Evaluation and Management of Childhood Obesity in the Primary Care Setting Joani Jack, M.D.

To provide primary care physicians and staff with efficient, evidence- based strategies for the assessment, prevention and treatment of childhood obesity Tennessee Chapter of the American Academy of Pediatrics

1999 Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009 (*BMI  30, or about 30 lbs. overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Tennessee Chapter of the American Academy of Pediatrics

● Widespread despair exists among physicians, parents, patients, educators, community leaders, and the public at large ● Despair leads to a tendency to “give up” on many levels, causing a worsening of the epidemic Tennessee Chapter of the American Academy of Pediatrics

 Lack of confidence  Failure to recognize and diagnose obesity  Lack of successful treatment options for the primary care setting  Uncertainty over next steps Physician Barriers Tennessee Chapter of the American Academy of Pediatrics

Perceived Physician Ability to Treat or Prevent Common Pediatric Conditions Preventing and Treating Obesity: Pediatricians’ Self-Efficacy, Barriers, Resources and Advocacy, Ambul Pediatr 2005;5: Tennessee Chapter of the American Academy of Pediatrics

Recommendations for Treatment of Child and Adolescent Overweight and Obesity, Pediatrics 2007, 120:S Tennessee Chapter of the American Academy of Pediatrics

Other Barriers  Parental perception of childhood obesity  The “What’s The Big Deal” phenomenon Tennessee Chapter of the American Academy of Pediatrics

 The media: “America is getting larger... how can we capitalize on that?”  The parents: “Our whole family is overweight and we are doing just fine. It’s not like we can do anything about it, anyway…”  The doctor: “Fat parents have fat kids… I don’t have the time to keep beating my head against the wall.” Tennessee Chapter of the American Academy of Pediatrics

In a 2004 conference on obesity, the speaker asked the audience of healthcare professionals to answer on paper the following question: People who are overweight are ______________ Obesity Treatment and Prevention Conference, Seattle, WA, 2004 Tennessee Chapter of the American Academy of Pediatrics

The Answers? ● Hopeless ● Lazy ● Pigs ● Impossible to help ● Unhappy ● Unmotivated ● Ugly ● Scary Tennessee Chapter of the American Academy of Pediatrics

 A group of 10- and 11-year old children were asked to study pictures of children with varying disabilities and rank them according to acceptability.  The obese child was ranked below all the physical deformities, including missing an arm and facial disfigurement. Richardson, SA, et al, Cultural uniformity in reaction to physical disabilities,” Amer Sociol Rev, 1961, 26: Tennessee Chapter of the American Academy of Pediatrics

Childhood obesity IS a big deal, and it is our responsibility, as the advocates of children, to persevere in finding a solution. Tennessee Chapter of the American Academy of Pediatrics

LESS… BETTER… MORE LESS concern about things that we cannot control BETTER preparation for the things that we can control MORE success in the treatment of childhood obesity Tennessee Chapter of the American Academy of Pediatrics

1.Risks and Target Behaviors 2.BMI Percentile and Weight Category 3.Readiness for change 4.History and Physical Examination 5.Intervention 6.Laboratory Evaluation 7.Referral 8.Follow-up Tennessee Chapter of the American Academy of Pediatrics

 Billing and coding  Office protocol  Map the workflow  Problem solving  Follow-up training Tennessee Chapter of the American Academy of Pediatrics

 Community pediatric offices ◦ Comprehensive Medical Care ◦ Hamilton Pediatrics ◦ Pediatrics on Dodds ◦ Soddy Daisy Pediatrics ◦ Family Health Services  Academic Primary Care ◦ University Pediatrics ◦ UT Family Practice  Federally Qualified Health Centers ◦ Dodson Avenue Health Center ◦ Southside Health Center  Community Family Practice Office ◦ Erlanger North Family Medicine Tennessee Chapter of the American Academy of Pediatrics

 United Healthcare Community Plan has verbally committed to funding a statewide program for  Regional trainings in major cities  Train-the-trainer approach for office trainings in each city Tennessee Chapter of the American Academy of Pediatrics

 Primary Care ◦ Academic general pediatric practice ◦ Federally Qualified Healthcare Center pediatric practice  Public Health ◦ Chattanooga-Hamilton County Health Department ◦ Women Infant Children’s program (WIC) ◦ Headstart  Community ◦ Community Health Worker ◦ East Chattanooga Improvement, Inc ◦ Educator/Parent of special needs child

◦ Action Plan and Team Development ◦ Healthy Weight Message ◦ Healthy Weight Assessment ◦ Healthy Weight Plan ◦ Sector Integration ◦ Policy Development and Implementation

Chattanooga Regional Healthy Weight Collaborative

Chattanooga Mobile Market

Chattanooga Food Desert

 61,924 total population (2010 Census)  14, 546 children 0-17 (ACS)  18,019 people living below the poverty level (ACS)  6,728 children 0-17 living below the poverty level (ACS)  22 public schools (Percent Population, Age , Below Poverty Level, ACS 5-yr Est.)

 2 grocery stores  1 produce stand  64 corner stores and gas stations  324 Restaurants  23 fast food chain restaurants (USDA, SNAP Retailers 2012) Chattanooga Food Desert

Grocery Stores with One Mile Radius

Chattanooga Mobile Market Stops with One Mile Radius

Combined Radius Showing Improved Access To Healthy Affordable Foods