1. An Integrated Care Approach to Preventing Childhood Obesity in Family Medicine Clinics Using 5-2-1-0 Messages at Well-Child Visits Jerica Berge, PhD, MPH, Associate Professor Renee Crichlow, MD, Assistant Professor Lisa Trump, MS, LAMFT, Intern University of Minnesota North Memorial Family Medicine Residency Program Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # G1b October 17, 2015

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Describe the evidence-based 5-2-1-0 childhood obesity prevention messages and how the clinic adapted them to be used within an integrated care model. Discuss the collaborative approach between behavioral health and medical providers in carrying out this intervention, including the development of the model, obtaining grant funding, and conducting feasibility research on the approach. Present feasibility data and lessons learned related to the population-level childhood obesity prevention approach.

4. Bibliography / References 1. Arcan C, Larson N, Bauer K, Berge J, Story M, Neumark-Sztainer D. Dietary and weight-related behaviors and body mass index among Hispanic, Hmong, Somali, and White adolescents. Journal of the Academy of Nutrition and Dietetics. 2014; 114: 375-383. 2. Berge JM, Wall M, Larson N, Forsyth A, Bauer KW, Neumark-Sztainer D. Youth dietary intake and weight status: Healthful neighborhood food environments enhance the protective role of supportive family home environments. Health & Place. 2014; 26: 69-77. 3.

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. An Integrated Care Approach to Preventing Childhood Obesity in Family Medicine Clinics Using 5-2- 1-0 Messages at Well-Child Visits www.letsgo.org

7. The Problem: Childhood Obesity Over 30% of American children and adolescents are overweight or obese –Increased risk for CV disease, DM II, metabolic syndrome, sleep apnea, bone/joint problems, certain cancers, early menarche, low self-esteem 1 – The 2nd leading cause of preventable death 2 Complex hormonal/genetic/environmental interplay, but typically the key factor is energy intake vs expenditure 1 http://www.cdc.gov/healthyyouth/obesity/facts.htm ; 2 Am J Clin Nutr. 2010 May; 91(5): 1499S–1505S

8. Energy Intake vs Expenditure The American family and daily lifestyle –High amount of screen time (TV, cellphone, video games, tablet) –Sedentary lifestyle –Sugary drinks –Low quality, high calorie diet

9. Obstacles On the family's side: –Infinite amount of perceived obstacles… –E.g., children are picky, TV provides entertainment, limited access to healthy food, addicted to sugar, higher cost On the clinician's side: –Low adherence to health care providers’ recommendations –Limited time with the patient –Other, perhaps more pressing, issues to address

10. How Can Clinicians Begin to Address This? Have many health conversations –Both with providers and other professionals (e.g., Behavioral Health) Keep it simple Make an impression Goal-creation Dispel misconceived notions –E.g., all juice is healthy

11. Our Strategy Address childhood obesity at a population level by using 5-2-1-0 message at well-child visits at Broadway Family Medicine Clinic Jerica Berge, PhD, MPH and Renee Crichlow, MD as project directors –Partnership with MAFP and UMN –SHIP grant

12. What are the 5-2-1-0 messages? 5: 5 or more servings of fruits and vegetables 2: 2 hours or less of screen time 1: 1 hour or more of physical activity 0: 0 sugar-sweetened beverages developed from www.letsgo.org

13. Broadway Family Medicine Clinic North Memorial Residency teaching clinic in North Minneapolis Primarily African-American and Hmong patient population Many lower SES patients Considered high risk for obesity

14. 5-2-1-0 Project in Primary Care/Family Medicine –5 fruits and Vegetables per day –No more than 2 hours of screen time per day –At least 1 hour of physical activity per day –Zero sugar-sweetened beverages per day Environmental targets: –Power point in lobby, posters, brochures, staff trained Integrated Care is key: –MedFT’s collaborate with physicians in delivering 5-2-1-0 messages and then do the follow-up

15. The 5-2-1-0 visit Who: Children 2 yrs and older all well-child visit with guardian present What: Present the the 5-2-1-0 messages to the family using motivational interviewing and goal-setting techniques Where: Family Medicine clinics When: Before or after medical appointment, typically lasting 5-10 minutes

16. Content of 5-2-1-0 visits 1. Motivational interviewing tactics used to address the family’s lifestyle related to the 5-2-1-0 message –What is a health strength they have as a family? –What are barriers that they face related to these messages? 2. Choose one of the 5-2-1-0 messages to focus on –Further discuss where the family is at related to the specific message

17. Content of 5-2-1-0 visit: Goal creation 3. Goal creation – Guide the family as they chose one aspect of 5-2-1-0 to work on and create a goal – How confident do they feel in being able to make a change? 4. Follow-up – Offer an opportunity for follow-up via email/ phone-call/text/clinic visit to discuss their progress

18. Our Results: June 2014-December 2015

19. Conversations During WCCs Number of 5-2-1-0 conversations since June 2013: 407 Average number of WCCs per day : 4-5 * August and September months: 10-15

20. 0 sugar- sweetened beverages per day 5 fruits and vegetables per day 2 hours or less of screen time per day 1 hour of physical activity per day Breakdown of Goals Selected

21. If Sugar-Sweetened Beverages are the Biggest Concern, What are Children Drinking? 57.4% 76.1% 52.8% 91.5% 12.5% 65.3%

22. How Confident are Families in Making Changes? 2.7% 1.1% 2.7% 1.9% 16.1% 8.2% 12.6% 20.2% 7.7% 26.8%

23. Common Family Health Strengths - Parent has the final say/authority -Parent is more conscious of it now -Parent thinks the goal is important -The family has made progress on health goals in the past -Parents want to make changes that promote health -Children already do part of the goal being discussed

24. Common Barriers That Make the Goal Challenging - Other adults watching the child -Children are more satisfied and behave better when they get what they want -Busy schedules and lack of time -Difficult habits to overcome -Parents don’t want to make the change for themselves

25. Optional Follow-Up Yes No Options for Follow-up 1.Phone call 2.Text message 3.Email 4.Office visit

26. Implementation of 5-2-1-0 at Broadway Family Medicine Getting other professionals on board I.e., Faculty, residents, provider assistants/nurses Making it beneficial for the residents Lessening their load vs. adding an additional component Keeping them in the loop Prioritizing their schedules

27. Initial Challenges in Implementation Learning Resident Preferences Flexibility to start and stop conversations Documentation requirements Tracking families Design for follow-up

28. Going Forward Research Plan -Investigate to see if behaviors change with 5-2-1-0 messages compared to regular WCCs Clinical Implementation Plan -Track with families and continue to discuss their goal in later visits -Continue to improve implementation 5-2-1-0 in the other three UMP residency clinics (Phalen Village, Smiley’s, Bethesda)

29. Questions?

30. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!