Problem Addressed

• Many overweight, obese teenagers: Over a third of youth in the United States have weight problems, with 16 percent of those age 6 to 19 being overweight and 19 percent being obese.¹
• Long-term health problems, psychological symptoms: Overweight and obese teens face an increased risk of a variety of health problems over the long term and are more likely to be obese as an adult (which carries its own set of health risks).^2-6 In addition, obese adolescents (particularly females) are more likely to exhibit psychological symptoms.^7-12
• Economic and social challenges: Overweight and obese adolescents often complete fewer years of formal education and face increased risk of serious social and economic problems later in life, including financial challenges.^13,14
• Unrealized potential of primary care–based programs: Several clinic-based programs have demonstrated some success in helping overweight and/or obese youth manage weight. However, most are designed for preadolescent children and their families, and consequently may have limited appeal to teenage girls who desire autonomy and are more likely to be influenced by peers than parents.¹⁵ Pediatric providers are ideally positioned to support overweight and obese teens in making lifestyle changes, as they have multiple contacts with teens who view them as credible sources of information and expect them to address weight management during visits.¹⁶ Yet many primary care providers report feeling uncomfortable, ineffective, and inadequately prepared to address overweight and obesity in adolescent patients during time-pressed office visits.¹⁶

Description of the Innovative Activity

• Identification of eligible teens: Girls between the ages of 12 and 17 with an age- and gender-adjusted body mass index (BMI) at or above the 90th percentile could generally participate, provided they were not pregnant or severely obese (greater than 99th percentile for age and gender-adjusted BMI), did not use medications that affect weight, and did not suffer from cognitive impairment or psychosis. Unlike other initiatives targeted at youth, the program served teens with or at high risk for depression and/or eating disorders. Kaiser identified eligible teens through its electronic medical record (EMR). Pediatricians and primary care physicians (PCPs) could also refer eligible patients to the program, while posters placed in the plan’s 23 clinics encouraged self-referrals.
• Enrollment and initial assessment: The health plan sent letters to both the teen and her parents introducing the program. Staff proactively called all eligible individuals to gauge their interest. Interested participants and their parents met with program staff and their pediatric provider for an upfront assessment to ensure suitability for the program. For those who would be participating in the program, this evaluation also included measurement of height and weight, a review of eating and physical activity habits (e.g., whether the teen regularly ate breakfast and participated in family meals; average screen time each day), and screening for eating disorders and depression. Following this session, the pediatric provider received a one-page summary of key findings. (See the “provider training and support” bullet below for more details.)
• Group meetings over 5-month period: Participating girls could attend a series of 16 meetings over a 5-month period led by one individual, typically a masters-level nutritionist or health educator, or a doctoral-level clinical psychologist. Key components of these sessions are described below:
  • Logistics: Groups of 8 to 14 girls met on a weekly basis for the first 3 months and every other week over the following 2 months; the typical participant attended approximately 10 of the 16 total meetings.¹⁵ During the 4-year trial, various 5-month courses were offered throughout the region, with sessions typically held in one of Kaiser's local primary care clinics.
  • Content and focus: Sessions focused on helping teens change eating habits and increase levels of physical activity. The curriculum emphasized topics pertinent to adolescent girls, including recognizing and avoiding disordered eating patterns, promoting positive body image, coping with family and peer teasing, and minimizing emotional eating. Session leaders taught specific behavioral and cognitive tools for coping, including self-monitoring of dietary intake, physical activity, and screen time; stimulus control and environmental changes; goal-setting and problem-solving; and cognitive restructuring techniques to combat negative self-talk.
  • Format: Each session lasted roughly 2 hours, consisting of 90 minutes of content plus breaks. Sessions included three distinct parts, outlined below:
    • Interactive discussion about progress since last session: Each session began with a 20-minute “check-in” period in which leaders reviewed the diet and physical activity habits of each participant since the last meeting, as documented on an easy-to-use food diary and physical activity tracking form distributed at the initial assessment. Participants discussed problems and barriers they faced in meeting behavior-related goals, with session leaders actively problem-solving with them.
    • Teaching practical skills: Session leaders spent roughly 30 minutes reviewing a specific topic related to diet and/or physical activity. These interactive sessions taught practical skills and strategies related to changing behaviors, as outlined in the sub-bullets below. By the end of the session, each participant set specific goals to work on before the next meeting.
      • Improving diet: Session leaders focused on reducing portion sizes, limiting consumption of energy-dense food, establishing regular meal patterns (especially breakfast), substituting water for sugar-sweetened beverages, reducing fast-food consumption, eating more family meals, and consuming more fruits and vegetables.
      • Increasing physical activity: Session leaders focused on the need for 30 to 60 minutes of physical activity at least 5 days a week. They encouraged participation in 15 minutes of daily yoga, limiting screen time to 2 hours or less each day, engaging in “found exercise” (e.g., taking the stairs instead of elevators), and using pedometers and resistance bands to set goals and track progress toward them. Because teens may be reluctant to exercise in front of others (due to fear of being victimized or embarrassed by peers), sessions focused on activities that can be done at home, such as yoga or dance videos. They also encouraged youth to get exercise through play, which can be important in overcoming the initial discomfort of increasing levels of physical activity. Participants who attended five of the first six sessions and completed their diet and exercise self-monitoring records received exercise gaming equipment to use at home.
    • Participation in physical activity: During the final hour, participants engaged in physical activity, often yoga-based stretching and strength training designed to increase body awareness, core strength, and coordination. As appropriate, instructors provided training in these areas and gave participants a booklet and video to encourage participation in yoga outside the sessions.
• Parent group sessions: During the first 3 months, the parents of participating girls attended a separate meeting (held at the same time as the teen sessions) designed to help them in supporting their daughters. During the initial trial, the typical parent attended approximately 8 of the 12 meetings.¹⁵ Also led by a nutritionist, health educator, or psychologist, these 60-minute sessions included a review of the nutritional and physical activity principles taught to the teens. Parents learned strategies and behaviors to help their daughters, including having regular family meals and activities and striking the right balance in trying to influence their teen’s behaviors (since too close monitoring can be counterproductive with often-rebellious teens). Session leaders emphasized the impact that parental attitudes, behaviors, monitoring techniques, and comments (e.g., about weight and shape) can have on their daughters. (The sessions did not focus on encouraging family members to make the same kinds of behavior changes.)
• Family activities: On several occasions during the 5-month trial, program leaders hosted family activities for participants, such as going to a rock-climbing wall or taking a group hike.
• Provider training, support, and interaction with patient: The program supported pediatric providers in effectively counseling teens on diet and physical activity. As outlined below, this support included formal training, two reports on each participant’s behaviors, and at least two formal appointments with the teen.
  • Training: Pediatricians, nurse practitioners, and physician assistants with adolescent patients in the program received training on how to effectively counsel and support teen patients in behavior change. Led by a pediatrician and project staff member well-versed in motivational enhancement techniques, these two 90-minute lunch-time sessions were held in each of the 23 Kaiser clinics with participating patients, with attendees receiving continuing medical education (CME) credits.
    
    • Session one: The first session focused on how to collect and review objective information with patients (such as data from food and exercise diaries and laboratory test results) and how to counsel patients on positive behavior change  during time-pressed visits. Training advocated use of an established approach known as FRAMES (provide feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, and promote self-efficacy).¹⁶ Based on principles of motivational interviewing, FRAMES emphasizes the need to engage teens in conversations and give them the information needed to make their own choices (rather than talking “at” them, as many pediatric providers do).
    • Session two: During the second session, participating providers watched and discussed a video that contrasted the traditional authoritarian approach to counseling with the approach advocated in the training.
  • User-friendly reports: Participating providers received two user-friendly, one-page reports for each patient in the program. The reports detailed the teen's height, weight, BMI, perceived confidence in controlling weight, and eating and exercise habits (e.g., screen time, meal patterns, physical activity patterns). They highlighted positive behaviors, trends to be reinforced, and issues and challenges to be addressed. Providers received the first report after the initial assessment, while the second came roughly a month after the group sessions ended.
  • Provider appointments with teen: Pediatric providers had at least two opportunities to interact with the patient as part of the program—the initial assessment at program entry (described earlier) and another appointment roughly a month after the sessions ended. Some participating patients also had regularly scheduled office visits during the program, providing additional opportunities for interaction with providers. Providers were encouraged to employ the techniques learned during training and to work with the teens to set one or two achievable behavior-related goals, paying particular attention to areas highlighted in the reports.

References/Related Articles

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Innovator Disclosures

Results

• Small but significant and sustained decline in normalized BMI: Seven months after completing the program, participating girls had experienced a slightly greater decline in BMI z-score (a normalized measure of BMI that takes into account expected growth patterns based on age and sex) than did a control group of similar teens receiving usual care, which consisted of educational materials for teens and their parents and a brief meeting with their PCP at the beginning of the program.¹⁵ The difference of 0.07 in BMI z-score reduction (a 0.15 in the intervention group, versus 0.08 in the control group) met the test of statistical significance.
• Better eating habits: Compared to those receiving usual care, participants reported less consumption of fast food (once a week in the intervention group, versus 1.55 times in the control group).¹⁵
• Improved psychosocial outcomes: Compared to those receiving usual care, participants reported greater satisfaction with their bodies and less internalization of social norms regarding female attractiveness, such as society’s emphasis on weight and body shape.¹⁵
• Generally high satisfaction: Teens and parents rated the program’s services highly (4.4 on a scale of 1 to 5 for both teens and parents) and believed that it met their needs (4.0 for teens and 3.9 for parents).¹⁵ Participating providers rated the training as moderately adequate in preparing them to work with overweight teens (mean rating of 6.28 on a scale of 1 to 10), with those completing all the training rating it more highly than those completing only part of it (7.43 versus 5.28).¹⁶
• Positive impact on patient interactions: Participating providers reported that the training had a moderate influence on how they interacted with patients (a mean of 5.75 on a scale of 1 to 10). Providers who completed the training reported greater ease in working with overweight teens and more confidence in motivating them to make lifestyle changes than did those completing only part of it.¹⁶

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Identifying physician champions: Two well-respected pediatricians (the former chief of pediatrics and a physician with expertise in weight management) expressed an interest in being “champions” for the program. They played a critical role in introducing it to and winning the support of their colleagues in Kaiser's 23 primary care clinics.
• Iterative development based on evidence, stakeholder input: A small group of individuals who had experience working with teens and expertise in nutrition, exercise physiology, and behavioral psychology took the lead in developing the curriculum and materials for both the teen and parent classes and provider training. While the group relied primarily on existing evidence and research to guide the content, they elicited substantial input from teens, parents, and pediatric providers on logistics and format, as outlined below:
  • Teen and parent input: Program leaders conducted 60- to 90-minute interviews to elicit the views of 24 teens and their parents on the best way to structure the program. Separate one-on-one sessions were conducted with each individual. As noted earlier, these interviews highlighted the need for a program designed exclusively for girls. The interviews also made it clear that teens respected and would listen to their pediatric providers.
  • Provider input: Program leaders met with roughly a dozen providers, focusing on how best to structure the training and support. These meetings highlighted the need to make the program minimally intrusive, with an emphasis on easy-to-use forms and fitting counseling into existing workflows. Program leaders made several refinements based on provider input, including expanding the initiative to include teens above the 90th (rather than the 95th) BMI percentile to maximize the program’s reach, and streamlining the initial four-page version of the patient-specific reports to a more user-friendly, one-page version.
• Initial and ongoing session leader training: Before the program began, staff designated to lead the group classes attended several days of intense training on the curriculum and how to lead the sessions effectively. During the first few months after classes began, program leaders held weekly meetings with session leaders, giving them feedback based on their review of audio and videotapes. Over time, the intensity of ongoing supervision tapered off, first to meetings every other week and then to monthly sessions.
• Ongoing evaluation to determine program future: As noted, the initial trial ran for roughly 4 years, ending in May 2009 when funding ceased. Since that time, Kaiser Permanente Northwest has not offered the program. Program leaders are working with the health plan to determine the appropriate course of action going forward. Kaiser leaders remain concerned about the program’s ability to generate a positive return on investment, due both to the significant amount of labor involved and the fact that cost savings may not materialize for many years, when participating teens will be well into adulthood and likely enrolled in another health plan. Program leaders are trying to determine if certain components can be delivered cost effectively on an ongoing basis (not just as part of a time-limited trial). To that end, consideration is being given to focusing provider training on those seeing a large volume of teen patients and to developing a Web-based version of the group sessions for both teens and parents. (Kaiser has successfully used online group sessions as part of other initiatives focused on behavior change.)

Resources Used and Skills Needed

• Staffing: As noted, the program made use of masters-level nutritionists and health educators and doctorate-level clinical psychologists, all of whom had prior experience working with teens on lifestyle interventions. For the most part, these staff already existed within Kaiser Permanente Northwest, although some turnover did occur during the study. Program leaders suggest that organizations adopting this program evaluate current staff to see if individuals with expertise working with teens on behavior change are available. Staff from the nutrition, health education, case management, and/or physical therapy department will often be qualified for and interested in this type of program.
• Costs: Kaiser has not analyzed data on program-related costs, although program leaders acknowledge that the staffing-related costs are substantial, including the extra compensation required to pay for the time involved in training providers and holding group sessions. Other costs include the materials and supplies used and distributed at the training and group sessions.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Consider partnerships: As noted, Kaiser Permanente Northwest did not continue the program in its original form due to lack of funding and some concerns about its costs and the long-term nature of any benefits. However, community-based organizations focused on youth (e.g., county health departments, local YMCA chapters and boys’ and girls’ clubs) may have an interest in promoting behavior change among teens and hence could be valuable partners, thus reducing the cost for any one organization.
• Consider ways to enhance efficiency, accessibility: Program leaders believe there may be ways to deliver the program more efficiently, such as focusing provider training on those caring for a high volume of teen patients and/or creating an online version of the group sessions, which would not only reduce costs but also make it easier for parents and teens to participate. During the initial trial, only about 10 percent of parents/teens chose to enroll, as the transportation requirements and time constraints associated with in-person sessions proved too burdensome for many.
• Leverage existing evidence and resources: Well-vetted programs (including this one) based on established evidence should be used to inform program development and implementation.
• Identify and work with “champion” physicians: As noted, two well-respected pediatricians became champions for this program, offering valuable input and eliciting support from their peers. Every provider who worked with patients in the program attended at least one of the provider training sessions, in large part due to the work of the two champions.
• Elicit stakeholder input: As noted, program leaders elicited substantial input from teens, parents, and pediatric providers on the best way to structure the program. These stakeholders made many suggestions that improved the initial design. In particular, providers gave valuable suggestions for integrating the program into existing processes and systems and for streamlining the content included in the two reports.
• Offer training during lunch, with CME credit: High provider attendance at the two training sessions also stemmed from the decision to offer the sessions over lunch and to allow participants to earn CME credits.

Sustaining This Innovation

• Continue to elicit input and refine program: After implementation, program leaders should periodically elicit additional input from parents, teens, and providers on the program and make adjustments as necessary.
• Consider integrating provider reports into EMR: Kaiser Permanente Northwest providers routinely use an EMR system at the point of care. Due to technical issues, however, the one-page reports could not be integrated into the system. Instead, providers received paper versions that could be scanned into the electronic record if so desired. The information in these reports likely would have had more impact if it had been easily accessible within the portion of the EMR routinely used during office visits.
• Consider greater emphasis on parent behavior change: As noted, the parent sessions focused primarily on ways to support teens in changing their behaviors, with relatively little emphasis (particularly in the early sessions) on encouraging parents to do the same. In hindsight, program leaders believe that emphasizing both could yield additional benefits (although they have not tested this theory).
• Assess appropriate amount of direction: While the curriculum encouraged teens to adopt healthier habits, it did not rigidly prescribe a formula for doing so. The goal was to empower teens with the skills and knowledge needed to make good choices. While this approach fits with research on the best ways to promote behavior change among teens in a manner respectful of their developing autonomy, program leaders have hypothesized that being more prescriptive early in the program could have yielded potential benefits by helping teens experience initial success that could then become self-sustaining. (Again, they have not tested this hypothesis.)