Integrating Obesity Management Into Pediatric Primary Care Page 2

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Integrating Obesity Management into Pediatric Primary Care
Childhood obesity a ects 12.5 million children in the United States and can lead to a myriad of health problems. Expert Committee Guidelines (ECG) on the treatment of children who are overweight or obese, released for use in 2007 are not being adequately utilized. In a primary care pediatric practice in Southeast Florida, a chart review was undertaken to determine if children ages 2 to 18 years were being identi ed as overweight or obese and counseled appropriately. A review of 100 charts showed
that the body mass index (BMI) was calculated 60% of the time and plotted on growth charts 15% of the time. The child’s BMI was assessed (underweight, normal weight, overweight, or obese) 15% of the time and nutritional counseling was provided 20% of the time. It was identi ed that the care given to overweight or obese children in this practice was not adhering to standards recommended by the ECG. The practice implemented a quality improvement project focusing on compliance with the 2007
ECG, led by a nurse practitioner. The project began with education on the ECGs, how to evaluate a child’s BMI, and a brief introduction on motivational interviewing. Three months later a second review of 100 charts of children from the ages of 2 – 18 years with a BMI of ≥ 85%, were reviewed for compliance with the ECG. Study results showed: BMI was plotted on the growth chart 90% of the time and 44% of the time BMI was assessed. The ECG’s were followed 17% of the time.
As a result of this study, a program began that identi ed overweight children and referred them to a nurse practitioner within the practice for a follow-up visit. It is di cult to address all areas of need during a well child visit and not all providers are comfortable with obesity counseling. The goal was to improve compliance with the ECGs and ultimately guide these children to a healthy weight. A counseling visit was designed based on the ECGs that assessed the child’s BMI, blood pressure, medical diag-
noses and co-morbidities, subjective and objective sequel of obesity, family history, nutrition, and physical activity. Healthy nutrition and activity teaching is incorporated into the visit and goals for the child are made using motivational interviewing techniques. Appropriate lab testing and follow-up visits are arranged. These visits have been well received by providers and families. Chart audits for the e ectiveness of these visits will be completed in the near future.
The childhood obesity epidemic may be plateauing but has not disappeared. While a single best solution for the treatment of childhood obesity remains elusive, evidence does support the use of the ECG in the primary care arena. Nurse practitioners working with children in the health care setting have an opportunity to impact this problem. Healthy lifestyle counseling early in childhood can begin children and their families on a journey to health that avoids obesity.
Nutrition Visit Forms
Snacks: ___________________________________________________________________
1
Children”s Medical Association, P.A.
NUTRITION COUNSELING VISIT
8430 W. Broward Blvd #300 Plantation, FL 33324
7489 N. University Dr. Tamarac, FL 33321
Desserts/Sweets:
none
rare
sometimes
routinely______________________________________
5810 Coral Ridge Dr. #110 Coral Springs, FL 33076
Meals:
mostly home am/pm
family eats together
school lunch/breakfast
fast food
restaurants
Assess Behaviors
brings lunch to school
Problem
Portion size:
age-appropriate
large portions
frequent seconds
NAME:____________________________ DOB:______________ AGE: ________ DATE:_____________
Eating behaviors:
picky
sneaks food
hungry right after meals
boredom eating
HEIGHT:___________ WEIGHT:___________ BP:__________ ACCOMPANIED BY:_____________
BMI:__________ BMI %:_____________
5% UNDERWEIGHT
5-84% HEALTHY WEIGHT
eats in front of TV
skips meals _______________________
85-94% OVERWEIGHT
95% OBESE
24 hour recall: breakfast_____________________ lunch________________________
12.5 million children (16.9%) are obese
8,9
FAMILY HISTORY:
OBESITY _____________________
HTN_____________________
dinner_______________________ snacks ______________________
5 (fruits & vegetables) 2
1
0 (sugary drinks) every day!
Children age 2 – 5 who have obesity should not lose more than 1 pound/month; older children and adolescents with
DIABETES_____________________
HYPERLIPIDEMIA________
PHYSICAL ACTIVITY ASSESSEMENT:
Childhood obesity disproportionately a ects American Indians, Blacks, &
EARLY DEATHS FROM CVD/CVA__________________
OTHER_________________
school PE/recess only_________ times per week
organized sports
gym
obesity should not lose more than an average of 2 pounds/week.
PMH: ________________________________________________________________________
Hispanics
plays outside
other________________________________________________
DIAGNOSES AND CO-MORBIDITIES:
TV/computer/video game time:
2 hours daily
2 hours daily
Adult health problems are now seen in obese children (DM, HTN,
abnormal lipids
abnormal A1C
abnormal FBS/GTT
PCOS
abnormal triglycerides
elevated liver enzymes
elevated BP
GERD
ASSESSMENT:
overweight
unchanged
improved
acanthosis nigricans
abnormal menses
disordered eating
sleep apnea
obese
unchanged
improved
Cholesterol & others)
orthopedic problems
GERD
depression
anxiety
Healthy Weight
Overweight
Obesity
acanthosis nigricans
family hx diabetes
family hx CVD
other _______________________________________________________________________
hyperlipidemia, unspecified
hyperinsulinemia
hypertriglyceridemia
impaired fasting glucose
other ______________________________
Children are often not identi ed as obese and provided appropriate
(BMI 5 -84%)
(BMI 85 -94%)
SUBJECTIVE:
(BMI > 95%)
PLAN:
Where/By Whom: Primary Care Office/Primary Care Provider
headaches
snoring
fatigue
school avoidance
Nutrition and physical activity counseling:
social isolation
polyuria
polydipsia
depression
health care
What: Planned follow-up themed visits (15-
abdominal pain
constipation
diarrhea
GE reflux
Advised 5 or more servings of fruit/veg daily,
2 hours TV/screen time, 1 or more hours of physical activity, and
joint/back pain
amenorrhea
abnormal menses
l ROS negative
other: ____________________________
0 sugary beverages
Expert Committee Guidelines (ECG) for the assessment and care of
Was taught the plate method of nutrition and portion control
OBJECTIVE:
Healthy snacks discussed
Ways to incorporate fruits and vegetables into daily diet discussed
1
overweight/obese children have been developed and are not utilized
Augmented (obesity-specific)
Augmented (obesity-specific)
1
Goals:
Weight maintenance or a decrease in BMI velocity.
4
poor linear growth
abnormal weight gain
acanthosis nigricans
other_________
Ways to incorporate more physical activity into daily routine discussed
hirsutism
excessive acne
hepatomegaly
Education on diet for improvement of high cholesterol/triglycerides
Family History
hypertrophy of tonsils
abdominal pain
otherwise normal exam
Ways to handle boredom eating discussed
Family History
Family History
Follow-up:
-
– 6
Low fat diet discussed
consistently
Review of Systems
NUTRITION ASSESSMENT:
Other ____________________________________________________________________
Review of Systems
Review of Systems
Handouts on above topics given to child/parent
months, if the BMI/weight status has not improved consider advancing to Stage 2.
Beverages: milk:
whole
low fat
fat free
with cereal only
lactaid
almond
none
other
Physical Exam
child motivated to make changes ______________________________________________
parent motivated to make changes _____________________________________________
Physical Exam
Physical Exam
Juice ______
soda _____
water
other______________________________
Child’s
Family”s Goals:
Fruit intake__________
veg intake_________
physical activity________________
Fruit:
daily
some
rarely
multiple servings daily
none
Purpose
TV/Screen time __________________
sugary drinks_________________________
Other ____________________________________________________________________
Vegetables:
daily
some
rarely
multiple servings daily
none
vegetarian
Labs:
pending
ordered
lipid profile
CMP
A1C
other___________________
Meat:
beef
chicken
fish
none
Referrals:
cardiology
ENT
endocrinology
RD
other ___________________
Follow up:
1 months
3 months
other ________________________________________
Where/By Whom: Primary Care Office/Primary Care Provider with appropriate training
Signature:___________________________________ Time spent: _______________
To improve the compliance with the evidence based practice guidelines on
What:
Determine
Risk Factors Present
childhood obesity as outlined by the Expert Committee (Barlow, et al, 2007) in
Risk Factors Absent
Health Risk
Goals:
Weight maintenance or a decrease in BMI velocity.
a pediatric primary care practice.
Factors*
Resources to Use in Daily Practice
Follow-up: Every 2 -
– 6 months, if the BMI/weight status has
not improved consider advancing to Stage 3.
Methods
-
Lab Screening
Good Health Club Toolkit – Includes printable healthy tip sheets by age
1
group in English and Spanish
Where/By Whom:
-disciplinary Team
The study site was a primary care pediatric practice in Florida with
for healthy behaviors.
- Includes printable materials
healthy weight
What:
3 locations, 9 pediatricians, and 3 ARNPs.
- Includes a printable Pediatric Obesity
dyslipidemia
3
-diabetes.
-
All providers were educated on the ECGs
by obtaining a non-
Assessment, Prevention and Treatment Guide and other resources for
-
Goals:
Weight maintenance or a decrease in BMI velocity.
Retrospective review of 100 charts was done after implementing the ECGs
all children between the ages of 9-11 and
healthcare providers. Also has printable educational materials including
again between 18-21.
2
Follow-up: Weekly or at least every 2 –
– 6 months, if the
the Stoplight Food Guides.
Inclusion criteria – children ages 2-18 yrs with a BMI ≥ 85% seen at the
overweight category,
BMI/weight status has not improved consider advancing to Stage 4.
Of note, some subspecialty clinics are screening for Vitamin D deficiency and insulin
– educational handouts including Kids My
study site for a well checkup
obtain a lipid profile.
Plate handouts for sale
Charts were reviewed for compliance with the elements stated in the ECG
Maintain weight velocity:
– 5210 Healthy Habits Questionnaire (English/Spanish)
for obesity
4
and other educational information to use in visits. Also available an online
Where/By Whom:
Results
Reassess annually
store for educational posters
What: Recommended for children with BMI >
- 3. Also
Follow up at every well-child visit.
- Includes resources and
printable educational materials
• BMI was assessed (underweight, normal weight, overweight, or obese) 44%
- Resources for families and healthcare providers.
Obesity-
-
Goals
Decrease in BMI.
of the time
Next Steps – A Practitioner’s Guide of Themed Follow-up Visits to Help
5
Follow-up:
Patients Achieve a Healthy Weight. Flip chart to guide patient visits.
• ECG were utilized 17% of the time
6,7
Available through the American Academy of Pediatrics.
• Education on the ECGs did not improve their usage
Dermatologic:
Endocrine:
Orthopedic:
References
Pediatric Obesity Clinical Decision Support Chart – Flip chart to aid in the
Acanthosis nigricans
Blount’s Disease
• Providers were still not comfortable managing overweight/obese children
Cholelithiasis
1.
lescent overweight and obesity: Summary
assessment, prevention, and treatment of children who are obese.
(PCOS)
report. Pediatrics. 2007;120(4):S164-S192.
Slipped capital femoral
in primary care. Would rather refer out to Endo
2.
n in children and adolescents: Full report. 2012.
Precocious puberty
epiphysis (SCFE)
Available through the American Academy of Pediatrics.
Intertrigo
GERD
3.
– 2015. Diabetes Care 2015;38(Suppl.1):S8-S16.
• Providers and sta became more aware of the number of children in the
Prediabetes:
4. Taveras EM, Rifas-
Arch Pediatr Adolesc Med. 2011;165(11):993-998.
Fifteen Minute Obesity Prevention Protocol,
Psychological/Behavioral Health:
Frequently Used ICD-10 Codes
glucose and/or impaired
5. Copeland K, Silverstein J, Moore K, et al. Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364-382.
practice who were overweight/obese
found in Barlow, S.(2007). Expert Committee
Anxiety
6.
ty. Child Obes. 2014;10(4):304-317.
glucose tolerance as
• A nutrition counseling visit was developed by the ARNP
Recommendations Regarding the Prevention,
Neurologic:
7. Haemer MA, Grow HM, Fernandez C, et al. Addressing prediabetes in childhood obesity treatment programs: Support from research an
Child Obes. 2014;10(4):292
demonstrated during a GTT
-303.
Depression
Assess ment, and Treatment of Child and
• R63.5 – abnormal weight gain
R73.0 – abnormal glucose
• The providers in the practice started identifying overweight/obese children
Pseudotumor cerebri
Premature adrenarche
8.
.
• E78.0 – pure hypercholesterolemia
• R73.01 – Impaired fasting glucose
Teasing/bullying
Adolescent Overweight and Obesity:
Type 2 Diabetes
9.
. Pediatrics. 2015;134(4): 649-657.
• E78.1 – hyperglyceridemia
• R73.09 – other abnormal glucose
and referring them to the ARNP for assessment and counseling
• E78.5 - hyperlipidemia ,unspeci ed
Summary Report. Pediatrics; 120, S164-S192.
• R73.9 – hyperglycemia, unspeci ed
• E28.2 – PCOS
• R03.0 – elevated blood pressure
Updated 08/19/15
• L83 –
acanthosis nigricans
reading without diagnosis of HTN
Linda Barreras, DNP, FNP-BC
Move on to next page
Presented by
Barlow, S.E. (2007). Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report Pediatrics, 120, S164-S192. doi: 10.1542/peds.2077-2329F Hassink, S.G. (2014). Pediatric Obesity. Elk Grove Village, IL: American Academy ofPediatrics. Ogden, C.L., Carroll, M.D., Kit, B.K., Flegel, K.M. (2012). Prevalence of Obesity and Trends in Body Mass Index Among US Children and Adolescents, 1999-2012.JAMA, 307, 483-490.

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