Pediatric PCMH and Childhood Obesity

1. Pediatric PCMH and Childhood Obesity Col Leslie Wilson AF SG Consultant for Pediatrics AFMOA/SGHM May 2012

2. Overview Pediatric PCMH and it’s role in childhood obesity Prevalence, trends and impact of childhood obesity Prevention, identification, management of childhood obesity Obesity outside the PCMH DoD response to the epidemic

3. Patient-Centered Medical Home (PCMH) • Team-based care model led by a personal physician (provider) that provides continuous, coordinated care, ideally over the long term, to maximize health outcomes • Introduced in 1967 by American Academy of Pediatrics (AAP), became policy within a decade • Adopted by Family Medicine in 2002 as part of the “Future of Family Medicine” project • Currently endorsed by all major primary care governing bodies • Joint Principles of PCMH published March 2007 • ASD (HA) Policy Memo on PCMH Implementation Sep 09

4. The Quadruple Aim Readiness Ensuring that the total military force is medically ready to deploy and that the medical force is ready to deliver health care anytime, anywhere in support of the full range of military operations, including humanitarian missions. Population Health Reducing the generators of ill health by encouraging healthy behaviors and decreasing the likelihood of illness through focused prevention and the development of increased resilience. Per Capita Cost Creating value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual health care activity. Experience of Care Providing a care experience that is patient and family centered, compassionate, convenient, equitable, safe and always of the highest quality.

5. The Quadruple Aim Where does childhood obesity fit? Readiness Ensuring that the total military force is medically ready to deploy and that the medical force is ready to deliver health care anytime, anywhere in support of the full range of military operations, including humanitarian missions. Population Health Reducing the generators of ill health by encouraging healthy behaviors and decreasing the likelihood of illness through focused prevention and the development of increased resilience. Per Capita Cost Creating value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual health care activity. Experience of Care Providing a care experience that is patient and family centered, compassionate, convenient, equitable, safe and always of the highest quality.

6. Readiness and Obesity“Too Fat to Fight” School lunches… A National Security Threat???

7. Per Capita Cost of Obesity 2009 Center for Disease Control and Prevention Cost of Obesity = $147 BILLION annually • Childhood obesity is estimated to cost $14 billion annually in direct health expenses • The hospital cost of pediatric obesity is also increasing • 1979: $35 million • 1999: $127 million • 2005: $237million

8. Population Health:Prevalence and trends 1/3 of all children and adolescents are overweight or obese 68% of all adults are overweight or obese http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm

9. Other disparities Adult women more obese than adult men Male obesity rates are growing faster than female Obesity more common in poor, less educated, minority

10. Background and Beginningsin the MHS priorities • AAP 2007 Produced Obesity Recommendations and Obesity Tool kit • White House Task Force on Childhood Obesity Report to the President: Solving the Problem of Childhood Obesity Within a Generation – 2010

11. White House and First LadyLet’s Move Campaign • 5 Pillars of Campaign • Creating a healthy start for children • Empowering parents and caregivers • Providing healthy food in schools • Improving access to healthy, affordable foods • Increasing physical activity • White House Memorandum • “Leading by example in the Military”

12. DOD Childhood Obesity Working Group • DoD Childhood Obesity Working Group Aug 2010 • Comprised of 11 DoD organizations • Multi-disciplinary • Subject matter experts • 4 Subcommittees • Nutrition and Healthy Choices ages 0-18 • Military Health System • Food and Fitness Environments • Education and Strategic Communication

13. DOD Childhood Obesity Working Group (MHS Sub-Committee)

14. Child Overweight in the DoDStratified by Service

15. Child Obesity in the DoD Stratified by Service

16. Defining the Problem Adult BMI between 25 and 30 = overweight Adult BMI ≥30 = obese Unlike adults, children grow in height as well as weight. Thus, the norms for BMI in children vary with age and sex The body mass index (BMI) is the accepted standard measure of overweight and obesity for children two years of age and older. Body mass index provides a guideline for weight in relation to height and is equal to the body weight divided by the height squared

17. Definitions – Overweight/Obese • CDC definitions • Ages 2 to 18 use BMI percentile (age/gender) • Underweight: < 5th percentile • Normal weight: 5th to < 85th percentile • Overweight: 85th to < 95th percentile • Obese: > 95th percentile • Severe Obese: 99th percentile • Ages 0 to 2 use height vs. weight • Overweight: > 95th percentile http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html

18. BMI Percentile and AHLTA • BMI and BMI percentile is automatically calculated in AHLTA • Accurate height and weight must be entered on the vital signs entry screen • The BMI will automatically populate immediately below these entries

19. BMI Percentile and AHLTA After height and weight are entered you can access the BMI percentile by clicking on the ‘growth chart’ tab. The percentile is displayed next to the BMI.

20. Etiology of Obesity • Etiology is multifactorial • Interaction of genetics and environment • Energy imbalance • Energy In = Energy Used + Energy Stored • Environmental factors • Television/Video games  • Sleep • Genetic factors  • Medication • Endocrine disease • Metabolic programming  • Nutrition during gestation and early life

21. Co-morbid conditions associated with obesity

22. Do Obese Children become Obese Adults? • Age • 25% obese preschoolers vs 50% school age kids remained obese • Parental Obesity • 80% teens remain obese if one parent is obese • Severity • 75% adolescents with severe obesity, remained severely obese • 8% adolescents with moderate obesity developed severe obesity as adult

23. Prevention of Childhood Obesity • Routine documentation of BMI • Talk to patients and their families • Identify those at risk • Anticipatory guidance/counseling • Nutrition • Physical activity • Healthy lifestyles • Praise for current healthy practices

24. Simple messaging for all

25. 5 things There are 5 things to remember under ‘5’

26. NONE for those under 2 • MAX of 2 hours for all others • No televisions in children’s bedrooms • Effects both sides of calorie equation Adapted from Maine Health Initiative www.letsgo.org

27. 60 minutes of activity per day • 30 minutes of vigorous activity • Start gradually • Maximize PE time • Sedentary children = Sedentary adults • Sedentary adults = Sedentary children

28. Watch the label - <10 calories/serving • Beware of fruit and sports drinks • Limit fruit juice • Only 100% • 4-6 ounces per day ages 1-6 • 8-12 ounces per day ages 7-18 • No juice for infants <6 months • Drink water and low fat milk Adapted from Maine Health Initiative www.letsgo.org

29. AHLTA making it Easier

30. Using an Obesity Toolkit

31. Start from the BeginningVital Signs • Targeted Review of Systems/Physical Exam • Height (%), Weight (%), Pulse, Respirations, BP • BMI and BMI% for age and gender • Blood Pressure for age, gender and height • Follow guidance per toolkit

32. History and Laboratory evaluation Risk Factors Lab Evaluation BMI 85-95%, no risk Fasting lipid profile BMI 85-95%, + risk Fasting lipid profile, ALT, AST and fasting glucose BMI >95% Fasting lipid profile, ALT, AST and fasting glucose Repeat all every 2 years • Ethnicity • Family/Personal Hx: • CV dz <55 men, <65 women • Dyslipidemia • Obese/overweight • Diabetes • HTN • Diet Behaviors • Physical Activity Behaviors

33. Once Identified:4 Stage approach

34. Childhood Obesity Tool KitAFMS Knowledge Exchange https://kx.afms.mil/kxweb/dotmil/kj.do?functionalArea=PediatricObesity

35. CarePointPopulation Health Portal Obesity module under development Prevalence in clinics, service, overall Metric for measuring annual BMI% for children seen in last 12 months Bring in blood pressure (maybe labs) Identify patient lists of overweight and obese enrollees Identify how well we diagnose overweight/obese May look at documentation of counseling for nutrition/physical activity

36. Raising the sensitive issue of weight AAP published “Parental Perceptions of Weight Terminology that Providers use with Youth” in Pediatrics, Sept 2011 Form therapeutic alliance and engage the family Gentle: “easy gainers” and some must “work extra hard” Use “unhealthy weight/weight problem” – avoid “obese” or “fat” Terms focus on health and function, rather than appearance Goal: growing into healthy body weight Avoid blaming approach

37. Obesity outside of the Medical Home The Fun Theory • Medical Community key advocates for Healthy Living • Need a Champion, develop a team • Look for community resources • HAWC, Youth Centers, AFESS, Fitness Centers • Get buy in from your base and community • Get involved in the schools • Nutrition, physical education • Track your interventions – are you making a difference? • “Be Our Voice” advocacy group from NICHQ

38. DoD Healthy Living campaign under development • Develop DoD CPG for Childhood Obesity • Update Child Development Program DoDI • Breastfeeding, nutrition, physical activity and screen time • Adopt Institute of Medicine (IOM) guidelines on childhood obesity with regards to foods sold in vending options • DoD Schools to annually measure BMI and provide education • TRICARE demonstration project for Obesity/Nutrition counseling • Follow AAP/IOM recommendations for meals in CDCs

39. Questions??