Nutrition in Clinical Practice http://ncp.sagepub.com/
Challenges and Successes of a Multidisciplinary Pediatric Obesity Treatment Program Stephanie M. Walsh, Wendy Palmer, Jean A. Welsh and Miriam B. Vos Nutr Clin Pract 2014 29: 780 originally published online 21 October 2014 DOI: 10.1177/0884533614551839 The online version of this article can be found at: http://ncp.sagepub.com/content/29/6/780
Published by: http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 12, 2014 OnlineFirst Version of Record - Oct 21, 2014 What is This?
Downloaded from ncp.sagepub.com at BRANDEIS UNIV LIBRARY on November 24, 2014
551839
research-article2014
NCPXXX10.1177/0884533614551839Nutrition in Clinical PracticeWalsh et al
Clinical Observations
Challenges and Successes of a Multidisciplinary Pediatric Obesity Treatment Program
Nutrition in Clinical Practice Volume 29 Number 6 December 2014 780–785 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614551839 ncp.sagepub.com hosted at online.sagepub.com
Stephanie M. Walsh, MD1,2; Wendy Palmer, MS, RD1; Jean A. Welsh, PhD, MPH, RN1,2,3; and Miriam B. Vos, MD, MSPH1,2,3
Abstract Background: Despite the well-documented need for multidisciplinary pediatric obesity treatment programs, few programs exist and best practices are not clearly defined. We describe the design and initial quality-related outcomes of the Strong4Life multidisciplinary pediatric obesity treatment program along with some challenges and solutions implemented over the first 2 years. The purpose of this report is to inform others interested in designing similar programs. Program Description: The Strong4Life Clinic obesity program was designed to provide children with the medical care, as well as the behavior change guidance and support needed to reverse their obesity and/or minimize the related health risks. This low-intensity program is designed to provide approximately 6 hours of care over 12 months from a medical provider, psychologist, registered dietitian nutritionist, exercise physiologist, and nurse. Results: Between August 2011 and February 2014, the Strong4Life clinic served 781 high-risk (mean sex- and age-adjusted body mass index [BMI] percentile 98.8) and racially/ethnically diverse (45% non-Hispanic black and 24% Hispanic) patients. Of the 781 patients seen, 66% returned for at least 1 visit. Nearly all returning Strong4Life patients stabilized or improved their BMI (90% of those who participated 97th percentile, and many have additional comorbid conditions.
Patient-Centered, Action-Oriented Counseling A core principal of the H4L clinic is the communication style used by the providers. All team members were trained in patient-centered counseling and most in motivational interviewing. Motivational interviewing (MI) decreases the focus on telling the patients “what to do” and instead uses patientcentered counseling to elicit intrinsic motivation for changing behavior and encourages them to explore their ambivalence to making that change.13,14 The tone of patient-centered counseling is nonjudgmental, empathetic, and encouraging.14 However, these conversations can be somewhat lengthy, and eliciting
motivation did not seem sufficient for the H4L program. We combined MI with the principles of action-oriented counseling. Action-oriented counseling has been used in many fields— most notably for smoking cessation15,16 and for increasing physical activity.17 Also referred to as the “5 As,”18 the actionoriented counseling framework can vary, but our version includes 5 steps: ask, advise, agree, assist, and arrange. The first step is to ASK questions to assess current daily activities and motivation level. The provider also asks about barriers, readiness to change,19 and previous attempts at change. Understanding why these previous efforts failed will inform the new goals. The transtheoretical model of health behavior change describes a progress of 6 stages of change. Initially, we asked each family where they were in the stages of precontemplation, contemplation, preparation, action, maintenance, and termination. However, possibly because of the multiple steps that it takes a parent to get a child into the H4L program, we found that the vast majority of families were very motivated and already in the “action” stage by the time they reached us.19 ADVISE, the next step, involves providing pertinent information about BMI, long-term health concerns, and benefits of change to the family. AGREE is the third “A” and is a discussion to set a realistic physical activity and nutrition goal. Goal setting is the core of our action-oriented counseling, and it has been supported as a health behavior change strategy in adult obesity treatment.20 However, there is less information in the pediatric literature. We aim to have each patient leave with 2 concrete goals—one for a nutrition change and one for physical activity. There is not a prescribed set of behavior goals that each family must master; however, most of the goals selected by families are supported by the literature. The patients or parents select the goal, and the provider working with them explores if the goal is feasible and if it is something that will improve their health. ASSIST is a planning step to collaboratively consider strategies to overcome the potential barriers to achieving these goals. For example, sometimes a child who does not have a bike will select the goal to “ride a bike every day for 30 minutes.” The barrier is that he or she would first need to buy a bike and helmet, so this may not be a realistic goal. The final step is to ARRANGE follow-up of their success in achieving the behavioral goals and any unexpected barriers that arose. It is critical to keep the focus on the goals rather than short-term improvement of weight or BMI. Patients have control over their actions but less control over their weight.
Team Members and Typical Visits at Strong4Life At the first appointment for the Strongh4Life clinic, the patient and family meet with the entire team, which includes a medical provider, a psychologist, an RDN, an exercise physiologist, a nurse, and a clinic administrator. The first visit is often with a physician, and the subsequent visits may be with a physician’s assistant. The psychologist conducts a new patient
Downloaded from ncp.sagepub.com at BRANDEIS UNIV LIBRARY on November 24, 2014
782
Nutrition in Clinical Practice 29(6)
evaluation with each family using an interview format and validated pediatric assessment tools to screen for depression, eating disorders, problems at school (including bullying), level of coping skills, and other factors. The assessment is used to determine their need for outside counseling or if they need to continue to see him or her on subsequent visits. The RDN and exercise physiologist meet with the patients and families at each visit. If needed, a social worker is available for issues related to food insecurity, durable medical equipment, and Medicaid. We have also used the Children’s Healthcare of Atlanta’s Health Law Partnership program for families that required legal representation in schools or other areas. Typical visits are 2 hours for new appointments and 1 hour for follow-up visits. As the program progresses, the program is tailored to meet the family’s and patient’s needs. By definition, this is a low-intensity program because of the relatively few contact hours with the providers. In 2010, the U.S. Preventive Services Task Force recommended a comprehensive, moderate- to high-intensity treatment program for obese children, which it defined as including >25 hours of contact in 6 months.21 When designing our program, we anticipated that weekly visits for patients would be extremely difficult and more costly. On the basis of our previous experience with single-provider weight management clinics, we initially planned for a schedule of 5–6 visits in 1 year. The first follow-up visit was scheduled at 1 month and then visits at 2 months, 5 months, 8 months, and 1 year. Over time, this schedule has evolved to be more flexible, except for the first followup visit. For all new patients, we schedule their first follow-up visit at ~1 month because this is the highest risk period for failing to achieve their goals. By intervening quickly, we can redirect a family before they become discouraged. The average number of visits attended by our patients is shown in the quality benchmarks section below.
Nutrition Intervention Because the nutrition component is a key to patient success, this is described in more detail. The RDN works in conjunction with other members of the team for a collaborative approach to obesity treatment. The nutrition care process begins with a detailed assessment on the initial visit, including 24-hour recall and food frequency for vegetables, fruit, fried food, restaurant foods, water, milk, juice, sugary drinks, and family meals per day. Initial assessment includes review of previous weight loss attempts, methods tried, and results. Depending on the age of the child, the child may report intake himself or herself. This is a key opportunity to gather valuable information that the parent may not be aware of, particularly if the child spends a large part of the day out of the home at school, sports, daycare, or other activities. The first visit is essential to establish good rapport with the patient and family. Many patients have a long list of unsuccessful experiences with diets, so it is important to establish trust before doing any nutrition education.
A nutrition diagnosis is determined by the RDN based on the risk factors assessed. Common nutrition diagnoses related to excess weight and obesity are (1) sugary beverage consumption, (2) low intake of fruits and vegetables, (3) excessive intake of high calories, (4) high-fat and high-sugar foods related to fastfood intake, and (5) eating away from home. The nutrition intervention consists of targeted education on a mutually agreed-on area for improvement. The nutrition curriculum covers basic principles of healthy nutrition that benefit all members of the family. Key areas include sugary beverages, MyPlate, food groups, healthy snacks, structured meals, and family meals. The RDN has a kit of education tools in the examination room to use with patients, including sugar beverage demonstration materials, balanced plate information, fast-food nutrition facts, and more. The nutrition approach in the clinic visit is collaborative between the patient and the caregiver, and in many cases, both leave with a nutrition goal. Nutrition and feeding practices for pediatric patients are dependent on parental or home caregiver engagement and support because most pediatric patients are not grocery shopping, preparing food, or structuring daily mealtimes. It is the parent or caregiver’s job to create structure for their children and be a role model for the establishment of healthy eating habits. Some common recommendations supported by the literature22 include the following: •• Meals and snacks are eaten at a table or in a designated eating space. •• Avoid screens during mealtime (television, cellphone, iPad, video games, etc). •• Mealtime should be pleasant but not playtime (no toys at the table). •• Avoid using the “clean plate rule.” •• Eat meals as a family as much as possible. •• Keep fresh fruits and vegetables in plain sight. •• Use nonfood rewards. •• Provide choices of healthy items.
Behavioral Feeding The H4L nutrition philosophy is presented as a continuum rather than “good” food vs “bad” food. There are foods that are more nutritious such as vegetables, fruits, whole grains, lean proteins, and low-fat dairy. There are foods that are less nutritious, such as convenience foods, processed foods, and sweet treats, that consist of refined grains, added sugars, added fats, and added salts. Refined foods also consist of foods altered with artificial ingredients to be sugar free, “diet,” or low fat that do not contain quality nutrition. At H4L, specific calorie goals are not used. Rather, families are encouraged to increase their nutritious foods and decrease the less nutritious foods. Instead of attempting drastic changes, we encourage them to make the next better choice. For example, a child who drinks 3 sugary drinks a day may start by decreasing to 2 sugary drinks and adding 1 glass of water per day rather than trying to stop the sugary drinks all at once.
Downloaded from ncp.sagepub.com at BRANDEIS UNIV LIBRARY on November 24, 2014
Walsh et al
783
The team also teaches families that healthy food tastes great and can be fun to eat. Teaching children about the different tastes and textures of foods early in life is critically important to their acceptance of a variety of foods as they turn into adults. Often children need to experience new foods multiple times before accepting a new taste or texture. This is a normal part of a child’s growth and development. At H4L, children are not labeled as picky eaters because it is a learned behavior developed over time.
Challenges and Solutions Over the first several years of our program, we identified challenges and worked as a team to solve them. The following issues and solutions are presented so others can learn from our experience.
Efficiency One of the crucial pieces to making the clinic a pleasant experience is to decrease wait times between providers. When the patient has to see 4 different providers for visits, there is the potential for significant wait times. We initially had very long appointments that would sometimes last >3 hours. The improved scheduling of patients was a key change to keep the clinic flowing well. Our new patient appointments are 2 hours (30 minutes per provider), and our followup appointments are 1 hour (15 minutes per provider). We have used timers and reminder knocks on the door to keep the staff on the appropriate time frame. This took practice and training with the providers and objective documentation to keep the flow going smoothly. Staff turnover leads to increased wait times because the new team members have to adjust to the tight time requirements. We also used the hospital’s efficiency team, which provided us with invaluable information regarding the way we run clinic and methods to improve flow.
Remembering Goals During the appointment, the Strong4Life team uses patientcentered counseling to set goals for physical activity and nutrition. The team will usually make 1 goal with the family in each area. These goals are then written on a “goal sheet” and sent home with the family. Initially, each team member wrote the goal on the sheet. We found that patients and families were struggling to remember the goals and would return with feedback that they were unsure at discharge what specific goal they had set. Even though the team reviewed the goals, the families often had difficulty with the wording. Over the past year, we have had the patients write the goals on the sheet, which has improved retention of the goals set. Follow-up calls to remind them of their goal were not successful for our team because very few parents answered or returned the calls. We have found
emailing the older teen patients is a successful way to remind them of goals and to touch base between visits.
Failure to Follow Up Attrition rates in childhood obesity programs approach 33%. While this ties in with the no-show rate, this is an area in need of improvement in many programs. Unlike the family that initially does not show for their first appointment, at H4L, if the family has made it to a visit, they have a level of motivation that we feel we should be able to foster. One of the ways we reduce attrition is to discuss what to expect at the second appointment so that they will come back even if they fail to meet or even attempt their goals. Families have sometimes felt shamed by medical providers in the past, and so we find it important to emphasize that we want to see them back even if they fail so that we can help them problem solve. We also reduced attrition by having the second appointment close in time to the first appointment so that it is during the time when the family is still motivated. We also use a clinic-specific scheduler, provide reminder phone calls, and involve the entire family in the treatment program as previously recommended.23 Despite these methods, 33% of patients do not return for a second visit, and this is an ongoing area of quality improvement.
Failure to Graduate The Strong4Life program is a 12-month program with yearly follow-up thereafter. The patients who are truly invested in the program rarely want to “graduate.” There is concern for relapse and difficulty with motivation. Part of our program is to help families realize all that they have accomplished and support them to continue to change without regular visits. We have been able to help families with this by arranging for follow-up with their PCP in a few months and having their first “graduation” visit in 6 months instead of 1 year. Some families require extra visits to solve their issues in feeding and physical activity. These families are not quite ready to graduate at the 1-year mark, and we often extend their time with us.
Quality Benchmarks of the Strong4Life Program Children’s Healthcare of Atlanta Institutional Review Board approval was obtained for review of clinic outcome data. Between August 2011 and February 2014, we have seen 781 patients at the Strong4Life Program. A description of this cohort is shown in Table 1. Our no-show rate in 2013 hovered around 20%, which is lower than typical nationally reported rates.23,24 Of the patients seen for initial evaluation, 33% failed to return for a second visit. This dropout rate is on the lower end compared with reported rates ranging from 27%–73%.23 The changes in BMI z percentile and BMI z score for our patients are presented in Table 2. On average, most patients
Downloaded from ncp.sagepub.com at BRANDEIS UNIV LIBRARY on November 24, 2014
784
Nutrition in Clinical Practice 29(6)
Table 1. Enrollment Characteristics of All Patients (N = 781) Who Participated in the Strong4Life Obesity Treatment Program Between August 2011 and February 2014. Characteristic
Value
Age, mean (SD), y Sex, female, No. (%) Race/ethnicity, No. (%) Non-Hispanic white Non-Hispanic black Hispanic Other Height, mean (SD), cm Weight, mean (SD), kg BMI z score, mean (SD) BMI percentile, mean (SD) [range]
12.0 (3.5) 474 (60.7) 223 (28.6) 354 (45.3) 190 (24.3) 42 (5.4) 151.6 (20.6) 86.1 (36.8) 2.5 (0.4) 98.8 (2.0) [88.4–99.9]
BMI, body mass index.
Table 2. Demographic Characteristics and Weight Trajectories of Overweight Children and Adolescents Who Attended at Least 2 Strong4Life (H4L) Obesity Treatment Program Appointments, Stratified by the Length of Time Enrolled Between August 2011 and February 2014.a Participation Time (Time From Baseline to Most Distal Follow-up Visit) Characteristic No. of H4L visits, mean (SD) [range] Age, mean (SD), y Baseline Follow-up Sex, female, No. (%) Race/ethnicity, No. (%) Non-Hispanic white Non-Hispanic black Hispanic Other Height, mean (SD), cm Baseline Follow-up Change (P value) Weight, mean (SD), kg Baseline Follow-up Change (P value) BMI percentile, mean (SD) Baseline Follow-up Change (P value) BMI z score, mean (SD) Baseline Follow-up Change (P value) BMI z score change, No. (%) Loss (>0.04) Stable (±
Challenges and Successes of a Multidisciplinary Pediatric Obesity Treatment Program Stephanie M. Walsh, Wendy Palmer, Jean A. Welsh and Miriam B. Vos Nutr Clin Pract 2014 29: 780 originally published online 21 October 2014 DOI: 10.1177/0884533614551839 The online version of this article can be found at: http://ncp.sagepub.com/content/29/6/780
Published by: http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 12, 2014 OnlineFirst Version of Record - Oct 21, 2014 What is This?
Downloaded from ncp.sagepub.com at BRANDEIS UNIV LIBRARY on November 24, 2014
551839
research-article2014
NCPXXX10.1177/0884533614551839Nutrition in Clinical PracticeWalsh et al
Clinical Observations
Challenges and Successes of a Multidisciplinary Pediatric Obesity Treatment Program
Nutrition in Clinical Practice Volume 29 Number 6 December 2014 780–785 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614551839 ncp.sagepub.com hosted at online.sagepub.com
Stephanie M. Walsh, MD1,2; Wendy Palmer, MS, RD1; Jean A. Welsh, PhD, MPH, RN1,2,3; and Miriam B. Vos, MD, MSPH1,2,3
Abstract Background: Despite the well-documented need for multidisciplinary pediatric obesity treatment programs, few programs exist and best practices are not clearly defined. We describe the design and initial quality-related outcomes of the Strong4Life multidisciplinary pediatric obesity treatment program along with some challenges and solutions implemented over the first 2 years. The purpose of this report is to inform others interested in designing similar programs. Program Description: The Strong4Life Clinic obesity program was designed to provide children with the medical care, as well as the behavior change guidance and support needed to reverse their obesity and/or minimize the related health risks. This low-intensity program is designed to provide approximately 6 hours of care over 12 months from a medical provider, psychologist, registered dietitian nutritionist, exercise physiologist, and nurse. Results: Between August 2011 and February 2014, the Strong4Life clinic served 781 high-risk (mean sex- and age-adjusted body mass index [BMI] percentile 98.8) and racially/ethnically diverse (45% non-Hispanic black and 24% Hispanic) patients. Of the 781 patients seen, 66% returned for at least 1 visit. Nearly all returning Strong4Life patients stabilized or improved their BMI (90% of those who participated 97th percentile, and many have additional comorbid conditions.
Patient-Centered, Action-Oriented Counseling A core principal of the H4L clinic is the communication style used by the providers. All team members were trained in patient-centered counseling and most in motivational interviewing. Motivational interviewing (MI) decreases the focus on telling the patients “what to do” and instead uses patientcentered counseling to elicit intrinsic motivation for changing behavior and encourages them to explore their ambivalence to making that change.13,14 The tone of patient-centered counseling is nonjudgmental, empathetic, and encouraging.14 However, these conversations can be somewhat lengthy, and eliciting
motivation did not seem sufficient for the H4L program. We combined MI with the principles of action-oriented counseling. Action-oriented counseling has been used in many fields— most notably for smoking cessation15,16 and for increasing physical activity.17 Also referred to as the “5 As,”18 the actionoriented counseling framework can vary, but our version includes 5 steps: ask, advise, agree, assist, and arrange. The first step is to ASK questions to assess current daily activities and motivation level. The provider also asks about barriers, readiness to change,19 and previous attempts at change. Understanding why these previous efforts failed will inform the new goals. The transtheoretical model of health behavior change describes a progress of 6 stages of change. Initially, we asked each family where they were in the stages of precontemplation, contemplation, preparation, action, maintenance, and termination. However, possibly because of the multiple steps that it takes a parent to get a child into the H4L program, we found that the vast majority of families were very motivated and already in the “action” stage by the time they reached us.19 ADVISE, the next step, involves providing pertinent information about BMI, long-term health concerns, and benefits of change to the family. AGREE is the third “A” and is a discussion to set a realistic physical activity and nutrition goal. Goal setting is the core of our action-oriented counseling, and it has been supported as a health behavior change strategy in adult obesity treatment.20 However, there is less information in the pediatric literature. We aim to have each patient leave with 2 concrete goals—one for a nutrition change and one for physical activity. There is not a prescribed set of behavior goals that each family must master; however, most of the goals selected by families are supported by the literature. The patients or parents select the goal, and the provider working with them explores if the goal is feasible and if it is something that will improve their health. ASSIST is a planning step to collaboratively consider strategies to overcome the potential barriers to achieving these goals. For example, sometimes a child who does not have a bike will select the goal to “ride a bike every day for 30 minutes.” The barrier is that he or she would first need to buy a bike and helmet, so this may not be a realistic goal. The final step is to ARRANGE follow-up of their success in achieving the behavioral goals and any unexpected barriers that arose. It is critical to keep the focus on the goals rather than short-term improvement of weight or BMI. Patients have control over their actions but less control over their weight.
Team Members and Typical Visits at Strong4Life At the first appointment for the Strongh4Life clinic, the patient and family meet with the entire team, which includes a medical provider, a psychologist, an RDN, an exercise physiologist, a nurse, and a clinic administrator. The first visit is often with a physician, and the subsequent visits may be with a physician’s assistant. The psychologist conducts a new patient
Downloaded from ncp.sagepub.com at BRANDEIS UNIV LIBRARY on November 24, 2014
782
Nutrition in Clinical Practice 29(6)
evaluation with each family using an interview format and validated pediatric assessment tools to screen for depression, eating disorders, problems at school (including bullying), level of coping skills, and other factors. The assessment is used to determine their need for outside counseling or if they need to continue to see him or her on subsequent visits. The RDN and exercise physiologist meet with the patients and families at each visit. If needed, a social worker is available for issues related to food insecurity, durable medical equipment, and Medicaid. We have also used the Children’s Healthcare of Atlanta’s Health Law Partnership program for families that required legal representation in schools or other areas. Typical visits are 2 hours for new appointments and 1 hour for follow-up visits. As the program progresses, the program is tailored to meet the family’s and patient’s needs. By definition, this is a low-intensity program because of the relatively few contact hours with the providers. In 2010, the U.S. Preventive Services Task Force recommended a comprehensive, moderate- to high-intensity treatment program for obese children, which it defined as including >25 hours of contact in 6 months.21 When designing our program, we anticipated that weekly visits for patients would be extremely difficult and more costly. On the basis of our previous experience with single-provider weight management clinics, we initially planned for a schedule of 5–6 visits in 1 year. The first follow-up visit was scheduled at 1 month and then visits at 2 months, 5 months, 8 months, and 1 year. Over time, this schedule has evolved to be more flexible, except for the first followup visit. For all new patients, we schedule their first follow-up visit at ~1 month because this is the highest risk period for failing to achieve their goals. By intervening quickly, we can redirect a family before they become discouraged. The average number of visits attended by our patients is shown in the quality benchmarks section below.
Nutrition Intervention Because the nutrition component is a key to patient success, this is described in more detail. The RDN works in conjunction with other members of the team for a collaborative approach to obesity treatment. The nutrition care process begins with a detailed assessment on the initial visit, including 24-hour recall and food frequency for vegetables, fruit, fried food, restaurant foods, water, milk, juice, sugary drinks, and family meals per day. Initial assessment includes review of previous weight loss attempts, methods tried, and results. Depending on the age of the child, the child may report intake himself or herself. This is a key opportunity to gather valuable information that the parent may not be aware of, particularly if the child spends a large part of the day out of the home at school, sports, daycare, or other activities. The first visit is essential to establish good rapport with the patient and family. Many patients have a long list of unsuccessful experiences with diets, so it is important to establish trust before doing any nutrition education.
A nutrition diagnosis is determined by the RDN based on the risk factors assessed. Common nutrition diagnoses related to excess weight and obesity are (1) sugary beverage consumption, (2) low intake of fruits and vegetables, (3) excessive intake of high calories, (4) high-fat and high-sugar foods related to fastfood intake, and (5) eating away from home. The nutrition intervention consists of targeted education on a mutually agreed-on area for improvement. The nutrition curriculum covers basic principles of healthy nutrition that benefit all members of the family. Key areas include sugary beverages, MyPlate, food groups, healthy snacks, structured meals, and family meals. The RDN has a kit of education tools in the examination room to use with patients, including sugar beverage demonstration materials, balanced plate information, fast-food nutrition facts, and more. The nutrition approach in the clinic visit is collaborative between the patient and the caregiver, and in many cases, both leave with a nutrition goal. Nutrition and feeding practices for pediatric patients are dependent on parental or home caregiver engagement and support because most pediatric patients are not grocery shopping, preparing food, or structuring daily mealtimes. It is the parent or caregiver’s job to create structure for their children and be a role model for the establishment of healthy eating habits. Some common recommendations supported by the literature22 include the following: •• Meals and snacks are eaten at a table or in a designated eating space. •• Avoid screens during mealtime (television, cellphone, iPad, video games, etc). •• Mealtime should be pleasant but not playtime (no toys at the table). •• Avoid using the “clean plate rule.” •• Eat meals as a family as much as possible. •• Keep fresh fruits and vegetables in plain sight. •• Use nonfood rewards. •• Provide choices of healthy items.
Behavioral Feeding The H4L nutrition philosophy is presented as a continuum rather than “good” food vs “bad” food. There are foods that are more nutritious such as vegetables, fruits, whole grains, lean proteins, and low-fat dairy. There are foods that are less nutritious, such as convenience foods, processed foods, and sweet treats, that consist of refined grains, added sugars, added fats, and added salts. Refined foods also consist of foods altered with artificial ingredients to be sugar free, “diet,” or low fat that do not contain quality nutrition. At H4L, specific calorie goals are not used. Rather, families are encouraged to increase their nutritious foods and decrease the less nutritious foods. Instead of attempting drastic changes, we encourage them to make the next better choice. For example, a child who drinks 3 sugary drinks a day may start by decreasing to 2 sugary drinks and adding 1 glass of water per day rather than trying to stop the sugary drinks all at once.
Downloaded from ncp.sagepub.com at BRANDEIS UNIV LIBRARY on November 24, 2014
Walsh et al
783
The team also teaches families that healthy food tastes great and can be fun to eat. Teaching children about the different tastes and textures of foods early in life is critically important to their acceptance of a variety of foods as they turn into adults. Often children need to experience new foods multiple times before accepting a new taste or texture. This is a normal part of a child’s growth and development. At H4L, children are not labeled as picky eaters because it is a learned behavior developed over time.
Challenges and Solutions Over the first several years of our program, we identified challenges and worked as a team to solve them. The following issues and solutions are presented so others can learn from our experience.
Efficiency One of the crucial pieces to making the clinic a pleasant experience is to decrease wait times between providers. When the patient has to see 4 different providers for visits, there is the potential for significant wait times. We initially had very long appointments that would sometimes last >3 hours. The improved scheduling of patients was a key change to keep the clinic flowing well. Our new patient appointments are 2 hours (30 minutes per provider), and our followup appointments are 1 hour (15 minutes per provider). We have used timers and reminder knocks on the door to keep the staff on the appropriate time frame. This took practice and training with the providers and objective documentation to keep the flow going smoothly. Staff turnover leads to increased wait times because the new team members have to adjust to the tight time requirements. We also used the hospital’s efficiency team, which provided us with invaluable information regarding the way we run clinic and methods to improve flow.
Remembering Goals During the appointment, the Strong4Life team uses patientcentered counseling to set goals for physical activity and nutrition. The team will usually make 1 goal with the family in each area. These goals are then written on a “goal sheet” and sent home with the family. Initially, each team member wrote the goal on the sheet. We found that patients and families were struggling to remember the goals and would return with feedback that they were unsure at discharge what specific goal they had set. Even though the team reviewed the goals, the families often had difficulty with the wording. Over the past year, we have had the patients write the goals on the sheet, which has improved retention of the goals set. Follow-up calls to remind them of their goal were not successful for our team because very few parents answered or returned the calls. We have found
emailing the older teen patients is a successful way to remind them of goals and to touch base between visits.
Failure to Follow Up Attrition rates in childhood obesity programs approach 33%. While this ties in with the no-show rate, this is an area in need of improvement in many programs. Unlike the family that initially does not show for their first appointment, at H4L, if the family has made it to a visit, they have a level of motivation that we feel we should be able to foster. One of the ways we reduce attrition is to discuss what to expect at the second appointment so that they will come back even if they fail to meet or even attempt their goals. Families have sometimes felt shamed by medical providers in the past, and so we find it important to emphasize that we want to see them back even if they fail so that we can help them problem solve. We also reduced attrition by having the second appointment close in time to the first appointment so that it is during the time when the family is still motivated. We also use a clinic-specific scheduler, provide reminder phone calls, and involve the entire family in the treatment program as previously recommended.23 Despite these methods, 33% of patients do not return for a second visit, and this is an ongoing area of quality improvement.
Failure to Graduate The Strong4Life program is a 12-month program with yearly follow-up thereafter. The patients who are truly invested in the program rarely want to “graduate.” There is concern for relapse and difficulty with motivation. Part of our program is to help families realize all that they have accomplished and support them to continue to change without regular visits. We have been able to help families with this by arranging for follow-up with their PCP in a few months and having their first “graduation” visit in 6 months instead of 1 year. Some families require extra visits to solve their issues in feeding and physical activity. These families are not quite ready to graduate at the 1-year mark, and we often extend their time with us.
Quality Benchmarks of the Strong4Life Program Children’s Healthcare of Atlanta Institutional Review Board approval was obtained for review of clinic outcome data. Between August 2011 and February 2014, we have seen 781 patients at the Strong4Life Program. A description of this cohort is shown in Table 1. Our no-show rate in 2013 hovered around 20%, which is lower than typical nationally reported rates.23,24 Of the patients seen for initial evaluation, 33% failed to return for a second visit. This dropout rate is on the lower end compared with reported rates ranging from 27%–73%.23 The changes in BMI z percentile and BMI z score for our patients are presented in Table 2. On average, most patients
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Table 1. Enrollment Characteristics of All Patients (N = 781) Who Participated in the Strong4Life Obesity Treatment Program Between August 2011 and February 2014. Characteristic
Value
Age, mean (SD), y Sex, female, No. (%) Race/ethnicity, No. (%) Non-Hispanic white Non-Hispanic black Hispanic Other Height, mean (SD), cm Weight, mean (SD), kg BMI z score, mean (SD) BMI percentile, mean (SD) [range]
12.0 (3.5) 474 (60.7) 223 (28.6) 354 (45.3) 190 (24.3) 42 (5.4) 151.6 (20.6) 86.1 (36.8) 2.5 (0.4) 98.8 (2.0) [88.4–99.9]
BMI, body mass index.
Table 2. Demographic Characteristics and Weight Trajectories of Overweight Children and Adolescents Who Attended at Least 2 Strong4Life (H4L) Obesity Treatment Program Appointments, Stratified by the Length of Time Enrolled Between August 2011 and February 2014.a Participation Time (Time From Baseline to Most Distal Follow-up Visit) Characteristic No. of H4L visits, mean (SD) [range] Age, mean (SD), y Baseline Follow-up Sex, female, No. (%) Race/ethnicity, No. (%) Non-Hispanic white Non-Hispanic black Hispanic Other Height, mean (SD), cm Baseline Follow-up Change (P value) Weight, mean (SD), kg Baseline Follow-up Change (P value) BMI percentile, mean (SD) Baseline Follow-up Change (P value) BMI z score, mean (SD) Baseline Follow-up Change (P value) BMI z score change, No. (%) Loss (>0.04) Stable (±
