ABSTRACT METHODS RESULTS CONCLUSIONS REFERENCES INTRODUCTION CONTACT INFORMATION: Mina Silberberg, PhD, Director of Research and Evaluation, Division of Community Health, Dept. of Community and Family Medicine, Duke University Medical Center, Box , Durham, NC 27710, Phone: , ABOUT IN4KIDS IN4Kids: Data from a Study of RD Integration into Primary Care 1 Dept. of Community and Family Medicine, Duke University Medical Center, Durham, NC; 2 Healthy Lifestyles Program, Duke University Health System, Durham, NC; 3 Depts. of Family Medicine and Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC; 4 Div. of General Pediatrics and Adolescent Medicine, UNC at Chapel Hill School of Medicine, Chapel Hill, NC; 5 North Carolina Division of Public Health, Raleigh, NC; 6 North Carolina Health and Wellness Trust Fund, Raleigh, NC Mina Silberberg, PhD, 1 Lori Carter-Edwards, PhD, 1 Gwen Murphy, MS, PhD, RD, LDN, 1 Meghan Mayhew, MPH, 1 Sarah Armstrong, MD, 2 Kathryn Kolasa, PhD, RD, LDN, 3 Eliana Perrin, MD, MPH, 4 Sheree Vodicka, MA, RD, LDN, 5 Cameron Graham, MPH, 6 Vandana Shah, JD 6 INTRODUCTION: Research indicates barriers to PCPs recognizing and counseling overweight children and their families, including lack of: knowledge about nutritional guidance, time to provide services, reimbursement, and skills in working with overweight children. Integrating a registered dietitian (RD) into primary care may help address these issues. METHODS: As part of the IN4Kids study, 272 primary care practice staff and providers at 13 primary care practices in North Carolina were surveyed to assess comfort, confidence, and perceived effectiveness in treating overweight children; knowledge of RD services and perceived benefits of RD integration; and awareness and use of NICHQ guidelines. Select comparisons by respondents’ role at the practice and having a dietitian on staff were assessed using Chi-square tests. RESULTS: Overall, respondents were most comfortable and confident recommending nutritional resources to parents and with their practice’s capacity to make changes to better address childhood obesity. They were least comfortable and confident with knowledge of billing for obesity as a diagnosis. Few (<6%) felt highly effective in all areas of treating childhood overweight, but respondents at practices with an RD were more likely to report comfort, confidence, and perceived effectiveness in dealing with overweight children. Respondents understood that RDs can discuss food choices with patients and parents, and create a nutrition plan. They also felt that having an RD in a practice greatly improves weight management and provides more time for nutritional counseling. Providing another set of billable visits was perceived to be the least important benefit of having an RD; staff in practices with an RD were more likely to know that RDs can bill independently (71.9% v. 50.2%, p<.05). Awareness of the NICHQ guidelines was low (20.5% overall). However, staff at practices with an RD were more aware of NICHQ guidelines than those at practices without an RD (37.5% vs. 17.9%, p<.05); and providers and management staff were more aware than staff in other roles (32.8% vs. 16.6%, p<0.05). CONCLUSIONS: Although primary care practices feel comfortable and confident in several areas of childhood overweight treatment, perceived effectiveness in these areas remains low, as is awareness of NICHQ guidelines around the treatment of childhood obesity. The presence of an RD is associated with greater comfort, confidence, effectiveness, and awareness relative to several aspects of treating childhood overweight. The financial viability of RD integration into primary care is not well understood; further exploration in this area is needed.  Practice-based interventions for overweight children have potential for large-scale replication.  Multiple barriers exist to PCPs recognizing and counseling overweight children and their families. 1, 2, 3, 4  Integration of a registered dietitian (RD) into primary care has the potential to address these issues. 1, 2, 3, 4  Little is known about attitudes and knowledge about treating overweight children across the full spectrum of staff at primary care practices. PURPOSE To assess primary care practice staff and providers’:  Comfort, confidence, and perceived effectiveness in treating overweight children;  Awareness and use of NICHQ guidelines; and,  Knowledge of RD services and perceived benefits of RD integration. Study Population Target population staff across 13 practices Mailed survey 278 completed and returned survey Exclusions: 5 dietitians or nutrition assistants and 1 with unknown practice role Study Sample: 272 respondents Measures: Comfort treating overweight children on 8 dimensions: 5-point Likert scale collapsed to comfortable/not comfortable Confidence treating overweight children on 8 dimensions: 5--point Likert scale collapsed to confident/not confident Perceived effectiveness treating overweight children on 3 dimensions: 5-point Likert collapsed to effective/not effective Knowledge of multiple RD services: 4-point Likert collapsed to agree/disagree Perceived benefits of RD integration: 4-point Likert greatly to not at all NICHQ Guideline awareness: yes/no Analyses: Frequency statistics Hypothesis-testing using Chi-square (Mantel-Haenszel for 3-way analyses) Statistical sig. set at p<.05 Comfort and Confidence in Treating Overweight Children Overall, respondents were most comfortable and confident with: 1) Recommending nutritional resources to parents 2) Their practice’s capacity to make changes to better address childhood obesity. Respondents were least comfortable and confident billing for obesity as a diagnosis Perceived Effectiveness in Treating Overweight Children Fewer than 6% of respondents felt they were highly effective at doing all of the following: 1) Raising the issue of overweight with parents 2) Recommending nutritional resources 3) Advising parents on different types of healthy foods Knowledge of RD Services and Billing Most commonly known that an RD can discuss food choices with patients and parents, and create a nutrition plan. Staff in practices with an RD were more likely to know that RDs can independently bill for services (71.9% v. 50.2%, p<0.05, crude and adjusted ). Perceived Benefits of RD Integration Respondents agree that having an RD in a practice greatly improves weight management; and provides more time to devote to nutritional counseling. Providing billable services was seen as the least important benefit of having an RD. Awareness of NICHQ Guidelines Funded by the North Carolina Health and Wellness Trust Fund, IN4Kids is a feasibility and effectiveness study of RD integration into primary care, with a focus on overweight children. Utilizing clinical, billing, and survey data, we are assessing incorporation of the RD into the practices; changes in practice staff and health care providers’ attitudes and behaviors; and changes in patient weight. In addition, we are assessing the financial viability of this clinical model. 1.Jay, M., A. Kalet, et al. (2009). "Physicians' attitudes about obesity and their associations with competency and specialty: a cross-sectional study." BMC Health Serv Res 9: Jelalian, E., J. Boergers, et al. (2003). "Survey of physician attitudes and practices related to pediatric obesity." Clin Pediatr (Phila) 42(3): Kolagotla, L. and W. Adams (2004). "Ambulatory management of childhood obesity." Obes Res 12(2): Perrin, E. M., K. B. Flower, et al. (2005). "Preventing and treating obesity: pediatricians' self- efficacy, barriers, resources, and advocacy." Ambul Pediatr 5(3): Providers and management staff were more knowledgeable of NICHQ guidelines than other staff (32.8% vs. 16.6%, p<0.05, crude and adjusted). Staff at practices with an RD were more aware of NICHQ guidelines than staff at practices without an RD (37.5% vs. 17.9%, p<0.05, crude and adjusted ). Overall, staff at practices with an RD reported more comfort, confidence, and perceived effectiveness in working with overweight children; these differences were significant for 6 of 19 dimensions, including all 3 effectiveness dimensions (p<0.05, crude and adjusted ). ●Although primary care practices feel comfortable and confident in several areas of childhood overweight treatment, perceived effectiveness is low. Moreover, staff are uncomfortable and lack confidence with billing for obesity as a diagnosis. ●Overall awareness of the NICHQ guidelines was low, with 20.5% aware. ●The presence of an RD is associated with greater awareness of NICHQ guidelines, knowledge that an RD can bill for services, and comfort, confidence and perceived effectiveness in working with overweight children. ● The financial viability of RD integration into primary care needs further study. CONTACT INFO.