1. FLAIR A Practice-Based Intervention to Address Unhealthy Behaviors in Families with Young Children New York City Research and Improvement Group

2. Our Team  M. Diane McKee, MD, MS  Darwin Deen, MD,MS  Alice Fornari, RD,PhD  Arthur Blank, PhD  Stacia Maher, MPH  Irina Polanco, MA  Patricia Lopez, MA  Adelyn Alvarez, MA  Jason Fletcher, MA  Jean Burg, MD  Robert Clarick, MD  Staff and clinicians too numerous to mention

3. Prescription for Health  5 year initiative of the RWJ Foundation  10 PBRN’s funded in Round II  Developing creative, practical strategies for promoting healthy behaviors among primary care patients, targeting  Lack of physical activity  Unhealthy diet  Tobacco use  Risky alcohol use

4. Pediatric Obesity in the Urban Context  1.3 million people reside in the Bronx  7% below the age of 5  32% African-American, 34% Hispanic  80 % sedentary; 75% eat few fruits and vegetables, 29% are obese  In NYC 43% of elementary public school children are obese (24%) or overweight (19%)* Thorpe Am J Public Health 2004

5. Research Questions  Can 2-4 year old check-up visits be successfully reframed to assess risk and initiate counseling for behavior change?  Can an intervention based on family lifestyle risk assessment change behaviors (for adults and children) that place families at risk?

6. The FLAIR Intervention Reframe preventive visits for 2-4 year olds to focus on family lifestyle risk assessment  Enhance screening for behaviors associated with pediatric (and adult) obesity  Deliver brief behavior change messages from clinicians for identified behaviors  Increase visit frequency to address additional behaviors  Referral to lifestyle counselors to augment clinicians’ efforts

7. FLAIR Tools  Pre-Visit Screener  Parental ht/wt  Family history  Behaviors associated with pediatric obesity  Goal Setting Action Plan  Follow-up Forms  Educational Materials

8. Project Characteristics  Behaviors: diet, sedentary/exercise, smoking  Creation of counseling-focused visit for 2 year olds emphasizing family behaviors  Low-income minority population  Sites (3 intervention, 3 control)  1 FM, 1 FM/Peds, 1 Med/Peds  Target 240 families in the intervention

9. Methods  We piloted a primary-care based intervention to address risk behaviors for overweight and obesity among preschool children.  We conducted focus groups (2 in English, 1 in Spanish), to understand what urban parents felt about the intervention to determine the acceptability of physician extenders as change agents.  Focus groups were audiotaped, transcribed and analyzed qualitatively.

10. Results  Parents expressed interest in making changes to achieve healthier families and believe that doctors should increase the focus on healthy habits during visits.  Parents were more accepting of discussions targeted at changing dietary habits and nutrition than those aimed at increasing physical activity (citing lack of access to safe outdoor space) or decreasing sedentary behaviors (citing many benefits and few costs of TV viewing).

11. Results  Contacts with the lifestyle counselor were described as empowering, noting her focus on strategies to achieve change (for the whole family, not an individual child) while understanding that many food behaviors relate to cultural heritage.  Parents expressed frustration with physicians for offering advice about what to do but not help with how to achieve goals, for dismissing their concerns about picky or under-eating, and in some cases for labels of overweight they felt were inappropriately applied.

12. Conclusions  Sample too limited to determine effectiveness  Very different approach for measuring outcomes required  Feasibility and acceptability of approach established  Screener must get incorporated into visit  Physicians will engage in goal setting  If there is a resource available  Lifestyle counselor role highly valued  Physicians referred a large proportion  Families engaged

13. Lessons for Future Interventions  Practices and clinicians hungry for help  Intervention never fully owned by the staff  An artifact: too little presence of the health educator  Physician orientation towards treatment rather than prevention  Really impossible to separate in most families  Keeping messages positive; avoid suggestion of poor parenting

14. Take Home  Parents welcome efforts to address family lifestyle behavior change in pediatric visits.  The model of physician goal setting with referral for behavior change counseling is highly acceptable to families.