Air Force Medical Operations Agency Excellent Healthcare Clinical

Air Force Medical Operations Agency Excellent Healthcare, Clinical Currency Pediatric PCMH and Childhood Obesity Col Leslie Wilson AF SG Consultant for Pediatrics AFMOA/SGHM May 2012 1

Overview n Pediatric PCMH and it’s role in childhood obesity n Prevalence, trends and impact of childhood obesity n Prevention, identification, management of childhood obesity n Obesity outside the PCMH n Do. D response to the epidemic Excellent Healthcare, Clinical Currency 2

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

The Quadruple Aim Readiness Population Health 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. 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. Experience of Care Per Capita Cost Providing a care experience that is patient and family centered, compassionate, convenient, equitable, safe and always of the highest quality. 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. Excellent Healthcare, Clinical Currency

The Quadruple Aim Where does childhood obesity fit? Readiness Population Health 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. 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. Experience of Care Per Capita Cost Providing a care experience that is patient and family centered, compassionate, convenient, equitable, safe and always of the highest quality. 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. Excellent Healthcare, Clinical Currency

Readiness and Obesity “Too Fat to Fight” School lunches… A National Security Threat? ? ? Excellent Healthcare, Clinical Currency 7

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

Other disparities n Adult women more obese than adult men n Male obesity rates are growing faster than female n Obesity more common in poor, less educated, minority Excellent Healthcare, Clinical Currency 10

Background and Beginnings in the MHS priorities n AAP 2007 Produced Obesity Recommendations and Obesity Tool kit n White House Task Force on Childhood Obesity Report to the President: Solving the Problem of Childhood Obesity Within a Generation – 2010 Excellent Healthcare, Clinical Currency

White House and First Lady Let’s Move Campaign n 5 Pillars of Campaign n Creating a healthy start for children Empowering parents and caregivers n Providing healthy food in schools n Improving access to healthy, affordable foods n Increasing physical activity n n White House Memorandum n “Leading by example in the Military” Excellent Healthcare, Clinical Currency 12

DOD Childhood Obesity Working Group n Do. D Childhood Obesity Working Group Aug 2010 n Comprised of 11 Do. D organizations n Multi-disciplinary n Subject matter experts n 4 Subcommittees Ø Nutrition and Healthy Choices ages 0 -18 Ø Military Health System Ø Food and Fitness Environments Ø Education and Strategic Communication Excellent Healthcare, Clinical Currency 13

DOD Childhood Obesity Working Group (MHS Sub-Committee) Excellent Healthcare, Clinical Currency 14

Child Overweight in the Do. D Stratified by Service Percentage that met criteria 16 15 16 12 14 14 12 15 10 8. 1 8 4 2 Air Force 10 6 13 Army Counseled 14 15 13 Dx Navy 0 1. 6 1. 7 Army Air Force Excellent Healthcare, Clinical Currency 1. 4 Navy

Child Obesity in the Do. D Stratified by Service 25 13 12 12 12 11 10 10 20 Percentage that met criteria 14 Dx 20 Counseled 20 14 15 10 6. 7 6. 4 5 9 Army Air Force Navy 0 Army Excellent Healthcare, Clinical Currency Air Force 5. 4 Navy

Defining the Problem n Adult BMI between 25 and 30 = overweight n Adult BMI ≥ 30 = obese n Unlike adults, children grow in height as well as weight. Thus, the norms for BMI in children vary with age and sex n 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 Excellent Healthcare, Clinical Currency 17

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

BMI Percentile and AHLTA n BMI and BMI percentile is automatically calculated in AHLTA Accurate height and weight must be entered on the vital signs entry screen n The BMI will automatically populate immediately below these entries n 12/2010 Excellent Healthcare, Clinical Currency 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. Excellent Healthcare, Clinical Currency 20

Etiology of Obesity n Etiology is multifactorial n Interaction of genetics and environment n Energy imbalance n Energy In = Energy Used + Energy Stored n Environmental factors n Television/Video games n Sleep n Genetic factors n Medication n Endocrine disease n Metabolic programming n Nutrition during gestation and early life Excellent Healthcare, Clinical Currency 21

Co-morbid conditions associated with obesity Excellent Healthcare, Clinical Currency 22

Do Obese Children become Obese Adults? n Age n 25% obese preschoolers vs 50% school age kids remained obese n Parental Obesity n 80% teens remain obese if one parent is obese n Severity n 75% adolescents with severe obesity, remained severely obese n 8% adolescents with moderate obesity developed severe obesity as adult Excellent Healthcare, Clinical Currency 23

Prevention of Childhood Obesity n Routine documentation of BMI n Talk to patients and their families n Identify those at risk n Anticipatory guidance/counseling n Nutrition n Physical activity n Healthy lifestyles n Praise for current healthy practices Excellent Healthcare, Clinical Currency

Simple messaging for all Excellent Healthcare, Clinical Currency 25

5 things There are 5 things to remember under ‘ 5’ Adapted from Maine Health Initiative www. letsgo. org Excellent Healthcare, Clinical Currency 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 Excellent Healthcare, Clinical Currency 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 Excellent Healthcare, Clinical Currency 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 Excellent Healthcare, Clinical Currency 29

AHLTA making it Easier Excellent Healthcare, Clinical Currency 30

Using an Obesity Toolkit Excellent Healthcare, Clinical Currency 31

Start from the Beginning Vital Signs n Targeted Review of Systems/Physical Exam n Height (%), Weight (%), Pulse, Respirations, BP n BMI and BMI% for age and gender n Blood Pressure for age, gender and height n Follow guidance per toolkit Excellent Healthcare, Clinical Currency

History and Laboratory evaluation Risk Factors Lab Evaluation n BMI 85 -95%, no risk n Ethnicity n Family/Personal Hx: n n n CV dz <55 men, <65 women Dyslipidemia Obese/overweight Diabetes HTN n Physical Activity Behaviors n n Fasting lipid profile, ALT, AST and fasting glucose BMI >95% n n Fasting lipid profile BMI 85 -95%, + risk n Diet Behaviors n n Fasting lipid profile, ALT, AST and fasting glucose Repeat all every 2 years Excellent Healthcare, Clinical Currency 34

Once Identified: 4 Stage approach Excellent Healthcare, Clinical Currency 35

Childhood Obesity Tool Kit AFMS Knowledge Exchange https: //kx. afms. mil/kxweb/dotmil/kj. do? functional. Area=Pediatric. Obesity Excellent Healthcare, Clinical Currency 37

Care. Point Population Health Portal n Obesity module under development n Prevalence in clinics, service, overall n Metric for measuring annual BMI% for children seen in last 12 months n Bring in blood pressure (maybe labs) n Identify patient lists of overweight and obese enrollees n Identify how well we diagnose overweight/obese n May look at documentation of counseling for nutrition/physical activity Excellent Healthcare, Clinical Currency 38

Raising the sensitive issue of weight n AAP published “Parental Perceptions of Weight Terminology that Providers use with Youth” in Pediatrics, Sept 2011 n Form therapeutic alliance and engage the family n Gentle: “easy gainers” and some must “work extra hard” n Use “unhealthy weight/weight problem” – avoid “obese” or “fat” n Terms focus on health and function, rather than appearance n Goal: growing into healthy body weight n Avoid blaming approach Excellent Healthcare, Clinical Currency 39

Obesity outside of the Medical Home n Medical Community key advocates for Healthy Living n Need a Champion, develop a team n Look for community resources n HAWC, Youth Centers, AFESS, Fitness Centers n Get buy in from your base and community n Get involved in the schools n Nutrition, physical education n Track your interventions – are you making a difference? n “Be Our Voice” advocacy group from NICHQ The Fun Theory Excellent Healthcare, Clinical Currency 40

Do. D Healthy Living campaign under development n Develop Do. D CPG for Childhood Obesity n Update Child Development Program Do. DI n Breastfeeding, nutrition, physical activity and screen time n Adopt Institute of Medicine (IOM) guidelines on childhood obesity with regards to foods sold in vending options n Do. D Schools to annually measure BMI and provide education n TRICARE demonstration project for Obesity/Nutrition counseling n Follow AAP/IOM recommendations for meals in CDCs Excellent Healthcare, Clinical Currency 41

Questions? ? Excellent Healthcare, Clinical Currency 42