|By Charles Homer, MD, MPH, President and Chief Executive Officer, National Initiative for Children’s Healthcare Quality|
The obesity epidemic is now receiving the attention it deserves, yet some people doubt our nation’s ability to address a public health problem that has emerged so rapidly, is of such magnitude, and has so many causes. Others are reluctant to take bold action in the absence of unequivocal data about what works. I don’t share in either the pessimism about our capacity to reverse the epidemic, nor the reluctance to act in the presence of uncertainty. It is clear to me that the risks of inaction for our nation and its citizens are greater than the risks of judicious but vigorous action informed by the best available evidence. Based on my experience in health care quality improvement, I’m optimistic that we can move forward based on the best available evidence, making changes while we gain new knowledge both through monitoring the response to those changes and concurrent traditional research.
Although society faces a long and difficult campaign against obesity, we will ultimately succeed if community stakeholders join forces and move forward. My colleagues in the health care sector have a critical role to play, in part in our traditional capacity as clinicians who monitor health, provide care, maintain relationships with patients and their families, and communicate effectively about health behaviors. Health care professionals need to refine and advance their skills, particularly in providing counseling about health behaviors and in managing patient populations. Looking beyond clinical care, health care providers can be effective as participants in community change by advocating for change in policy and the environment related to better nutrition and increased physical activity, and in joining forces with individuals in other sectors of the community to create healthier environments and promote behavior change.
At the National Initiative for Children’s Healthcare Quality (NICHQ), we are working together with the Health Resources and Services Administration (HRSA) on a major new effort, Collaborate for Healthy Weight, which is focused on the prevention and treatment of childhood and adult obesity. The major component of this effort (http://www.collaborateforhealthyweight.org) is the Healthy Weight Collaborative, a two-phase nationwide quality improvement initiative. Our goal is to foster clinical practice improvements and community mobilization targeting obesity across the lifespan. We will do this by bringing together community-level health care, public health organizations, and leaders from other sectors that are actively engaged in addressing obesity as a multifaceted problem. By fostering innovation and developing partnerships, we intend to help these communities apply creative solutions that can be widely replicated to promote healthy weight and advance health equity in communities throughout the United States.
NICHQ has been working on the challenge of childhood obesity for more than a decade. Our first step was to determine whether there was sufficient evidence to guide practitioners. After reviewing the literature and interviewing experts in the field, we concluded that although there was no definitive evidence linking clinical practice changes to population outcomes related to obesity, we could identify the kinds of interventions that would likely be effective. Extrapolating from efforts to prevent tobacco use, we defined target behaviors based on emerging evidence about the role of television viewing and sugar-sweetened beverages, and applied the chronic care model for clinical office practice. This approach was fully consistent with the subsequent recommendations of the “Expert Panel on Prevention and Treatment of Childhood Obesity,” convened by HRSA, the Centers for Disease Control and Prevention, and the American Medical Association. Indeed, they were so closely aligned that we developed an implementation guide that summarizes expert recommendations for the prevention and treatment of childhood obesity and has been widely used by practices serving children across the nation.
After NICHQ had launched programs to address childhood obesity within the health care system, we recognized the importance of the closing the gap between clinical office practice and the wider community. Health care professionals need to provide comprehensive services for people who are already overweight or obese. Programs that offer physical activity or nutritional guidance are often outside the walls of the clinic, so we incorporated into our programming a strong emphasis on developing mechanisms to connect clinicians to community resources. From a prevention standpoint, it became clear that most U.S. communities do not make it easy for people to make healthy choices about diet and exercise. So for clinicians to be effective in preventing obesity, they need to work with the broader community to create a healthier environment. With funding from the Robert Wood Johnson Foundation, NICHQ’s “Be Our Voice” campaign has trained more than 300 health care professionals to be effective advocates for positive change in their communities, created an advocacy learning guide, and more recently an online advocacy training module (http://www.nichq.org/advocacy).
The Healthy Weight Collaborative, NICHQ’s largest-ever program, is allowing us to extend our obesity work and develop new partnerships with a wide variety of organizations. During phase one of the collaborative, we are working closely with a group of 10 experienced, multisector community teams representing health care, public health, and community-based programs. Each team will draw on its own experience in primary care, public health, and at least one other community sector (such as schools or workplaces). For 1 year, the teams will use the “Breakthrough Series Collaborative™” approach, developed by the Institute for Healthcare Improvement, to test and refine a broad set of expert recommendations. Teams will focus their interventions in three main areas: building stronger coalitions across multiple community sectors, providing effective care (including tracking weight status), and creating a healthier community through policy and environmental changes. Because the range of potential interventions is so large, we created the more tightly focused set of recommendations that provide our best assessment of where to start.
The 1-year timeframe is quite accelerated, because a typical learning collaborative might continue for 18 months or even longer for such a complex topic. Even so, we expect that we will be able to show positive effects on the trajectory of change, both in terms of improving clinical practices and in implementing at least one new policy measure in a community. In July 2012, we will initiate phase two, including a “virtual collaborative” involving a larger set of 40 organizations with multisector experience. Our approach is to build on evidence and expert opinion to produce practical knowledge that can be applied in the community. The basic concept is to use an adaptive approach and “learn by doing,” whether the objective is to increase clinical tracking of body mass index or to improve school cafeteria menus. The overall goal will be to develop experience with a comprehensive array of innovative approaches and resources suitable for use by communities throughout the United States.
Although NICHQ’s core mission focuses on child health, this effort to promote collaboration and innovation to reduce obesity targets the full age spectrum. Moreover, a key priority of this initiative is to promote health equity, so we will work to make sure that the benefits of these efforts will apply broadly. We are excited by this opportunity to tap the expertise of many leading organizations, and we are confident that if we design an obesity prevention strategy that works well for children, it will work well for everybody.
About the Author
Charles Homer, MD, MPH, is president and chief executive officer of the National Initiative for Children’s Healthcare Quality, Boston, which he cofounded in 1999. Dr. Homer is an associate professor of the Department of Society, Human Development and Health at the Harvard University School of Public Health and an associate clinical professor of pediatrics at Harvard Medical School. His leadership roles related to children’s health have included work with the Institute of Medicine, the National Committee for Quality Assurance, the National Quality Forum, the American Academy of Pediatrics, and the U.S. Preventive Services Task Force.