lessonsfrompractice bolling

7/29/2019 LessonsFromPractice Bolling

1/51

PRACTICAL OBESITY CARE:

LESSONS FROM PRACTICE

Christopher F. Bolling, MD

National Program Chair, AAP Provisional Section on Obesity

Obesity Chair, Kentucky Chapter, AAP


2/51

There is no timelike the present

LESSON #1


3/51

GUIDELINES EXIST

American Academy of Pediatrics 2007 recommendations

www.aap.org/obesity


4/51

AND MORE

SUPPORT TOO

NICHQ and the Childhood Obesity Action Network

www.nichq.org/childhood_obesity


5/51

THE PROVISIONAL

SECTION ON OBESITY


6/51

ACKNOWLEDGMENT TO

DO THE RIGHT THING

HEDIS measure from NCQA


7/51

AND NOT JUST

ACKNOWLEDGED, BUT

MANDATED

HEDIS measure from NCQA

Healthcare providers should document BMI percentile for ageand gender annually in every patients chart between the agesof two and seventeen years.

Healthcare providers should document evidence of counselingfor good nutrition and activity annually in every patients chart

between the ages of two and seventeen years.


8/51

SOME POWERFUL

PARTNERS

The Clinton Foundation &The American Heart Association


9/51

WITH GREAT

RESOURCESAlliance for a Healthier Generation


10/51

SUPPORT AT THE

HIGHEST LEVELS

Lets Move!


11/51

SOME GOOD

TEAMWORKPhysicians should screen

for BMI percentile

Physicians should give a

prescription for goodnutrition and increasedactivity


12/51

MY STATE (KENTUCKY) IS

REPRESENTATIVE


13/51

www.ncsl.org/.../programs/health/ObesityMap.jpgThe 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
http://www.ncsl.org/.../programs/health/ObesityMap.jpghttp://www.ncsl.org/.../programs/health/ObesityMap.jpg


14/51

Take Credit forWhat You Are

Already Doing!

LESSON #2


15/51

KEEP SCREENING

BMI PERCENTILE!

BMI Percentile for age and gender

And the less savory alternatives:Abdominal circumference

Body fat analysis

Fitness assessment


16/51

PRACTICE BASIC

PREVENTION

Promote breastfeeding

Encourage on demand feeding

Limit juice starting early on

Talk about feeding cuesPrepare parents for neophobia

Some great programs (more to follow!)


17/51

Know yourcommunity

LESSON #3


18/51

LIVE THE SOCIO-

ECOLOGICAL MODEL

You are not alone!


19/51

Boys 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 SportsTeams

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


20/51

Obesity Care in

your office iscompletely

scalable

LESSON #4


21/51

Severity

Timing

Complexity

AND SCALABLE IN

DIFFERENT WAYS


22/51

Pay attention toreadiness

LESSON #5


23/51

Our Internal Medicine/Family Medicine brethren getthis because of dealing with substance abuse

Our patients behavior is their behavior Pediatrics is very prescriptive

Cold turkey is never an option

We cant let challenges with behavior change causeus to blame our patients

IS READINESS THE KEY?


24/51

Provides us with a great opportunity to bemore 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 dont have time forthat! hurdle

And lastly

Its fun!

MOTIVATIONAL INTERVIEWING


25/51

Set a goodexample

LESSON #6


26/51

Does not mean you need to beperfect, just trying your best

The value of advocacy

Office wellness

Let your patients and parents seeyou out there!

SO, WHAT DOES

THAT MEAN?


27/51

THINKING GLOBALLY

AND ACTING LOCALLY


28/51

EVERYBODY

INTO THE ACT


29/51

SEEING YOU IN ACTION


30/51

Make it your own

LESSON #7


31/51

BASE YOUR LEVEL OF

INTERVENTION ON

Your motivation

Your level of comfortYour resources

Your community

Your patients need


32/51

Basic Training 14 MDs, 3 NPs, 2 PAs

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) orPA Rachell (Activity Guru)

Use CBT basic goal setting with MI counseling techniques

Patients pick goals and follow-up schedule

Frequently use local resources

OUR PROGRAM


33/51

Handed outto interestedfamilies

BASIC TRAINING

INFO SHEET


34/51

OUR LAB

SHEET


35/51

GOAL

SHEET


36/51

SPECIALIZED BEHAVIOR SHEETS

FROM CDC, USDA ETC


37/51

OR FROM OTHER PROGRAMS


38/51

GET CREATIVE!


39/51

Pick some goodworkhorses

LESSON #8


40/51

A GOOD PREVENTION

STRATEGY


41/51

KEEPING IT GOING


42/51


43/51


44/51

Pay attention to

outcomes, butkeep them in

perspective

LESSON #9


45/51

Very important for many reasonsKeep your improvement cycles goingWeight management programs are

notoriously difficult to gauge assuccessfulHard to move the BMI needle, so look

at proven intermediate steps

Measure absolutely, but dont let itparalyze you from acting

OUTCOMES


46/51

Organize yourreferral strategy

LESSON #10


47/51

Prevention &HealthyLifestylePromotion

Identi-fication PracticeIntervention MidlevelReferral HighLevelReferral

SurgicalIntervention TreatmentFailure

Various Medical Providers

Environment

Schools

Community Interventions

Hospital Based Programs

THE OBESITY SPECTRUM

KNOW YOUR


48/51

KNOW YOUR

TERTIARY CENTER

Diverse and effective centers

Obesity is a chronic disease: think ADHD,asthma

Stay engaged

Know your other resources, especiallydietitians


49/51

Co-morbidities may need more than youcan give, but address them as your

comfort level increases Severe obesity-these patients can really

derail you if you arent careful

The social services dilemma

Easy to forget that readiness is still afactor

A FEW OTHER THOUGHTS

ON REFERRALS


50/51

1) No time like the present2)Take credit for what you are already doing

3)Know your community

4)Its scalable5)Pay attention to readiness

6)Set a good example

7)Make it your own8)Pick some good workhorses

9)Be practical about outcomes

10)Organize your referral strategy

TEN LESSONS


51/51

Please feel free to contact me

Christopher F. Bolling, [email protected]

859-341-5400 office

859-630-8403 cell

859-578-3172 fax

QUESTIONS?
mailto:[email protected]:[email protected]

lessonsfrompractice bolling

Documents