TRIM LIFESTYLE TRIM LIFESTYLE PROGRAMPROGRAM

Lynchburg Family Medicine Lynchburg Family Medicine ResidencyResidency

Dr Stacey Hinderliter, Dr Jennifer Cunningham, Dr Shital Dr Stacey Hinderliter, Dr Jennifer Cunningham, Dr Shital Patel Patel

TRIM-Training Residents in TRIM-Training Residents in Modifying- LifestyleModifying- Lifestyle

►Childhood obesity project at LFM Childhood obesity project at LFM residency to identify and treat residency to identify and treat overweight or obese children overweight or obese children

►Children above the 85th percentile for Children above the 85th percentile for BMI are offered enrollmentBMI are offered enrollment

►Partly funded by AAFP AIM HIPartly funded by AAFP AIM HI

ObjectivesObjectives► Identify overweight and obese children:Identify overweight and obese children:

Measure height and calculate BMI at all office Measure height and calculate BMI at all office visits not just preventive visitsvisits not just preventive visits

►Educate families about 5-3-2-1-0 Healthy Educate families about 5-3-2-1-0 Healthy LifestyleLifestyle Visit Powerpoint and Healthy Lifestyle notebookVisit Powerpoint and Healthy Lifestyle notebook

►Educate residents about obesity prevention Educate residents about obesity prevention and treatmentand treatment Resident involvement in program developmentResident involvement in program development Resident training and evaluationResident training and evaluation

► 6 monthly office 6 monthly office visits with the visits with the patient’s primary patient’s primary care physiciancare physician

► Primary care Primary care physician provides physician provides intensive individual intensive individual family education family education and counseling and counseling

► Each visit was created Each visit was created by resident/faculty by resident/faculty teamsteams

► Residents trained and Residents trained and tested as each visit was tested as each visit was developeddeveloped

► Each visit incorporates Each visit incorporates one step of the 5-3-2-1-one step of the 5-3-2-1-0 Healthy Lifestyle0 Healthy Lifestyle

► Families were encouraged to keep track of the Families were encouraged to keep track of the changes they made in Healthy Lifestyle changes they made in Healthy Lifestyle notebooknotebook

► Incentives were provided at each office visit to Incentives were provided at each office visit to encourage patients to complete the programencourage patients to complete the program

5-3-2-1-0 Healthy Lifestyle5-3-2-1-0 Healthy Lifestyle

► • • 5 servings of fruits and vegetables daily5 servings of fruits and vegetables daily

► • • 3 healthy meals a day: home-cooking3 healthy meals a day: home-cooking

► • • 2 hours or less of screen time: TV, 2 hours or less of screen time: TV, computer,computer,video gamesvideo games

► • • 1 hour physical activity: sweat1 hour physical activity: sweat

► • • 0 or almost 0 drinks containing sugar0 or almost 0 drinks containing sugarwww.dukehealth.org : 5-3-2-1-almost none healthy lifestyle

Visit 1-Zero Sugary DrinksVisit 1-Zero Sugary Drinks

►How to read labelsHow to read labels►Other names for sugarOther names for sugar►Healthy servingsHealthy servings►Water bottleWater bottle►Sugar free drink mix Sugar free drink mix ►Sugar free drink ideasSugar free drink ideas

Visit 2-Visit 2-11 Hour of Physical Hour of Physical ActivityActivity

•One hour can broken up into small bits•Weight lifting of 1-2 pounds OK for children•Don’t have to be on a team•Pedometer: 2000 steps = 1 mile•Soft balls

•One hour can broken up into small bits•Weight lifting of 1-2 pounds OK for children•Don’t have to be on a team•Pedometer: 2000 steps = 1 mile•Soft balls

Visit 3-Visit 3-55 Servings of Fruits Servings of Fruits & Vegetables & Vegetables

•Whole fruits and vegetables vs juice•Fiber in the diet•How to get fruits and veggies into meals and snacks•My Plate-fill ½ plate with fruit/veggies•$5 grocery gift card and recipes

Visit 4-Visit 4-TWO HOURS TWO HOURS of SCREEN TIMEof SCREEN TIME

•What is a screen?•No TV in child’s bedroom or during meals•Effects of TV on BMI, attention and behavior problems•BMI higher from watching TV vs reading a book•Cards, jump ropes, frisbees, games etc.

Visit 5Visit 5- - 33 Healthy Meals a Healthy Meals a Day: Home CookingDay: Home Cooking

•Benefits of healthy meals•Review of My Plate-Protein, Grains and Starches•Eyeballing healthy portions•Involve child in grocery shopping and meal preparation•$10 grocery gift card, measuring cup, recipes

Visit 6- Visit 6- Let’s ReviewLet’s Review5-3-2-1-0 Healthy Lifestyle5-3-2-1-0 Healthy Lifestyle

► Changes made by family based on Changes made by family based on each step of Healthy Lifestyleeach step of Healthy Lifestyle

► Review reading food labelsReview reading food labels► Reinforcement of My Plate and Reinforcement of My Plate and

eyeballing portionseyeballing portions► Gift certificate for children’s museum, Gift certificate for children’s museum,

skating, or bowlingskating, or bowling

Motivational Motivational InterviewingInterviewing

How to get your patient to How to get your patient to want to do what you want want to do what you want

them to dothem to do

DefinitionDefinition

►Patient centered directive method for Patient centered directive method for enhancing intrinsic motivation to enhancing intrinsic motivation to change by exploring and resolving change by exploring and resolving ambivalenceambivalence

►Miller WR, Rollnick S. Miller WR, Rollnick S. Motivational Motivational Interviewing: Preparing People for Interviewing: Preparing People for Change Change 22ndnd edition, New York: Guilford edition, New York: Guilford Press, 2002Press, 2002

Four Guiding PrinciplesFour Guiding PrinciplesRULERULE

►RResist arguing and esist arguing and persuasionpersuasion

►UUnderstand your patient's nderstand your patient's motivationmotivation

►LListen to your patientisten to your patient►EEmpower your patientmpower your patient

What it is notWhat it is not

►Not arguingNot arguing►Not offering advice without the Not offering advice without the

patient's permissionpatient's permission►Not doing most of the talkingNot doing most of the talking►Not giving a “prescription”Not giving a “prescription”

How to do itHow to do it►Establish rapportEstablish rapport►Set an agendaSet an agenda►Get permissionGet permission►Ask open-ended Ask open-ended

questionsquestions►Use reflective listeningUse reflective listening

How long does it take a How long does it take a physician to interrupt a patient?physician to interrupt a patient?

ABOUT 15 SECONDS!ABOUT 15 SECONDS!

More toolsMore tools

►Consider pros and consConsider pros and cons►Determine degree of interest and Determine degree of interest and

confidenceconfidence►Provide a menu of choicesProvide a menu of choices►Provide information, let patient Provide information, let patient

interpret itinterpret it►Summarize and close the dealSummarize and close the deal

Pros and consPros and cons

►What’s good about_______?What’s good about_______?►What might happen if you don’t What might happen if you don’t

change ________?change ________?►How would changing_______ affect How would changing_______ affect

your family?your family?►What’s bad about_________?What’s bad about_________?

Giving informationGiving information

►Ask permission-May I tell you about Ask permission-May I tell you about _____?_____?

►Provide nothing but the facts- Provide nothing but the facts- Being overweight can cause_______.Being overweight can cause_______.

►Let patient interpret it- What does Let patient interpret it- What does this mean to you?this mean to you?

Can you make a change?Can you make a change?

► Limit sugary drinks Limit sugary drinks to 1-2 times a dayto 1-2 times a day

► Use 1% or fat free Use 1% or fat free milkmilk

► Drink more water- Drink more water- can try flavored can try flavored water or sugar free water or sugar free drink mix.drink mix.

► Limit sugary drinks Limit sugary drinks to 1-2 times a dayto 1-2 times a day

► Use 1% or fat free Use 1% or fat free milkmilk

► Drink more water- Drink more water- can try flavored can try flavored water or sugar free water or sugar free drink mix.drink mix.

On a scale of 1-10:On a scale of 1-10:► How interested are How interested are

you in making a you in making a change?change?

► How confident are How confident are you that you can you that you can make a change?make a change?

► Why did you choose Why did you choose a low number?a low number?

► What would it take to What would it take to choose a higher choose a higher number?number?

On a scale of 1-10:On a scale of 1-10:► How interested are How interested are

you in making a you in making a change?change?

► How confident are How confident are you that you can you that you can make a change?make a change?

► Why did you choose Why did you choose a low number?a low number?

► What would it take to What would it take to choose a higher choose a higher number?number?

Can you make a change?Can you make a change?

► Be active everydayBe active everyday► Be active for 1 hour Be active for 1 hour

a daya day► Split activity into Split activity into

smaller parts:smaller parts: 30 minutes twice a 30 minutes twice a

dayday 15 minutes 4 times a 15 minutes 4 times a

dayday

► Be active as a family Be active as a family 1-2 times a week1-2 times a week

► Be active everydayBe active everyday► Be active for 1 hour Be active for 1 hour

a daya day► Split activity into Split activity into

smaller parts:smaller parts: 30 minutes twice a 30 minutes twice a

dayday 15 minutes 4 times a 15 minutes 4 times a

dayday

► Be active as a family Be active as a family 1-2 times a week1-2 times a week

On a scale of 1-10:On a scale of 1-10:► How interested are How interested are

you in making a you in making a change?change?

► How confident are How confident are you that you can you that you can make a change?make a change?

► Why did you choose Why did you choose a low number?a low number?

► What would it take to What would it take to choose a higher choose a higher number?number?

On a scale of 1-10:On a scale of 1-10:► How interested are How interested are

you in making a you in making a change?change?

► How confident are How confident are you that you can you that you can make a change?make a change?

► Why did you choose Why did you choose a low number?a low number?

► What would it take to What would it take to choose a higher choose a higher number?number?

Can you make a change?Can you make a change?

► Offer fruits and Offer fruits and vegetables at snack vegetables at snack timetime

► Fill ½ your plate with Fill ½ your plate with fruits and vegetables fruits and vegetables at mealsat meals

► Try new fruits and Try new fruits and vegetablesvegetables

► Limit juice to once a Limit juice to once a dayday

► Offer fruits and Offer fruits and vegetables at snack vegetables at snack timetime

► Fill ½ your plate with Fill ½ your plate with fruits and vegetables fruits and vegetables at mealsat meals

► Try new fruits and Try new fruits and vegetablesvegetables

► Limit juice to once a Limit juice to once a dayday

On a scale of 1-10:On a scale of 1-10:► How interested are How interested are

you in making a you in making a change?change?

► How confident are you How confident are you that you can make a that you can make a change?change?

► Why did you choose a Why did you choose a low number?low number?

► What would it take to What would it take to choose a higher choose a higher number?number?

On a scale of 1-10:On a scale of 1-10:► How interested are How interested are

you in making a you in making a change?change?

► How confident are you How confident are you that you can make a that you can make a change?change?

► Why did you choose a Why did you choose a low number?low number?

► What would it take to What would it take to choose a higher choose a higher number?number?

TRIM Lifestyle resultsTRIM Lifestyle resultsTRIM Lifestyle resultsTRIM Lifestyle results

111 overweight and obese children

TRIM Lifestyle ResultsTRIM Lifestyle ResultsTRIM Lifestyle ResultsTRIM Lifestyle Results

TRIM Lifestyle ResultsTRIM Lifestyle ResultsTRIM Lifestyle ResultsTRIM Lifestyle Results

BMI changes in TRIM BMI changes in TRIM graduatesgraduates

BMI changes in TRIM BMI changes in TRIM graduatesgraduates

TRIM Lifestyle UsersTRIM Lifestyle UsersTRIM Lifestyle UsersTRIM Lifestyle Users

TRIM Lifestyle FutureTRIM Lifestyle FutureTRIM Lifestyle FutureTRIM Lifestyle Future

►Option of Mini-program-3 visitsOption of Mini-program-3 visits Family can choose what works best for Family can choose what works best for

themthem

► Improve training for each new resident Improve training for each new resident classclass

►More focus on Motivational Interview More focus on Motivational Interview MethodsMethods

►Community OutreachCommunity Outreach

Any questions?Any questions?Any questions?Any questions?