Important Points Made by Speakers
• More is known about public health strategies than about clinical strategies for preventing obesity. (Dietz)
• Education and training for health professionals need to be improved at all levels to address obesity. (Dietz)
• Clinical approaches are essential to achieve the caloric deficits necessary for severely obese people to lose weight. (Burnet, Dietz)
• The time and effort invested in building relationships pay off in engagement and sustainability. (Burnet)
• Obesity prevention and treatment programs can engage not only patients but also health care providers. (Buchholz)
The preceding chapter summarizes the workshop session addressing goal 4 of Accelerating Progress in Obesity Prevention (IOM, 2012a) with respect to workplace environments. This chapter summarizes a second session on that same goal as directed at health care providers and insurers. This session looked at the health care system and at its interactions with other organizations, including schools. Accelerating Progress in Obesity Prevention calls for health care professionals to make obesity prevention part of routine preventive care and for insurers to cover obesity prevention, screening, diagnosis, and treatment. However, many barriers exist to achieving these objectives, and disadvantaged populations have difficulty accessing health care in general, much less health care emphasizing obesity prevention.
Standing committee member William Dietz, recently retired director of the Division of Nutrition, Physical Activity, and Obesity in the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention (CDC), reviewed the strategies outlined in Accelerating Progress in Obesity Prevention for involving the health care system in obesity prevention and some of the steps that can be taken in pursuing those strategies. Deborah Burnet, professor of medicine and pediatrics at the University of Chicago, described a medically based after-school program that has been successful and could be applied elsewhere. Finally, Ryan Buchholz, a pediatrician and internist at Unity Health Care, described a similar program instituted at a federally qualified health center that also has succeeded in reducing weight among patients and family members.
Summary of Remarks by William Dietz
Relatively little is known about optimal approaches to preventing and treating obesity in primary care, Dietz stated. In the context of the health care system, obese individuals are an underserved group (Puhl and Brownell, 2003).
Accelerating Progress in Obesity Prevention (IOM, 2012a) outlines three strategies for expanding the role of health care providers and insurers in obesity prevention and treatment. The first is to provide standardized obesity-related care and advocate for healthy community environments. While some progress has been made in this area, many trends still point toward an insufficient rate of change in obesity. Among boys and men, the prevalence of obesity has continued to increase, driven in particular by increases among African American boys (Ogden et al., 2012). Also, the prevalence of severe obesity has continued to increase among all groups (Flegal et al., 2012). When severe obesity is defined as a body mass index (BMI) greater than or equal to 120 percent of the 95th percentile (Flegal et al., 2009), about 9 percent of African American boys and more than 12 percent of African American girls fall into this category (Wang et al., 2011). Severe obesity also is increasing among adults, with especially high levels among African American women (Flegal et al., 2012).
Clinical approaches are essential to achieve the caloric deficits necessary for severely obese people to lose weight, said Dietz. One relevant model is the chronic care model, in which a patient’s environment—including family, school, worksite, and community— interacts with the medical system around obesity prevention and care (Dietz et al., 2007). Dietz mentioned several programs that have used elements of this model to achieve measures of success:
• Group sessions with the parents of overweight preschoolers conducted in a primary care setting had an effect on weight (Quattrin et al., 2012). Intriguingly, changes in children’s weight predicted changes in parental weight, with parents in the study losing two BMI units.
• A descriptive pilot study of community-based treatment in a YMCA led to an overall weight loss among children and adolescents, with greater losses among those who attended more sessions (Foster et al., 2012).
• Treatment of extreme adult obesity in primary care practices using behavioral counseling, structured diets, and medications produced substantially greater weight loss than occurred in a control group (Ryan et al., 2010).
• Primary care delivered through both in-person and remote support has demonstrated effectiveness in some obese patients (Appel et al., 2011; Wadden et al., 2011).
An important characteristic shared by these studies, Dietz noted, is that the care was delivered by care extenders such as nutritionists and nurse practitioners. Engagement of a broad range of staff is critical in dealing with chronic diseases, and physicians need to partner with other staff members, he said.
The second strategy in Accelerating Progress in Obesity Prevention is to ensure coverage of, access to, and incentives for routine obesity prevention, screening, diagnosis, and treatment. Lack of reimbursement often is cited as a barrier to obesity treatment, Dietz observed. Yet, an experiment under way with the Alliance for a Healthier Generation has demonstrated that even when reimbursement is available, it often is not used (Rask et al., 2013). Reasons include a lack of awareness by both providers and families of a benefit’s availability, varying acceptance of billing codes, precertification or enrollment requirements, copayments, and low use of BMI-specific diagnostic codes. Dietz also called attention to the possibility of bias against obese people among medical providers
and to a lack of self-efficacy among physicians and other providers, who may not know how to start a conversation about obesity or what to emphasize.
The third strategy in Accelerating Progress in Obesity Prevention is to encourage healthy weight gain during pregnancy and breastfeeding and promote breastfeeding-friendly environments. In this regard, Dietz called attention to a model for obesity prevention and care that integrates efforts in the medical system with environmental supports. Dietz said CDC has been supporting the development of Baby-Friendly Hospitals in the southeastern United States, which has the lowest rates of breastfeeding among African American mothers (CDC, 2011b, 2013a). These hospitals emphasize early initiation of breastfeeding, skin-to-skin contact, rooming in, feeding cues, limited use of pacifiers, and breastfeeding support following discharge. Another promising model program Dietz noted was developed by ChildObesity180,1 which serves children in out-of-school programs and emphasizes drinking water instead of sugar-sweetened drinks, snacking on fruits and vegetables, and engaging in physical activity.
A major challenge is to disseminate successful approaches, said Dietz, which requires the involvement of health care professionals. For example, BMI still is not routinely measured in pediatric practices (Hillman et al., 2009). Physicians also recognize that obesity occurs in an environmental context and that restricting interventions to the walls of a clinic is not likely to be effective. But Dietz pointed out that efforts at building advocacy skills among physicians for changes in the environment are in their infancy.
The severity of a condition needs to be aligned with reimbursement for treatments, Dietz said. In the adult population, about 40 percent of obesity-related costs are generated by the 8 percent of patients with a BMI above 35, yet care is treated as though one size fits all (Arterburn et al., 2005). Dietz suggested that, as the payment structure in medicine changes in conjunction with the Patient Protection and Affordable Care Act of 2010,2 it may be possible to incorporate changes in the medical system that will lead to more effective treatment for chronic conditions such as obesity than is the case today.
2Patient Protection and Affordable Care Act, Public Law 111-148, 111th Cong. (March 23, 2010).
Dietz particularly emphasized the importance of education. He suggested that education for health professionals needs to be improved at all levels, with corresponding changes in curricula, to address obesity prevention, treatment, and bias. Competencies also need to be based on the needs of the population and of the health care system. As an example, Dietz noted that providers generally are not taught how to talk with their patients effectively about body weight. The terms fatness, bulk, and obesity are resisted by patients, whereas weight, excess weight, and increased BMI are much more acceptable. With African American patients, providers also need to address the validity of BMI as a measure of obesity since, Dietz pointed out, this measure is sometimes mistrusted. But weight is a marker for risk of type 2 diabetes, and many families have experience with blindness, chronic renal disease, or amputation as consequences of diabetes. Therefore, engaging patients around these family experiences may increase their understanding and motivation.
Physicians generally have not been trained to help patients change behaviors, which is one reason why other providers, including nurses, dieticians, and physician assistants, will be critical in addressing obesity prevention (Frenk et al., 2010; IOM, 2012a). In addition, Dietz explained that community-based care is essential after adults lose weight to help them keep it off. Training in behavior change, an understanding of how to work in teams, and the ability to link public health and clinical systems are the kinds of skills all health care providers are going to need to address not just obesity but other chronic conditions as well.
“If we start early educating [medical] students … they change their perspective on obesity from an individually based problem to one that has many more environmental determinants.” —William Dietz
Summary of Remarks by Deborah Burnet
The city of Chicago has high rates of diabetes and childhood obesity (Chicago Health Atlas, 2013; City of Chicago, 2013). Building on previous successes with a diabetes prevention program, investigators with the University of Chicago School of Medicine, in partnership with
the Woodlawn Community School, developed the Power-Up program to meet the needs of overweight African American children and their parents in an after-school setting (Choudhry et al., 2011). Burnet explained that the University of Chicago and school staff developed their relationship for more than a year so that the interests and motivations of each partner would be clear before community-based participatory research began. Champions within the school were critical and did not always come from traditional leadership positions. For example, a security guard at the school, who had the keys to every door, knew where everything was, and knew every child by name, was a pivotal partner.
The program organizers attended Parent-Teacher Association (PTA) meetings and coffees to obtain parents’ input, collaborated with teachers on the curriculum, involved staff in program implementation, iteratively refined the program with teachers and parents, engaged children in “branding” and making the program their own, and shared research grant dollars with the school. Burnet explained that the program took the form of 14 weekly interactive sessions for grades K-2, 3-4, and 5-6 and was later expanded to 20 sessions. More recently, the program focused on third- and fourth-grade students. The program used the lay health leader model in which the leaders were the after-school teachers, who were trained by a behavioral psychologist and research staff and received continued support throughout the program.
Burnet described how data were collected on site, including height, weight, BMI, and blood pressure for both the children and parents, along with self-reported measures of dietary intake and physical activity and knowledge, beliefs, and attitudes regarding nutrition and physical activity. Blood was not collected so as to keep the data collection as user-friendly as possible. Of the 70 children in the after-school program, 40 were enrolled in the research—16 boys and 24 girls, all African American, ranging in age from 5 to 12. Twenty-eight parents also participated (several had two or more children enrolled). At baseline, approximately half the children were overweight or obese, which mirrors the current data for Chicago public schools and many other urban areas (Chicago Public Schools and Chicago Department of Public Health, 2013; Margellos-Anast et al., 2008).
The program produced changes in BMI z-scores after 14 weeks (Choudhry et al., 2011). Burnet explained that the changes were most pronounced in the normal-weight and overweight groups; the obese group did not exhibit significant changes in their BMI z-scores. According
to Burnet, and consistent with Dietz’s observation, the heaviest children need additional medical intervention and a more intensive program.
Burnet noted that the study was small, involving just one school; it did not have a control condition; and participants were not followed beyond 14 weeks. Also, parents had difficulty participating in person because of competing commitments. A good way to involve parents, said Burnet, was to use cell phone texting, which was common in the community and among the school’s parents. The Power-Up program instituted text messages to parents twice a day on such topics as the U.S. Department of Agriculture’s (USDA’s) food and activity pyramid, recommended servings of fruits and vegetables, and the activities in the Power-Up sessions. The texts also included questions such as “What kind of exercise did you do with your child today?” The families that participated in the texting program were comfortable with texting and texted responses to questions more than half the time within 5 minutes, Burnet said. They reported that the texting helped them keep in touch with the program and make healthy changes within their families.
The Power-Up program has had a sustainable impact at the school. It has led to new playground equipment, a greenhouse for growing vegetables, healthy snack choices, an after-school newsletter that highlights a “veggie or fruit of the month” and healthy recipes, and weekly visits of a produce van. When the Chicago White Sox baseball team and the University of Chicago formed a partnership to work on social marketing around childhood obesity, they used Power-Up as a cornerstone of the endeavor.3 At White Sox home games on Sundays, Power-Up All Stars booths at the park offer healthy nutrition and exercise activities, and children can go online to participate in related activities and earn prizes.
Burnet provided several lessons drawn from her experience with Power-Up:
• The time and effort invested in building relationships pay off in engagement and sustainability.
• Building on common practices, such as cell phone texting, can produce greater acceptance and change.
• Creative use of technology can address time constraints and scalability.
• The heaviest children need to be referred for more intensive medical care.
• Multiple policies are converging on obesity prevention— including policies affecting schools—which helps clinicians and community leaders work together.
• Partnerships can lead to broader policy changes and can open the door to research programs involving clinics, communities, workplaces, and schools.
• Providers as well as students need to learn to work in teams.
During the discussion session, the sustainability of the Power-Up program was a prominent topic. Burnet and her colleagues are no longer running the program, although they still interact with it. The program has reached the point where the school is continuing it because of the benefits it provides to participants. Collaborations with other schools on the South Side of Chicago and with other research and service delivery programs have helped support the program. Burnet stated that the political environment in Chicago also has helped, in that the leadership of the city and of the Chicago Department of Public Health are keenly interested in obesity prevention.
Burnet particularly emphasized the need to help organizations and surrounding communities find the resources to make such programs sustainable. For example, the South Side Health Resource Mapping project4 engages high school students each summer to map all the publicly available resources in neighborhoods. Not only can these maps direct residents to nearby services, but they also can be used to advocate for additional resources in underserved communities. In addition, resources are needed to enable other schools to experience the benefits of programs like Power-Up and find ways to institutionalize such approaches.
“The kids became agents of change within their families. They would say, ‘I want to go to the grocery store, I want to make the shopping list.’ Getting their input and valuing their contributions is really important.” —Deborah Burnet
Summary of Remarks by Ryan Buchholz
The Upper Cardozo Health Center sees about 400 patients per day, and more than 40 percent of the children seen between the ages of 2 and 18 are either overweight or obese, with 25 percent in the latter category, Buchholz stated. The center is part of Unity Health Care, a network of 30 health centers around the District of Columbia, which together serve more than 100,000 patients in the District. Buchholz noted that Upper Cardozo alone sees about 22,000 patients each year, drawn mainly from the surrounding ethnically and economically diverse neighborhood of Columbia Heights.
Healthy weight is not an easy topic to bring up with patients, said Buchholz. Very little time usually is left at the end of a visit to address the issue, and it needs to be raised in a sensitive way, using appropriate terminology. Buchholz explained that providers are trying to establish and maintain a rapport with their patients and do not want to be confrontational about weight.
A problem such as obesity, which has multifactorial origins, requires a multifactorial intervention, even in the primary care setting, said Buchholz. At the Upper Cardozo Health Center, such an intervention was created in 2008 by three physician assistants who adapted the Ways to Enhance Children’s Activity and Nutrition (We Can!) program developed by the National Institutes of Health (NIH) to offer evening sessions for families. Every Wednesday evening, a team of providers, medical assistants, and volunteers, including patient registration clerks, meets with patients for 2.5 hours. The providers include physician assistants, family nurse practitioners, internists, family physicians, and pediatricians, all of whom wear their We Can! t-shirts at the center to engage other patients and staff in the program. The team assesses BMIs, reviews health knowledge and behaviors, offers both structured and unstructured physical activity with healthy snacking, and often joins with participants to prepare healthy food using the demonstration kitchen at the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) office in the building. Buchholz explained that people of all ages attend the sessions. The majority are children aged 5 to 15, but many are adults.
Activities might include going to a grocery store to buy a vegetable that a patient has never tried before, playing soccer at a nearby field, or teaching participants how to read food labels. Buchholz stated that patients have played a role in shaping the program—for example, requesting times when they can be away from their children and engage in activities on their own. Patients are free to attend the sessions when they want. Although some come just once, many have attended 2 to 10 sessions. Buchholz noted that in 2010, the program had 584 visits, in 2011 about 800, and in 2012 about 1,300. Because almost all of the center’s pediatric patients are covered under Medicaid, the center has been able to bill for visits without a copay, which has enabled it to offer the program on a regular basis.
The program has had measurable benefits among patients, Buchholz pointed out. Among those who have attended multiple times, children’s average BMI has dropped almost 0.2 percentile points with each additional visit, and adults’ average weight has declined with each successive visit (Buchholz et al., 2011).
The program has standardized some procedures and information, Buchholz noted. BMI is automatically calculated and tabulated. A single template is used to ask about healthy activity and health knowledge. Every child receives a core of basic information over time.
The program has engaged not only patients but also staff, who have become instrumental to its success. Additional programs, such as the Fruit and Vegetable Prescription program, supported by Wholesome Wave, and the farmers’ market program DC Greens, have complemented the We Can! efforts. A new initiative to rank parks in Washington, DC, in terms of cleanliness, accessibility, exercise level, safety, and other measures, known as the DC Park Prescription program, enables providers to inform patients about opportunities for physical activity, Buchholz explained.
Buchholz added that federally qualified health centers are an excellent platform for such programs, and the Affordable Care Act is about to greatly expand their role in the health care system. But each center has a different patient population with different needs, Buchholz noted, so providers need to listen to the voices of their patients to know what will work in each location. Like Burnet, Buchholz emphasized the importance of staff members who devote the time and energy needed to keep a program thriving, along with champions for the program within the institution.
The Upper Cardozo Health Center has relatively limited capability to conduct comparative effectiveness research or biostatistical analysis. Providers often have little sense of which patients are most likely to attend the program repeatedly, although Buchholz suggested during the discussion session that future research might be able to identify the factors that contribute to participation. To this observation, Dietz added that research has shown that programs designed to meet patients’ rather than providers’ needs have much better persistence.
In discussing the sustainability of the program, Buchholz noted that, as the health care system moves away from fee-for-service payments, it will be necessary to find new ways of supporting such programs. Unity Health Care sets aside a small budget for the program, and the DC Medicaid managed care organizations have been supportive. But the health care system will continue to evolve, driven partly by patient needs and partly by policy initiatives such as the Affordable Care Act, Buchholz noted, which will have implications for such programs.
“The clinical setting can be a challenging environment to address obesity compared with the great strides made in public health.” —Ryan Buchholz