FLAIR Family Lifestyle Assessment of Initial Risk

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FLAIRFamily Lifestyle Assessment of Initial Risk

• New York City Research and Improvement Group (NYC
  RING)
• Darwin Deen, MD
• Professor, Family and Social Medicine
• Albert Einstein College of Medicine
• Bronx, NY
• deen_at_aecom.yu.edu

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Pediatric Obesity in the Bronx

• 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
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RWJ Prescription for Health

• 5-year initiative of the RWJ Foundation
• 10 PBRNs 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

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NYC RING Mission

• 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

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FLAIR Team

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

• 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

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• 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?
  Childrens BMI?
• Can home visits be used to advance family
  nutrition assessment?

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Montefiore Medical Center Initiatives

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

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Practical Approaches to Child and Adolescent
Obesity in the Bronx

• The Montefiore Pediatric Obesity Prevention
  (MPOP) Workgroup

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• 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 BN 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 OConnor, 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, BN Fit Program, Div
  of Adolescent Medicine

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MPOP Workgroup Goals

• 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.

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MPOP Workgroup Activities

• Pediatric Overweight Chart Form
• List of Resources
• Advocacy Activities

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FLAIR Intervention

• 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

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FLAIR Tools

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

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Expected Outcomes

• 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

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Adoption of Intervention by Primary Care Providers

• Initial Chart Review (n80)
• Visits 12/05-3/06
• with FLAIR screen 31
• with goal setting 29
• BMI charted 46
• 2-3 y.o.
• Mean BMI for age 17.6
• 85 14
• 95 25
• 4-5 y.o.
• Mean BMI for age 16.9
• 85 20
• 95 17

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Adoption of Intervention by Primary Care Practices

• Referrals to lifestyle counselor 79
• Contacts with lifestyle counselor 34
• Phone 21
• Appointments 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

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FLAIR Screening

• Preliminary Findings (n70)
• Parental Family History
• DM- 43
• HTN- 45
• CAD- 16
• Parental History
• DM- 3
• HTN- 16
• CAD- 7
• Parental BMI (mean)
• Mom- 30
• Dad- 27

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FLAIR Screening

• 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

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Referrals (n79)Initial Goal Setting

• Reduce juice 14
• Reduce fast food 3
• Change milk 16
• Decrease soda 6
• Family meals 7
• Quit smoking 8
• Increase outdoor activity 11
• Decrease TV time 20
• Overweight sibling 11

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MPOP School-Based HealthObesity Initiative

• 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

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Staying Sane Public Health Advocacy

• 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!

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MPOP Changing Vending Machine Options

• 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