A Tool Kit for Battling Childhood Obesity: Implementing the ABCD Program for Childhood Obesity in Pediatric Primary Care James Scibilia, MD Kathleen Sweeney, CPNP

Background Prevalence of obesity increased significantly from 1980 to 2004 (NHANES, 2004) 2-5 years 5.0% - 13.9% 6-11 years 6.5%-18.8% 12-19 years 5.0% - 17.4% More than 9 million children and youth over 6 years of age are obese (Miller, 2007) 1 in 7 children in the United States are overweight (Harbaugh, 2006) The probability of childhood obesity persisting into adulthood is estimated to increase from 20% at 4 years of age to approximately 80% by adolescence. (Caprio & Myron, 2005)

Implications for Children and Society Physical Health Type 2 Diabetes Hypertension Dyslipidemia Glucose Intolerance/ Insulin Resistance Hepatic Steatosis Sleep Apnea Orthopedic Complications Emotional Health Low self-esteem Negative body image Depression Social Health Stigma Discrimination Negative stereotyping Bullying

AAP Recommendations Stage 2 - Structured Weight Management Protocol Implemented by primary care provider highly trained in weight management Development of a plan including specifics related to diet and macronutrients, physical activity, screen time Increased monitoring and follow-up (AAP,2008)

Why ABCD Program? Gap in primary care based programs for pediatric obesity Lack of access to tertiary care based programs Established relationships with primary care providers Development of specific provider guidelines for ease and time constraints of implementation Importance of program portability

Purpose of Program Does a structured intervention program using a “tool kit” to deliver information regarding dietary modifications, nutrition education and activity recommendations in a pediatric primary care center influence the Body Mass Index (BMI) of children identified as being obese?

ABCD Program The “ABCD” acronym describes the intervention strategies: A= “Activity Goals” B= “Behavior modification” C=“Close contact and counseling” D= “Dietary Modifications”

Pilot Study Twelve week program implemented by PCP based on diet and activity modifications(Unpublished data, manuscript in process) ABCD Program for weight management in pediatric primary care appears to be associated with improvement and/or stabilization of BMI’s across all age groups (p=o.oo8)

Pilot Study Implications Need for program revision – improved retention at 5 visits versus 6 Structured provider guidelines and parent/child educational binders Recruitment based on family and child motivation and readiness to change Portability assessed through multi-site implementation

ABCD Program Specifics Cognitive Behavioral Theory/Motivational Interviewing 10 week program – 30 minute visits bi-weekly with same provider Assessment of motivation, perceptions, co morbidities, family history Assessment of current diet and activity patterns Intake lab work –Lipid Panel, Liver Panel, FBS, Insulin Individual binders consisting of educational materials/take home assignments Pedometers and food/activity logs

ABCD Program Specifics Individualized based on developmental level and specific issues Health vs. Weight Lifestyle Changes vs. Diet Concrete & attainable goals set biweekly Activity – Increase pedometer steps X 2000/day Behavior – Identify triggers for “boredom eating” Diet – Add fruit to breakfast 4x/week Take home assignments Compare 3 cereal box labels Find 2 healthy fast food choices

Phase II Multi-Site Implementation BMI Changes Tri-State Pediatrics N=14, Retention 88% Pediatrics South N=17, Retention 92% BMI Changes Reimbursement Issues – Varies by carrier, Importance of appropriate coding

Future Implications School-Based ABCD programs Partner with community resources Web-based programs Early identification and intervention by PCP Follow-Up - Maintain lifestyle changes?

References American Academy of Pediatrics. (2003). Committee on Nutrition Policy Statement: prevention of pediatric overweight and obesity. Pediatrics, 112(2), 424-430. Caprio, S., & Myron, G. (2005). Confronting the epidemic of childhood obesity. Pediatrics, 115(10), 494-495.

References Kaufmann, J. (2008). Developmental Differences in Adherence to the ABCD Program for Pediatric Weight Management. Unpublished manuscript, University of Pittsburgh Center for Research and Development. Harbaugh, B.L. (2007). Nurses and families rising to the challenge of overweight children. Nurse Practitioner 32(3), 30-55, 42-43 Miller, J.L., Silverstein, J.H. (2007). Management approaches for pediatric obesity. Nature Clinical Practice Endocrinology and Metabolism, 3(12), 810- 818.