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Service Delivery Innovation Profile

Multidisciplinary, Clinic-Based Teams Support Obese Children in Changing Behaviors, Leading to Increased Physical Activity, Improved Diet, and Weight Loss


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Snapshot

Summary

The Healthy Weight Initiative operates specialized clinics serving obese children at eight community health centers in Massachusetts. At each clinic, a multidisciplinary team consisting of a physician, nutritionist, and case manager works with the child and his/her family to develop a weight control self-management plan tailored to the child's needs. At subsequent visits, the child sees each team member, with a focus on monitoring and promoting progress in meeting the goals outlined in the plan. The program also supports weight loss and behavior change by providing free exercise apparel and equipment and, for families at selected sites, coupons to purchase fruits and vegetables at local farmer's markets. The overall program has helped children reduce or stabilize their body mass index, cut back on screen time and intake of sweetened beverages, and increase physical activity and consumption of fruits and vegetables. The farmer's market coupons have stimulated positive changes in diet.

Evidence Rating (What is this?)

Suggestive: The evidence consists of longitudinal, patient-specific clinical assessment and survey data on 485 patients who visited the clinic at least twice, and findings from surveys of 60 families who used program-provided coupons at one of three farmer's markets during a 4-month period in 2010.
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Developing Organizations

Boston Medical Center; Ceiling and Visibility Unlimited
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Date First Implemented

2006
The program was first implemented at a single site in 2006 and replicated at additional sites in 2007 and 2008.begin pp

Patient Population

Vulnerable Populations > Childrenend pp

Problem Addressed

Childhood obesity is a widespread, growing problem with severe health consequences. Traditional hospital- and primary care-based treatment approaches have several drawbacks that limit their effectiveness.
  • A growing epidemic: Overweight and obesity are rapidly becoming the most common chronic conditions of childhood, with roughly 30 percent of children age 2 to 19 being overweight or obese. African-American and Latino youth—along with children and adolescents from low-income families—face an even greater risk of weight problems.1
  • Severe health consequences: Roughly 60 percent of obese children age 5 to 10 have at least one risk factor for cardiovascular disease, such as elevated total cholesterol, triglycerides, insulin, or blood pressure, while 25 percent have two or more risk factors. Overweight and obesity put children at current and future risk of serious health problems, including cardiovascular disease, type 2 diabetes, and mental health problems such as anxiety and depression.2
  • Drawbacks of hospital-based treatment: Many obese children receive referrals to hospital-based specialists for treatment. Drawbacks of this approach include inadequate supply of subspecialists, long waiting times for an initial consultation, high treatment costs, and more fragmented care when treatment moves outside the patient's medical home and community.3
  • Limitations of primary-care based treatment: Primary care clinics face significant challenges in managing pediatric obesity, as outlined below:
    • Inadequate time and knowledge: Effectively managing overweight and obesity requires substantial time, making it challenging to address these issues during a typical primary care appointment.4 In addition, most primary care providers lack training in obesity management and health behavior change, making treatment less effective.5
    • Lack of access to support staff: Dietitians and other ancillary providers often are not available during visits to provide counseling about obesity and health behavior change. Patients and families often find it difficult to meet separately with these providers each month.5

What They Did

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Description of the Innovative Activity

The Healthy Weight Initiative operates specialized clinics serving obese children at eight community health centers in Massachusetts. At each clinic, a multidisciplinary team consisting of a physician, nutritionist, and case manager works with the child and his/her family to develop a weight control self-management plan tailored to the child's needs. At subsequent visits, the child sees each team member, with a focus on monitoring and promoting progress in meeting the goals outlined in the plan. The program also supports weight loss and behavior change by providing free exercise apparel and equipment and, for families at selected sites, coupons to purchase fruits and vegetables at local farmer's markets. A detailed description of the program follows:
  • Program enrollment: Primary care physicians at the 8 community health centers refer children age 3 to 21 to their center's childhood obesity clinic based on body mass index (BMI) at or above the 85th percentile according to Centers for Disease Control and Prevention (CDC) curves. Most of the referred children are between the ages of 8 and 13. Referrals generally come from providers within the clinic, but some of the sites also accept outside referrals. After the referral, the child's parent or guardian schedules an appointment for the first clinic visit, which typically takes place within a few weeks.
  • Initial team-based assessment: During the initial visit, a team consisting of a primary care clinician with an interest in obesity, a dietitian, and a case manager conducts an initial assessment of the child. During this session (which typically lasts 1 hour), each team member meets with the child separately, with roles divided as follows:
    • Physician: As team leader, the physician assesses the severity of the child's obesity, takes a family history, monitors laboratory results, and screens for related health conditions such as sleep apnea, depression, high cholesterol, and diabetes. Children with such conditions may be referred to a specialist for concurrent treatment.
    • Dietitian: The dietitian assesses the child's 24-hour food recall, including fruit and vegetable consumption and sweetened beverage intake.
    • Case manager: The case manager assesses levels of physical and sedentary activity, including the amount of time spent watching television, playing video games, and engaging in physical activity.
  • Development of self-management plan: At the initial meeting, the team begins working with each family to develop a culturally appropriate, achievable self-management plan based on the child's unique circumstances, including the resources available in the family's community. In collaboration with the child and his or her family, the team sets behavior modification goals, which may include targets for losing weight, reducing or increasing consumption of specific foods and beverages, increasing levels of physical activity, and reducing screen time (e.g., television and video games).
  • Monthly visits to support adherence to self-management plan: For the next 6 months, the child comes in for monthly visits with the same team, with each visit typically lasting 40 to 45 minutes. These sessions focus on making any necessary adjustments to the self-management plan, supporting adherence to it, and assessing progress toward these goals with the child and parent. (The team encourages parents to sit in if the child is amenable). The program also offers additional support to low-income families, as outlined below:
    • Free or low-cost sports equipment, gym memberships: To encourage increased physical activity, children may receive sports apparel and equipment, such as sneakers, sweatpants, sports bras, medicine balls, and jump ropes at no cost. Staff may also help them obtain free or discounted gym memberships.
    • Farmers market coupons: In collaboration with an outside organization, the "prescription produce" program provides some families with coupons for fruits and vegetables at several local farmers markets. To be eligible, the family must have at least one child with a BMI above the 85th percentile. The coupons can be used to buy $1 worth of produce per day for each family member. For example, a family of 4 receives coupons worth $28 per week.
  • Graduation and followup: After six visits, children graduate from the program and continue to see their primary care physician at the center. Children with ongoing weight-management problems can reenroll in the program, and hence continue to receive team-based services and support.
  • Ongoing provider support: Periodic cross-clinic meetings and various information technology (IT) resources and tools support the teams in providing high-quality services, as outlined below:
    • Regular cross-clinic meetings to share lessons, best practices: The teams hold monthly teleconferences and two face-to-face meetings a year to share best practices and solve common problems. The monthly teleconferences typically include expert lectures, review of performance data (see last bullet below), and presentations by clinics about unique aspects of obesity management at their sites. Face-to-face meetings, which typically last 8 hours, include training in effective strategies for promoting behavior change, a review of best practices by experts in obesity management, team presentations about progress and challenges at their sites, and collaborative data review aimed at improving the overall initiative.
    • Structured data collection and display: A data collection form, called the Pediatric Obesity Assessment Tool, provides a structured mechanism for collecting data on lifestyle factors (diet, levels of physical activity, screen time, family history), physical parameters (weight, BMI, blood pressure, physical examination), laboratory results (cholesterol, diabetes screening), and goals outlined in the self-management plan (including progress toward meeting them). Electronic and paper-based versions of the form allow for standardized data collection at the point of care at all sites. The electronic form displays previous weight, BMI, and other prior entries, allowing for comparison with current data and assessment of progress during the visits.
    • Web-based performance reporting: The Web-based data collection and quality monitoring system provides reports on key process and outcome measures, including BMI, diet, and physical activity. Quality reports track performance over time, such as the percentage of patients that have reduced BMI. The teams compare their own performance to that of other teams, thus supporting continuous quality improvement at each site.

Context of the Innovation

The Whittier Street Health Center provides medical and dental care to poor and underinsured adults and children in Boston's Roxbury neighborhood. Dr. Shikha G. Anand, the center's pediatric director, noticed that between one-third and one-half of the center's pediatric patients were obese, yet center-based providers did not have adequate time to provide comprehensive obesity treatment during standard 15-minute visits. To promote behavior change, the center would set up separate appointments with other health professionals, including dietitians and case managers. However, the children often missed these followup appointments. As a result, Dr. Anand began looking for ways to provide more effective care to obese children during primary care visits.

Did It Work?

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Results

The overall program has helped children reduce or stabilize their BMI, cut back on screen time and intake of sweetened beverages, and increase physical activity and consumption of fruits and vegetables. The farmer's market coupons have stimulated positive changes in diet.
  • Lower or stable BMI, driven by positive behavior changes: Longitudinal, patient-specific data show that among 485 patients who visited a clinic more than once, 46 percent had lower or stabilized BMI (as measured from the first to most recent visit). More than half (52 percent) reported engaging in less screen time, while a sizable minority reported other improvements in health-related behaviors, including less consumption of sweetened beverages (44 percent), greater intake of fruits and vegetables (31 percent), and more physical activity (27 percent).
  • Dietary improvements stimulated by coupons: A survey of 60 families using farmer's market coupons in three communities suggest that the coupons have led to positive dietary changes, as outlined below:
    • Greater awareness: Among surveyed families, 86 percent reported increased awareness of the importance of eating fruits and vegetables.
    • Indications of dietary improvements: The vast majority of the families (93 percent) reported using all coupons provided. In addition, 92 percent reported that the coupons led them to make significant changes in their diet. Finally, the vast majority indicated an intention to continue buying fruits and vegetables at the farmer's market during the next season, with all participants planning to do so if coupons are available and 93 percent planning to do so even if they are not.

Evidence Rating (What is this?)

Suggestive: The evidence consists of longitudinal, patient-specific clinical assessment and survey data on 485 patients who visited the clinic at least twice, and findings from surveys of 60 families who used program-provided coupons at one of three farmer's markets during a 4-month period in 2010.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Opening initial clinic: Following meetings with administrators and staff at the Whittier Street Health Center, Dr. Anand developed the team treatment model. In 2006, she opened the first Healthy Weight Clinic as part of the center.
  • Partnering with nonprofit agency: Based on promising initial results at Whittier, Dr. Anand began looking for ways to expand the program to additional health centers. In 2007, she partnered with Ceiling and Visibility Unlimited, a not-for-profit foundation that supports innovative community programs and services that support better health care for underserved children. Dr. Anand met regularly with leaders of this organization to discuss how to replicate the program at other centers.
  • Expanding to additional sites: In 2007, the program, renamed the Healthy Weight Initiative, started accepting applications from other health centers. When selecting sites, program leaders looked for centers with organizational commitment to the concept, a track record of addressing obesity, a substantial patient need for services, and strong clinical leadership, including a clinician with pediatric and family medicine training willing to serve as the clinic champion. In 2007 and 2008, 7 additional Healthy Weight Clinics opened in Boston (Bowdoin Street Health Center and Codman Square Health Center), Cape Cod (Community Health Center of Cape Cod), Holyoke (Holyoke Health Center), Lawrence (Greater Lawrence Family Health Center), Lowell (Lowell Community Health Center), and New Bedford (Greater New Bedford Community Health Center). The program will add more sites in 2011. Before each clinic's opening, Dr. Anand and staff from Ceiling and Visibility Unlimited spent several days training physicians, dietitians, case managers, and other staff on efficient operation of the clinic.
  • Obtaining sports equipment and apparel: In late 2008, the Healthy Weight Initiative and Ceiling and Visibility Unlimited partnered with Good Sports, a Boston-based, not-for-profit group that aims to increase youth participation in sports, fitness, and recreational programs. Good Sports agreed to donate exercise equipment and apparel to help patients reach fitness goals that previously may have been inaccessible due to cost considerations.
  • Adding prescription produce program: In 2010, the Healthy Weight Initiative partnered with Wholesome Wave Charitable Ventures, a not-for-profit group dedicated to improving access to fresh fruits and vegetables for underserved families. Together, the organizations developed and implemented the prescription produce program on a pilot basis at three sites: Dorchester, Holyoke, and Lawrence. The program will be expanded to four more sites in 2011.

Resources Used and Skills Needed

  • Staffing: At each clinic, the clinical champion, dietitian, and case manager play major roles in the program, with other physicians, nurses, and administrative staff also making important contributions.
  • Costs: The annual cost of operating the 8 Healthy Weight Clinics totals roughly $300,000. The prescription produce pilot program cost $20,000 to operate for one season at three farmer's market sites.
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Funding Sources

Ceiling and Visibility Unlimited; Paul and Phyllis Fireman Foundation; Wholesome Wave; Massachusetts Department of Agriculture
Third-party payers generally cover clinical care provided through the program by physicians and dietitians; most payers will not cover case management services.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Assess need for service: The program needs a critical mass of obese patients to make it operationally feasible.
  • Identify clinical champion: The program will not get off the ground without strong clinical leadership, including a champion who believes in the approach and will promote it with peers.
  • Create team approach: Childhood obesity is best addressed through a multidisciplinary team, which allows providers to spend more overall time on weight management and makes children less likely to discount messages coming from a single authority figure.

Sustaining This Innovation

  • Tailor message to individual: By getting to know the child and family, providers can give information specific to the child's diet, family, culture, and environment. Team members should not assume that all families with a particular ethnic background share the same cultural attitudes. For example, immigrants from separate regions of a country may have different dietary habits.
  • Set short-term, attainable goals with patients: The program will be most effective if teams work with patients to set attainable short-term goals, and then build on those goals over time. For example, instead of instructing a child to exercise every day for 30 minutes and lose 20 pounds, set a goal to exercise 3 times a week for at least 20 minutes, and to lose 5 pounds during the next month.
  • Address mental health issues: Many obese children get caught in a cycle where depression causes them to overeat, and then subsequent weight gain perpetuates their depression. To assist these patients, make sure that staff receive training on how to recognize this cycle, and that social workers or psychologists can be made available for patients who need a referral for mental health services.

More Information

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Contact the Innovator

Shikha Anand, MD, MPH
Director of Strategic Alliances and Initiatives, Obesity Program Director
National Initiative for Children's Healthcare Quality
Assistant Professor of Pediatrics
Boston University School of Medicine
31 Winter Street, 6th Floor
Boston, MA 02108
(617) 515-2523
E-mail: shikha.anand@gmail.com

Innovator Disclosures

Dr. Anand has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Anand SG, Adams WG, Zuckerman BS. Specialized care of overweight children in community health centers. Health Aff (Millwood). 2010;29(4):712-7. [PubMed]

Weintraub K. How one program changes the way kids drop pounds and gain self-esteem. Boston Globe. April 5, 2010. Available at: http://www.boston.com/news/health/articles/2010/04/05/a_weight_loss_win/

Singer N. Eat an apple (doctor's orders). New York Times. August 12, 2010. Available at: http://www.nytimes.com/2010/08/13/business/13veggies.html

Footnotes

1 Ogden CL, Carroll MD, Flegal KM. High body mass index for age among U.S. children and adolescents, 2003-2006. JAMA. 2008;299:2401-5. [PubMed]
2 U.S. Centers for Disease Control and Prevention. Overweight and obesity: NHANES Surveys (1976-1980 and 2003-2006). July 24, 2009. Available at: http://www.cdc.gov/obesity/childhood/prevalence.html
3 Anand SG, Adams WG, Zuckerman BS. Specialized care of overweight children in community health centers. Health Aff (Millwood). 2010;29(4):712-7. [PubMed]
4 O'Brien SH, Holubkov R, Reis EC. Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics. 2004;114:e154-9. [PubMed]
5 Story MT, Neumark-Stzainer DR, Sherwood NE, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110:210-4. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 25, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 27, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.