1. TRIM Lifestyle Program
Stacey Hinderliter, MD
Memona Tazamal, MD PGY-2

2. Outline Lynchburg Background Pediatric Obesity TRIM TRIM Data/Results
Conclusion
References
Contact Info

3. Lynchburg, VA is an independent city located at the heart of Central VA
Known as the “City of Seven Hills”
Located in the foothills of the Blue Ridge Mountains along the banks of the James River
Home to ~77,203 people covering an area of 2, 122 square miles
Average Household income for a household is ~$32, 234
12.3% of families and 15.9% of the population are below the poverty line
In 2009, about 27% of Lynchburg Children lived in poverty when the state average was 14 percent

5. BACKGROUND
Virginia
31% of children years are overweight or obese
Lynchburg
#8 on the Top 10 Most Obese Metropolitan Areas, obesity rate of 33%
LFMR
: 39% children 2-17 years had BMI > 85%
: 90 children with BMI 30 or higher

6. Gallup tracks Americans' height and weight daily, and then determines obesity by calculating a respondents' Body Mass Index (BMI) based on these self-reports. The 26.5% found to be obese in the United States in 2009 is up from 25.5% in Looking in-depth at the health-related behaviors, community conditions, and physical health across the 10 most obese metro areas reveals that on almost every item these 10 places rank among the bottom two-thirds of all 187 metro areas surveyed.

7. In order of worst to best health behavior
Ranked amongst the 3rd worst healthy behavior index in the 10 most obese metro areas

8. Pediatric Obesity
Obesity occurs when the energy intake exceed energy expenditure
BMI: indirect measure of obesity
BMI > 95th percentile for age = obesity
BMI 85th-95th percentile for age = overweight
Affecting as many 34 % of American children
Prevalence has been growing in the developed world more than in developing
BMI can be used for tracking childhood obesity trends within a population
To note: BMI doe not reflect adiposity accurately since a muscular individual can have the same BMI as an oversized endomorph
High lean body mass can elevate weight, leading to a higher BMI without corresponding high adiposity
The medical consequences of obesity accounted for 40% of the health care budget by 2006
What is contributing to this trend?
Genes do play a role however do not account for dramatic recent increases in prevalence
Exogenous influences such as
Family dinner demise
Fast/prepackaged food
Sedentary lifestyles (spending more time watching T.V and playing videogames)
Diminished physical activity
Underdiagnosis
Lack of reimbursement for treating obesity since ICD-9 codes reflect more of the medical complications (which have better reimbursements)

9. Training Residents in Modifying (TRIM) Lifestyle
A family-centered and community project designed to reduce childhood obesity and to promote fitness for the entire family.
A resident centered program involving
Community outreach
Fitness
Childhood obesity
Resident education
In order to combat this issue, we came up with a program to encourage residents to learn about community outreach, fitness, childhood obesity as well as apply the learned techniques to their clinic population
Fitness (AAFP) is defined as physical activity, healthy eating, and emotional well-being.

10. Objectives
To improve identification of overweight and obese children in a primary care office
To introduce the concept of a Healthy Lifestyle program for overweight and obese children that takes place in the primary care office
To discuss the results of an office-based Healthy Lifestyle program and implications for future efforts
To utilize Motivational Interviewing
Educate residents about obesity prevention and treatment
To identify overweight and obese children at Lynchburg Family Medicine
Weight + height measurement at every visit
Target population: Children 2-17 years with a BMI > 85%
BMI >25 overweight
BMI > 30 obese
Resident involvement in program development
Resident training and evaluation

11. Intervention TRIM Lifestyle Visits
Monthly 20 minute visit with the PCP x 6
Each visit focuses on an aspect of lifestyle
Motivational interview methods are utilized to inspire change by the child and family.
Patient centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence
Resist arguing and persuasion
Understand your patient's motivation
Listen to your patient
Empower your patient
How to do it?
Establish rapport
Set an agenda
Get permission
Ask open-ended questions
Use reflective listening
What Not to Do?
Not arguing
Not offering advice without the patient's permission
Not doing most of the talking
Not giving a “prescription”

12. Each visit created by resident/faculty teams
PCP will use a PowerPoint tool on his/her laptop during the visit for visualization and reinforcement of information
Each PowerPoint will be tailored to patient’s age
Pre-school: 2-5 years
Elementary school: years
Middle/High School: years
Families were encouraged to keep track of the changes they made in Healthy Lifestyle notebook
Incentives were provided at each office visit to encourage patients to complete the program
End of each visit, a Health Lifestyle Notebook will be provided for the family to take home
Includes written educational materials
Physical Incentive
Food journal
Questions for next visit
Residents trained and tested as each visit was developed
Each visit will provide an incentive related healthy activity to the family

13. 5, 3, 2, 1, 0 Healthy Lifestyle 5
Servings of fruits and vegetables daily 3
Healthy meals a day (emphasis on home-cooking) 2
Hours or less of screen time (T.V, computer, video games) 1
Hour of physical activity (sweat)
Or almost 0 drinks containing sugars

14. Types of Physical Activity
Walking
Running
Jump rope
Sports- soccer, baseball, football, softball
Dancing
Obstacle course
Relay race/Tag
Biking
Badminton
Skate boarding
Roller Skates
WHAT CAN YOU THINK OF?
EXAMPLE of one of the slides for the One hour of physical activity visits

15. Visit 1 (No sugary drinks)
How to read labels
Review other names for sugar
Healthy servings
Water bottle
Sugar free drink mix
Sugar free drink ideas
Visit 1
Consent form from parents
Mental health surveys: Pediatric Symptom Checklist for parent-all ages, PSC Youth for years
Fitness survey: parent fills out for child ages 2-10 years, child fills out years
Notebook-encourage them to bring with every visit
Powerpoint and educational tools with PCP
Incentives-water bottle, book, Crystal light

16. TRIM Lifestyle Results
114 overweight and obese children
Total # with BMI>85% 114
No show for visit 1 23
contacted but no response 38
not interested 7
Enrolled %

17. TRIM Lifestyle Results

18. TRIM Lifestyle Results

19. Decrease Sugary Drinks

20. Increase Physical Activity

21. Decrease Screen Time

22. 3 Healthy Meals

23. Fruits & Vegetables

24. Decrease in BMI for TRIM graduates 47%

25. 3-6 month BMI Follow-up for TRIM Graduates

26. Resident and Faculty Experience

27. Testing Results

28. Visit PowerPoints

29. Survey Results
PERCENTAGE

30. CONCLUSION Project has increased awareness of BMI in office
Easy to measure-weight and height at each visit
Determine BMI percentile and offer intervention
Increased Resident Education about how to manage obese and overweight children
Basic understanding of nutrition and physical activity
Also applicable to adults
Increased use of motivational interviewing to modify behaviors and attain appropriate goals
Can be adapted to smoking cessation, adult education, etc.

31. CONCLUSION Many families want help for their overweight child
Time commitment is a problem for many families
Changes can be made by families but difficult to sustain
Education about healthy lifestyle can be incorporated into office care

32. THE NEXT STEP
Meaningful use- Children’s Health Quality Measure NQF #0024
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Body Mass Index Assessment for Children/Adolescents
Coding for BMI
BMI 85-<95% V85.53
BMI>95% V85.54
Diet/Nutrition Counseling V65.3
Exercise Counseling V65.41

33. NEW EVIDENCE
High attrition rates in Pediatric Obesity programs: 27-73%
Scheduling issues
Program not meeting expectations
Cochran review 2009
Pediatrics 2012-review of 33 programs

34. What is TRIM Lifestyle?
An exciting way to gain the tools to make a change!
Healthy and fun ways to reverse weight gain and take control of your life.
Incentives and prizes!
Practical solutions!
An initiative for the whole family!

35. Let’s Work on Becoming Healthier Everyday!
It’s as easy as—
5 Servings of Fruits and Vegetables
3 Healthy Meals a day
2 Hours or less of screen time
1 Hour of Physical Activity
0 Sugary Drinks

36. It’s your choice! You can learn about 1 or more ways to change
You can stop or restart at any time

37. Can you make a change? Fruits and veggies Healthy meals and portions
Screen time
Physical activity
No sugary drinks
On a scale of 1-10:
How interested are you in making a change?
How confident are you that you can make a change?
Why did you choose a low number?
What would it take to choose a higher number?

38. Any questions?