchter, Manager, Health Education, CFCCJ Leuchter, Manager, Health Education, CFCC K O’Connor, MD, Pediatric Chief Resident, CHAMK O’Connor, MD, Pediatric Chief Resident, CHAM M Pappo, MS, RD Clinical Nutrition Manager, Montefiore Medical CenterM Pappo, MS, RD Clinical Nutrition Manager, Montefiore Medical Center M Puri, MD, Fellow, Pediatric EndocrinologyM Puri, MD, Fellow, Pediatric Endocrinology A Rich, MD, Medical Director, Montefiore CHCCA Rich, MD, Medical Director, Montefiore CHCC J Rieder, MD, MS, Director, B’N Fit Program, Div of Adolescent MedicineJ Rieder, MD, MS, Director, B’N Fit Program, Div of Adolescent Medicine I Sharif, MD, MPH Director, CHCC Fun & FitI Sharif, MD, MPH Director, CHCC Fun & Fit R Siegel, LMSW, Behavior Therapist, B’N Fit ProgramR Siegel, LMSW, Behavior Therapist, B’N Fit Program

MPOP MPOP Workgroup GoalsWorkgroup Goals

To develop a collaborative approach to the To develop a collaborative approach to the management of at-risk and overweight youth.management of at-risk and overweight youth.

To develop a practical set of evidence/ To develop a practical set of evidence/ consensus-based tools to screen for and consensus-based tools to screen for and manage at-risk and overweight youth.manage at-risk and overweight youth.

MPOPMPOP Workgroup Workgroup ActivitiesActivities

1.1. Pediatric Overweight Chart FormPediatric Overweight Chart Form

2.2. List of ResourcesList of Resources

3.3. Advocacy ActivitiesAdvocacy Activities

FLAIR InterventionFLAIR Intervention

Reframe preventive visits for 2-4 y.o. to focus on Reframe preventive visits for 2-4 y.o. to focus on family lifestyle risk assessmentfamily lifestyle risk assessment

Enhance screening for behaviors associated with pediatric Enhance screening for behaviors associated with pediatric (and adult) obesity(and adult) obesity

Deliver brief behavior change messages from clinicians for Deliver brief behavior change messages from clinicians for identified behaviorsidentified behaviors

Increase visit frequency to address additional behaviors Increase visit frequency to address additional behaviors

Referral to lifestyle counselor to augment clinicians’ effortsReferral to lifestyle counselor to augment clinicians’ efforts

FLAIR ToolsFLAIR Tools

Pre-Visit Screener Pre-Visit Screener Parental ht/wtParental ht/wt Family historyFamily history Behaviors associated with pediatric obesityBehaviors associated with pediatric obesity

Goal Setting Action PlanGoal Setting Action Plan Follow-up FormsFollow-up Forms Educational MaterialsEducational Materials

Expected OutcomesExpected Outcomes Providers engage families to change behaviors Providers engage families to change behaviors

2 y.o. visit “salient” to families2 y.o. visit “salient” to families Providers appropriately assess behavior and respondProviders appropriately assess behavior and respond

Increase contacts focused on behavior changeIncrease contacts focused on behavior change

Learn how to incorporate activities into practicesLearn how to incorporate activities into practices

Some behavior change (how much?)Some behavior change (how much?)

Preliminary efficacy data on preventing excess Preliminary efficacy data on preventing excess weight gainweight gain

Adoption of Intervention Adoption of Intervention by Primary Care Providersby Primary Care Providers

Initial Chart Review (n=80)Initial Chart Review (n=80) Visits 12/05-3/06Visits 12/05-3/06

with FLAIR screenwith FLAIR screen 31%31% with goal settingwith goal setting 29%29% BMI charted BMI charted 46%46%

2-3 y.o.2-3 y.o. Mean BMI for age Mean BMI for age 17.617.6

>85% >85% 14%14%>95%>95% 25%25%

4-5 y.o.4-5 y.o. Mean BMI for age Mean BMI for age 16.916.9

>85%>85% 20%20%>95%>95% 17%17%

Adoption of Intervention Adoption of Intervention by Primary Care Practicesby Primary Care Practices

Referrals to lifestyle counselorReferrals to lifestyle counselor 7979 Contacts with lifestyle counselorContacts with lifestyle counselor 3434

– PhonePhone 2121– AppointmentsAppointments 1313

Referrals to lifestyle counselors from what Referrals to lifestyle counselors from what proportion of docs at each site?proportion of docs at each site? 8/8 at Tremont8/8 at Tremont 4/6 at Castle Hill4/6 at Castle Hill 2/2 at University Ave2/2 at University Ave

Differences by site in referral processDifferences by site in referral process Speed of adoption: variableSpeed of adoption: variable

FLAIR ScreeningFLAIR Screening

Preliminary Findings (n=70)Preliminary Findings (n=70) Parental Family HistoryParental Family History

DM- 43%DM- 43% HTN- 45%HTN- 45% CAD- 16%CAD- 16%

Parental HistoryParental History DM- 3%DM- 3% HTN- 16%HTN- 16% CAD- 7%CAD- 7%

Parental BMI (mean)Parental BMI (mean) Mom- 30Mom- 30 Dad- 27Dad- 27

FLAIR ScreeningFLAIR Screening

NutritionNutrition Juice/soda- 3/dayJuice/soda- 3/day Milk- 3/day (71% whole, 3% skim)Milk- 3/day (71% whole, 3% skim) Fast food- 1.3/weekFast food- 1.3/week

TV time- 36% 0-2 hours/weekdayTV time- 36% 0-2 hours/weekday Family Meals- mean 3.8 meals/weekFamily Meals- mean 3.8 meals/week Outdoor Activity- mean 3.6 days/weekOutdoor Activity- mean 3.6 days/week Smoking- 22% with smoker living in the homeSmoking- 22% with smoker living in the home

Referrals (n=79)Referrals (n=79)Initial Goal SettingInitial Goal Setting

Reduce juiceReduce juice 1414 Reduce fast foodReduce fast food 33 Change milkChange milk 1616 Decrease sodaDecrease soda 66 Family mealsFamily meals 77 Quit smokingQuit smoking 88 Increase outdoor activityIncrease outdoor activity 1111 Decrease TV timeDecrease TV time 2020 Overweight siblingOverweight sibling 1111

MPOPMPOP School-Based School-Based HealthHealth

Obesity Initiative Obesity Initiative 13 School-based Health Centers

(SBHCs) New Clinical Guidelines for

Overweight Healthy Kids – A community-based fitness &

nutrition initiative of the MSHP

Classroom Fitness & Nutrition School/Community-Centered

Activities CSA and Policy Efforts

Staying Sane Staying Sane Public Health AdvocacyPublic Health Advocacy

Medical model is inadequate by itselfMedical model is inadequate by itself Obesity is a worldwide public health issueObesity is a worldwide public health issue Will never be solved in MD office aloneWill never be solved in MD office alone Blaming/excusing- vs. responsibilityBlaming/excusing- vs. responsibility Recognize our tendency to internalize our Recognize our tendency to internalize our

feelings of powerlessness and impotencefeelings of powerlessness and impotence Play a public health role!Play a public health role!

MPOPMPOP Changing Vending Changing Vending Machine OptionsMachine Options

Letter sent by MPOP to Person in charge Letter sent by MPOP to Person in charge of vending machines to request offering of vending machines to request offering healthier alternatives for Montefiore healthier alternatives for Montefiore Patients and staffPatients and staff

Positive response and the requested Positive response and the requested changes are being implementedchanges are being implemented