Approaches to Obesity
Prevention and Treatment at
School-Based Health Centers
Matt Haemer MD
Assistant Professor in Pediatrics
Section of Nutrition
CU School of Medicine
Medical Director
LIFEStyle Medicine Weight Management
Children’s Hospital Colorado
[email protected]
Faculty Disclosure
• Dr Haemer has no relevant financial or
other conflicts to disclose.
1. to describe effective strategies to
discuss weight status
2. to understand tools to support
lifestyle screening and counseling
and the potential benefit
3. to describe effective strategies to
deliver clinical obesity prevention and
treatment services through SBHCs
Audience Survey:
Please Raise Your Hands if you:
1. Think changing a family’s behavior for a
child’s weight can be hard?
Discuss Body Mass Index at every
checkup >2yrs?
Get a BMI (Ht/Wt) at sick visits?
Had difficulty describing weight status
with a patient’s family?
Have a referral resource to send obese
children for treatment?
#1. Range of Visit Goals
1. Raising Awareness of a weight issue
2. Enhancing Motivation to change
3. Changing or Maintaining Healthy
Behaviors with Specific Goals
Objective 1: Strategies to
Discuss Weight Status
A. A range of goals for the visit
B. Definitions of weight status
C. Awareness of weight status
D. Ideal language: motivating and nonstigmatizing
BMI / Weight Status>2y
Percentile Ranges:
 <5th underweight
 5-85th healthy
 85-95th overweight*
 >95th obese
• excess adiposity
 >99th severe
• Comorbidities
• ~4% population
*<2yrs wt/length >95% is ‘overweight’
3yo Girl: BMI 90th% = Overweight
Which Plot is Concerning?
Awareness: BMI vs. Visual
4 yo
85-95th %
95th %
> 99th %
It is OK to devote a visit to
raising awareness without
setting specific goals.
 The first step is Awareness of :
-BMI status
-healthy behaviors
 Raising awareness tactfully may be all
you can accomplish in a visit.
 Resistant patients may be more willing to
talk about making changes…at next
Awareness – Language
• Communicating with children and families
 Use ‘obesity’ for documentation
 English: ‘overweight’ or ‘unhealthy weight’
are more acceptable (Puhl PEDIATRICS 9.26.11)
 Spanish: ‘demasiado peso por su salud’ is
most motivating and nonstigmatizing
(Knierim PAS 2014)
• Focus groups followed by survey of 525 parents
in Denver Health
Seidell JC Arch Int Med 1996
Cameron AJ Med J Aust 2009
Language - English
Unlikely to make their child feel bad
Motivating to parents to help their child
Desirable for doctors' use
High BMI
Too much weight for his/her health
Unhealthy weight
Language - Spanish
Unlikely to make their child feel bad
Motivating to parents to help their
Desirable for doctors' use
Gordo (fat)
Indice de masa corporal alta (high body mass index)
Sobrepeso (overweight)
Peso (weight)
Demasiado peso para su edad (too much weight for his/her age)
Demasiado peso para su salud (too much weight for his/her health)
Awareness – Language
• Ask if families are aware?
 Motivators for Children
 Peer acceptance, confidence, athletic performance,
feeling comfortable in clothes
 Motivators for Parents: consequences of
Obesity in adulthood – FamHx
 DM, CVD, Cancer, Arthritis, Liver Disease
 Avoidance of Health Risk may not be a
sufficient motivator
Seidell JC Arch Int Med 1996
Cameron AJ Med J Aust 2009
Questions on Raising
Objective 2:
Screening and Counseling
for Healthy Lifestyles
A. Tools for Lifestyle Screening
B. Skills for effective counseling
C. Results – universal screening and MI
counseling in SBHCs and community
health centers
• HEDIS measures: document weight
status with BMI, discuss nutr/phys activity
Generic Lifestyle Advice (5210)
<1 minute
Health Team Works
Example Screening form
1. Do you eat 5 or more fruits and vegetables per day? YES  NO 
2. Do you eat breakfast everyday? YES  NO 
3. Do you watch TV, videos or play computer games for no more than 2
hours per day? YES  NO 
4. Do you take gym class or participate in sports or dance in or outside of
school 5 or more times per week? YES  NO 
5. Do you have a favorite sport or physical activity that you love to do?
6. Do you eat dinner at the table with your family at least once a week?
7. Do you have a TV in your bedroom? YES  NO 
8. Do you eat in front of the TV? YES  NO 
9. Do you drink soda, juice, or other sugar sweetened drinks one or more
times a day? YES  NO 
10. Would you like to talk to your doctor about making changes to
improve your health? YES  NO 
(if yes, continue to page 2)
(Page 2)
“Menu for Action”
Counseling Tool
Adapted from the Jump Up &
Physical Activity and Nutrition Survey and the
Maine Center for
Public Health
Keep Me Healthy
Goal Setting Worksheet
Where to find tools?
1. AAP “Let’s Go” Initiative
2. NICHQ – COAN Childhood Obesity Action
3. Health Team Works – Colorado Toolkit
Counseling – General Styles
Collaborative Goal Setting
1. Generic Lifestyle Advice (5210) <1min
• Suggested minimum for every visit
2. Brief Focused Advice <3 minutes
• Engage-Advise-Elicit-Assist
• Collaborative Goal Setting
3. Brief Negotiation 5 minutes
• Motivation Interviewing for a short clinic
Uncover the family’s motivation
Elicit Change Talk
Collaborative Goal Setting
Set Specific Goals to Monitor if possilble
Why do providers worry their
counseling is not effective?
Acute Care Counseling Model:
I tell patient what to do and why
 then they do it
• What if someone “knows” about the
health risks of obesity, but doesn’t
• Perhaps “Health” is not is their top priority
• People act in ways they see as
consistent with Core Values
Values and Behavior Change
- How Many Providers Think
Health Behavior
Core Value: Maintaining Good Health
Dan Bessesen MD
Endocrinology UC Denver Health
Core values for most men
Resnikow Quantum Change Study
1. Wealth
2. Adventure
3. Achievement
4. Pleasure
5. Be respected
6. Family
7. Fun
8. Self Esteem
9. Freedom
10. Attractiveness
11. Popularity
Health didn’t make the top 11 !!!
Resnikow K, International Journal of Behavioral Nutrition and Physical Activity; 2006; 3: 25
Core values for women
Resnikow Quantum Change Study
2. Independence
3. Career
4. Fitting in
5. Attractiveness
6. Knowledge
7. Self control
8. Be loved
9. Happiness
10. Wealth
11. Faithfulness
Health didn’t make the top 11 !!!
Core values for Teens and
1. Peer Acceptance
2. Acceptance
3. Acceptance
4. Attractiveness
5. Being cool
6. Sports performance
7. ?Safety
8. ?Academics
9. ?Environmental health
10.? Family
Long term health #999 or higher for some?
Values and Behavior Change
What Core Values do Mom, Dad,
Child, Grandparents follow:
Family? Being a success? Fun?
Respect? Feeling accepted?
Wearing ‘cute’ clothes? Health? Health Behavior
How do we align healthy diet and activity with
the family/ child’s core values?
•Understand we can’t “make” them
•Figure out what is important to them
•Help them see how healthy behavior fits in
•Changing behaviors may be easier than
changing someone else’s values
•Self preservation technique for providers
Treatment – Counseling
• Motivational Interviewing (MI) or
• “Brief Negotiation” in 5 minutes
 Critical for ambivalent patients:
• Motivation to change comes from within
• Not from Provider
• Allows the person to see Healthy Change
as consistent with values
• We are more likely to do things that we say we
will do
= “I could…” “I can…” “I will…” “because…”
Motivational Interviewing for
Childhood Obesity
 Open-ended questions
 “tell me about what makes eating healthier
hard for you…”
 Affirmations
 “you feel like being more athletic is
 Reflections: make them think again
 “so… you eat less healthy snacks because
the vending machine and the corner store are
“you aren’t
concerned about your weight right now…”
Motivational Interviewing for
Childhood Obesity
 Roll with Resistance –
 Resist the urge to tell them what to do
 Reframing
 Instead of patient: “I do nothing 5 days a week”
 “You are able to exercise 2 days a week, what
allows you to succeed in that?”
 Summaries
 “So, being athletic is important to you, so you plan
to start packing a healthy snack for after school
instead of buying from the vending machine, and
you are willing to keep track of what you eat daily.
We’ll talk again in 2 months.”
Treatment – Counseling
• Motivational Interviewing (MI) or “Brief
Negotiation” 5 minutes
 Visit Outline
1. Negotiate Agenda
2. Assess Readiness
3. Explore Ambivalence
4. Tailor Goals to Readiness
5. Collaborative Goal setting
6. Summarize the Visit, Goals, and Follow-up
Read this book to learn and practice:
Motivational Interviewing in Health Care: Helping Patients
Interactive Online Training
1. Kaiser Permanente’s MI for Pediatric
Weight Management Online Tutorial
2. “Change Talk”
interactive training simulation
Internet or Mobile App:
Collaborative Goal Setting
Use a menu of changes
Choose targets together
Use a nonjudgmental style
Elicit Confidence in the Change
 Uncover barriers and
 Make the change realistic
• Environment
• Social Support
When a general goal is chosen,
make it Specific…
• Cognitive Behavioral techniques
 For motivated child / family
 Self Monitoring  successful change
• Specific
• Measurable – daily weekly, learn cues
• Accountability – parent, other support
• Reward – for new healthy routine
• Time limited – report back, troubleshoot
Goal Setting Form - Example
My Health GOALS
I want do this:_____________________________________
It is important to me because:__________________________________
My Specific goal is to:_____________this much:________ each: day – or - week
Someone to help me:________________________
My reward for good work:_____________________
Make a mark each day when you do it. You can write how many times you did
your goal each day and each week.
Thurs Fri
Buddy/Parent sign here at end of week:___________________ Reward: Yes /No
Results –
• What BMI outcomes are possible
 universal screening
 MI counseling in SBHCs and
community health centers
 Connections to community resources
The S.T.O.P – I.T. Trial
School&community-health centers Prevent &
Treat Childhood
Obesity through Community
Partnership and
Grant #3109: “A University-Clinic-Community
Collaborative to Prevent and Treat Childhood
Obesity in Commerce City, CO”
The Colorado Health Foundation
STOP-IT Overview of Strategy
Goal: to test Feasibility and Effectiveness
A. Enhanced Primary Care for Obesity
1. Training in clinical obesity care (comorbidities)
2. Training in counseling – MI
3. Technology-support for screening, counseling,
and community resource referral
B. Community-Based Treatment
1. Multidisciplinary
2. Delivered by trained local staff
3. At a School or Recreation Center
Intervention Overview
1. Clinical information system
HeartSmart screening/counseling system
2. Decision support
Training: Comorbidity Management and Referral
laboratory protocols, counseling prompts
3. Redesigned Delivery System
New local community-based treatment
4. Patient Self-Management Support
Trained for MI counseling, collaborative goal setting
5. Community resources supporting health
Advertised during well-child visits using HeartSmart
Setting - Population
4 SBHC’s and 2 community clinics
82% Medicaid
79% Hispanic, 20% non-Hispanic white
Children 2-18yrs
Weight Status
BMI 85-99th Percentile at baseline
BMI >99th Percentile
-or- Attended Treatment Program
Training: Motivational Interviewing
Weight Management Specialists:
PI - pediatrician, psychologist, and study coordinator
10 Nurse Practitioners and 1 MD trained
5 min interaction
Follow-up visits every 3 months
Techniques: Modeling, role-play, audit and feedback
Four 90 min sessions
Every 2 weeks, Booster at 4 months
Electronic screening/counseling system
Prompts for MI counseling
Intervention: Electronic Support
Parent or Teen enters: Medical Assistant enters:
•Family History
•12 Lifestyle factors
•Readiness Assessment
Waiting area
Kiosk or Tablet
•Blood Pressure
Items Surveyed
Fruits and Vegetables/ day
*Hours Sedentary / day
*Hours Active / day
Sugar Sweetened Drinks / day
*Breakfast /wk
*Sleep Duration
*Family Meals /wk
Eating with TV /wk
High Fat-Sugar snack-dessert / day
Restaurant Meals /wk
Milk Fat %
Readiness to Change: Importance of Discussing Healthy Habits
* associated with baseline weight status – Haemer PAS 2012
Results: Feasibility
• Completed Screenings 12 month study:
 768 of 776 total = 98.9% of well-child exams
• Time to Complete – electronic time stamp
 Mean 3.5 minutes
• 12 Lifestyle ?’s, family history, readiness to change
• While waiting or being checked into clinic
Results: Population
 Number of Overweight or Obese Children:
• 182 Intervention
• 66 controls
 Follow-up Duration: Mean 13.5, median 12 months
 Weight Status: 41% Overweight or Obese
 Age:
• 31% Preschool 2-5 years
• 43% Elementary School 6-11 years
• 29% Adolescents 12-18 years
Number of Follow-Up Visits:
Mean Change (CI): -0.10 (-0.17, -0.03) -0.003 (-0.11, 0.10)
Difference in Mean Changes:
p= 0.158
Trajectory Change 12 mo Pre-Post
Mean Difference, Pre to Baseline
Mean Difference, Baseline to Post
Difference in Slopes,
Before and After
BMI Z-score
p value
Objective 3
• Clinical prevention and treatment
approaches through SBHCs:
1. Tailor referral resources based on
readiness to change
2. Promote healthy lifestyle resources in the
3. Weight management in the community
setting - partnerships between SBHC and
community organizations
Treatment Program
“The Healthy Living Program” (HeLP)
“La Vida Saludable”
24 total contact hours
Designed to meet USPSTF recommendations
@School or community recreation center
Families with kids 2-18 years
At least one child BMI >85th, most >95th
Care Coordinator Role
Recruitment into community-based
• Project Coordinator develops and maintains
list of referred patients
• Project Coordinator contacts families and
describes the resource available to them
• How many people to invite to participate?
 3-4 times the number of people desired for
participation in the class
Care Coordinator Role
Beginning the Program
• Makes reminder calls
During and after the Program
• Communicates participation, outcomes,
successes back to the referring provider
• Reminds families to visit their primary care
provider for follow up after the program
Healthy Living Program
• 2/wk x 6 or 12 weekly sessions
• Every other session format
1. 6 sessions Multidisciplinary
(2 hrs)
• Fitness Class (90 min) child 6-16
• Parenting Skills (75 min)
• Parent/teen nutrition
discussion (45min)
• 2-5 yrs preschool curriculum –
 Healthy food exposure
• Meal
Healthy Living Program
2. Six sessions – Cooking Matters Classes
• family nutrition class, shopping/meal planning skills
• Meal preparation
• Recipes and groceries for home
Healthy Living Program
Community-Based Staff
during study:
1. Care Coordinator
2. Health Educator
3. Personal Trainers
4. Undergrad Student Intern
- Or - Potentially
1. School Nurse/Clinic staff
2. Health Educator
3. PE teacher
4. Other school staff
Healthy Living – Outcomes
Enrollment Since 2011-2012
• 2288 screened  892 eligible 80 Families with 163
children attended
• Mean attendance 8 of 12 classes
• 67% of families attend 6 or more classes
• Mean child age 8 years
• 25% preschoolers
• 89% Hispanic/Latino
• 37% Maternal Education < High School
• 97% Income < 185% Federal Poverty Level; 57% < FPL
• 71% Report Food Insecurity
Healthy Living
Pre-Post Outcomes 2 months n = 87
 BMI: mean change -0.3 kg/m^2 (p<0.05)
 Fitness: 96% improve on at least one measure
• Mean improvement on Pacer running test (+3), situps
(+13), and pushups (+4) P<0.05
 Dietary Improvements Reported by >80% (mean
Fruit and vegetable intake
Water intake
Whole Grains
Home cooked meals and cooking skills
 Quality of Life: score 8083/100 (p <0.05)
12 Month BMI data collection complete May 2014
STOP-IT Take Home Points
Community Partnerships to locate resources
Dedicated and flexible providers
Technology enabled efficiency
Screening enhanced patient ownership
Care coordinator was important to success
Summary of Objectives:
1. Use motivating and non-stigmatizing
language to discuss weight status
2. Use tools for universal lifestyle
screening and try motivational
interviewing techniques for counseling
3. Providers at SBHCs and community
clinics can make a difference with
screening, counseling, and referral to
obesity treatment delivered in the
Questions or Comments?
Thank you for your time!
Matt Haemer MD MPH
[email protected]
Treatment –Primary Care vs Specialty
Match to Severity and Readiness
Prevention for all patients (5-2-1-0) Healthy Lifestyle Messages
Stage 1: Prevention Plus for overweight and ‘less ready’ obese.
• Ideal: q1-3 month FU
REFERRALS vs. Clinic Programming:
Stage 2 Structured Weight Management prevention plus not effective
and BMI 95th - 98th percentiles. Local RD vs. Children’s*
More frequent visits, written diet and exercise plans; RD +/- psychol
Stage 3 Comprehensive Multidisciplinary Intervention if 3 - 6 months of
structured weight management has failed to achieve targets. Children’s*
Multidisciplinary obesity care team (dietitian, behavior, fitness)
Stage 4 Tertiary Care Intervention BMI 99th percentile+ and
comorbidities or for if Stage 2 and 3 were ineffective. Children’s*
Diet and activity counseling, +/- meal replacement, Very Low Cal
Diets, medication and surgery
 Referral Resource: MEND Program Stage 2~3, community-based
“Mind Exercise Nutrition Do-It” Program - YMCAs
*Children’s Hospital Referral Questions: Renee Porter PNP 720-777-3352
Referring to Children’s
Lifestyle Medicine Program
• Stage 2: RD visits
• Stage 3-4:Multidisciplinary Treatment
 MD (weight and comorbidity specialists)
• Nutr, GI, Cards, Endo, Pulm/Sleep
 RD
 PhD Psych
 Exercise Physiologist and Fitness Center

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