1. TRIM LIFESTYLE PROGRAM Lynchburg Family Medicine Residency Dr Stacey Hinderliter, Dr Jennifer Cunningham, Dr Shital Patel

2. TRIM-Training Residents in Modifying- Lifestyle ► Childhood obesity project at LFM residency to identify and treat overweight or obese children ► Children above the 85th percentile for BMI are offered enrollment ► Partly funded by AAFP AIM HI

3. Objectives ► Identify overweight and obese children:  Measure height and calculate BMI at all office visits not just preventive visits ► Educate families about 5-3-2-1-0 Healthy Lifestyle  Visit Powerpoint and Healthy Lifestyle notebook ► Educate residents about obesity prevention and treatment  Resident involvement in program development  Resident training and evaluation

4. ► 6 monthly office visits with the patient’s primary care physician ► Primary care physician provides intensive individual family education and counseling

5. ► Each visit was created by resident/faculty teams ► Residents trained and tested as each visit was developed ► Each visit incorporates one step of the 5-3-2-1-0 Healthy Lifestyle

6. ► 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

7. 5-3-2-1-0 Healthy Lifestyle ► 5 servings of fruits and vegetables daily ► 3 healthy meals a day: home-cooking ► 2 hours or less of screen time: TV, computer, video games ► 1 hour physical activity: sweat ► 0 or almost 0 drinks containing sugar www.dukehealth.orgwww.dukehealth.org : 5-3-2-1-almost none healthy lifestyle

8. Visit 1-Zero Sugary Drinks ► How to read labels ► Other names for sugar ► Healthy servings ► Water bottle ► Sugar free drink mix ► Sugar free drink ideas

9. Visit 2- 1 Hour of Physical Activity One hour can broken up into small bits Weight lifting of 1-2 pounds OK for children Don’t have to be on a team Pedometer: 2000 steps = 1 mile Soft balls One hour can broken up into small bits Weight lifting of 1-2 pounds OK for children Don’t have to be on a team Pedometer: 2000 steps = 1 mile Soft balls

10. Visit 3- 5 Servings of Fruits & Vegetables Whole fruits and vegetables vs juice Fiber in the diet How to get fruits and veggies into meals and snacks My Plate-fill ½ plate with fruit/veggies $5 grocery gift card and recipes

11. Visit 4- TWO HOURS of SCREEN TIME What is a screen? No TV in child’s bedroom or during meals Effects of TV on BMI, attention and behavior problems BMI higher from watching TV vs reading a book Cards, jump ropes, frisbees, games etc.

12. Visit 5- 3 Healthy Meals a Day: Home Cooking Benefits of healthy meals Review of My Plate-Protein, Grains and Starches Eyeballing healthy portions Involve child in grocery shopping and meal preparation $10 grocery gift card, measuring cup, recipes

13. Visit 6- Let’s Review 5-3-2-1-0 Healthy Lifestyle ► Changes made by family based on each step of Healthy Lifestyle ► Review reading food labels ► Reinforcement of My Plate and eyeballing portions ► Gift certificate for children’s museum, skating, or bowling

14. Motivational Interviewing How to get your patient to want to do what you want them to do

15. Definition ► Patient centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence ► Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change 2 nd edition, New York: Guilford Press, 2002

16. Four Guiding Principles RULE ► Resist arguing and persuasion ► Understand your patient's motivation ► Listen to your patient ► Empower your patient

17. What it is not ► Not arguing ► Not offering advice without the patient's permission ► Not doing most of the talking ► Not giving a “prescription”

18. How to do it ► Establish rapport ► Set an agenda ► Get permission ► Ask open-ended questions ► Use reflective listening

19. How long does it take a physician to interrupt a patient? ABOUT 15 SECONDS!

20. More tools ► Consider pros and cons ► Determine degree of interest and confidence ► Provide a menu of choices ► Provide information, let patient interpret it ► Summarize and close the deal

21. Pros and cons ► What’s good about_______? ► What might happen if you don’t change ________? ► How would changing_______ affect your family? ► What’s bad about_________?

22. Giving information ► Ask permission-May I tell you about _____? ► Provide nothing but the facts- Being overweight can cause_______. ► Let patient interpret it- What does this mean to you?

23. Can you make a change? ► Limit sugary drinks to 1-2 times a day ► Use 1% or fat free milk ► Drink more water- can try flavored water or sugar free drink mix. ► Limit sugary drinks to 1-2 times a day ► Use 1% or fat free milk ► Drink more water- can try flavored water or sugar free drink mix. 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? 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?

24. Can you make a change? ► Be active everyday ► Be active for 1 hour a day ► Split activity into smaller parts:  30 minutes twice a day  15 minutes 4 times a day ► Be active as a family 1- 2 times a week ► Be active everyday ► Be active for 1 hour a day ► Split activity into smaller parts:  30 minutes twice a day  15 minutes 4 times a day ► Be active as a family 1- 2 times a week 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? 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?

25. Can you make a change? ► Offer fruits and vegetables at snack time ► Fill ½ your plate with fruits and vegetables at meals ► Try new fruits and vegetables ► Limit juice to once a day ► Offer fruits and vegetables at snack time ► Fill ½ your plate with fruits and vegetables at meals ► Try new fruits and vegetables ► Limit juice to once a day 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? 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?

26. TRIM Lifestyle results 111 overweight and obese children

27. TRIM Lifestyle Results

29. BMI changes in TRIM graduates

30. TRIM Lifestyle Users

31. TRIM Lifestyle Future ► Option of Mini-program-3 visits  Family can choose what works best for them ► Improve training for each new resident class ► More focus on Motivational Interview Methods ► Community Outreach

33. Any questions?