(image: NYC RING and Prescription for Health logos)

• 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-year initiative of the RWJ Foundation
• 10 PBRN's funded in Round II
• Aims: Develop practical strategies for promoting healthy behaviors among primary care patients, targeting:
  • Lack of physical activity
  • Unhealthy diet
  • Tobacco use
  • Risky alcohol use

To address health and health care of underserved urban communities through quality improvement projects and research initiatives.

• 25 practices
• 450,000+ primary care visits/yr
• 60% Latino, 35% AA
• Primarily low income and wc
• Most sites with partial EMR and ability to access CIS

(image: map titled "NYC RING Practices")

• 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
• Jennifer Klein, RD
• Jean Burg, MD
• Robert Clarick, MD
• Frank Silagy, MD
• Claudine Smith, MD
• Staff and clinicians at our 3 intervention sites

• FLAIR Primary Research Questions
  • Can 2-4 y.o. well visits be successfully reframed to assess risk and initiate counseling for behavior change?
  • Can an intervention based on family lifestyle risk assessment change behaviors (of adults and children)?
• FLAIR Secondary Research Questions
  • What is a reasonable estimate of effect size for changing family diet and exercise behaviors? Children's BMI?
  • Can home visits be used to advance family nutrition assessment?

• Childhood obesity management programs
  • B'N Fit
  • CHCC Fun & Fit
  • Starting Right
• Consults
  • Endocrine Clinic
  • Hyperlipidemia Clinic
  • Hypertension Program
• Sources of tools/training
  • FLAIR
  • School Health Obesity Initiative

The Montefiore Pediatric Obesity Prevention (MPOP) Workgroup

• D Appel, MD Director, Montefiore School Health Program
• K Ayoob, EdD, RD, Nutrition Clinic, Rose F. Kennedy Center
• P Belamarich, MD Medical Director, PASS
• S Braganza, MD Division of Social Pediatrics
• M Charlop, MD, MPH Director, Community Health Division, MSHP
• D Deen, MD, MS Professor of Epidemiology and Population Health
• J Flynn, MD, MS Director, Pediatric Hypertension Program
• C Isasi, MD, PhD Division of Health Behavior and Nutrition
• U Khan, MD B'N Fit Division of Adolescent Medicine
• M Larkin, MD, Co-Director, Starting Right, SBHCCF
• E Larrier, Executive Director, Bronx Community Health Network (BCHN)
• J Leo, MD, Montefiore School Health Program
• J Leuchter, Manager, Health Education, CFCC
• K O'Connor, MD, Pediatric Chief Resident, CHAM
• M Pappo, MS, RD Clinical Nutrition Manager, Montefiore Medical Center
• M Puri, MD, Fellow, Pediatric Endocrinology
• A Rich, MD, Medical Director, Montefiore CHCC
• J Rieder, MD, MS, Director, B'N Fit Program, Div of Adolescent Medicine
• I Sharif, MD, MPH Director, CHCC Fun & Fit
• R Siegel, LMSW, Behavior Therapist, B'N Fit Program

• To develop a collaborative approach to the management of at-risk and overweight youth.
• To develop a practical set of evidence/consensus-based tools to screen for and manage at-risk and overweight youth.

1. Pediatric Overweight Chart Form
2. List of Resources
3. Advocacy Activities

Reframe preventive visits for 2-4 y.o. 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 counselor to augment clinicians' efforts

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

• Providers engage families to change behaviors
  • 2 y.o. visit "salient" to families
  • Providers appropriately assess behavior and respond
• Increase contacts focused on behavior change
• Learn how to incorporate activities into practices
• Some behavior change (how much?)
• Preliminary efficacy data on preventing excess weight gain

Initial Chart Review (n=80)
Visits 12/05-3/06 with FLAIR screen with goal setting BMI charted 2-3 y.o. Mean BMI for age      17.6      >85%      >95% 4-5 y.o. Mean BMI for age      16.9      >85%      >95%	31% 29% 46%     14% 25%     20% 17%

• Referrals to lifestyle counselor             79
  • Contacts with lifestyle counselor    34
    

    — Phone — Appointments

    21 13

• Referrals to lifestyle counselors from what proportion of docs at each site?
  • 8/8 at Tremont
  • 4/6 at Castle Hill
  • 2/2 at University Ave
• Differences by site in referral process
• Speed of adoption: variable

Preliminary Findings (n=70)

• Parental Family History
  • DM- 43%
  • HTN- 45%
  • CAD- 16%
• Parental History
  • DM- 3%
  • HTN- 16%
  • CAD- 7%
• Parental BMI (mean)
  • Mom- 30
  • Dad- 27

• Nutrition
  • Juice/soda- 3/day
  • Milk- 3/day (71% whole, 3% skim)
  • Fast food- 1.3/week
• TV time- 36% 0-2 hours/weekday
• Family Meals- mean 3.8 meals/week
• Outdoor Activity- mean 3.6 days/week
• Smoking- 22% with smoker living in the home

Reduce juice Reduce fast food Change milk Decrease soda Family meals Quit smoking Increase outdoor activity Decrease TV time Overweight sibling

14 3 16 6 7 8 11 20 11

• 13 School-based Health Centers (SBHCs)
• New Clinical Guidelines for Overweight
• Healthy Kids – A community-based fitness & nutrition initiative of the MSHP
• Classroom Fitness & Nutrition
• School/Community-Centered Activities
• CSA and Policy Efforts

• Medical model is inadequate by itself
• Obesity is a worldwide public health issue
• Will never be solved in MD office alone
• Blaming/excusing- vs. responsibility
• Recognize our tendency to internalize our feelings of powerlessness and impotence
• Play a public health role!

• Letter sent by MPOP to Person in charge of vending machines to request offering healthier alternatives for Montefiore Patients and staff
• Positive response and the requested changes are being implemented