Pediatric Obesity Initiative: Your Office and POWER

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Pediatric Obesity Initiative Your Office and
POWER

• Brandi Rudolph, MD
• Resident, Pediatrics, Psychiatry, Child and
  Adolescent Psychiatry
• Indiana University School of Medicine,
  Indianapolis, IN

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Questions

• How do I calculate BMI and know its significance?
• - calculating BMI - interpreting BMI
• What is the link between lifestyle and obesity?
• - nutrition - (in) activity
• - environment - genetics
• What are the complications of obesity?
• - liver disease
• - metabolic syndrome definition and
  significance
• - cause and effect of endocrine issues
• What are the treatment options?
• - nutrition education - activity education
• - pharmacotherapy - surgical options
• What you can do?

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Questions

• How do I calculate BMI and know its significance?
• - calculating BMI - interpreting BMI
• What is the link between lifestyle and obesity?
• - nutrition - (in) activity
• - environment - genetics
• What are the complications of obesity?
• - liver disease
• - metabolic syndrome definition and
  significance
• - cause and effect of endocrine issues
• What are the treatment options?
• - nutrition education - activity education
• - pharmacotherapy - surgical options
• What you can do?

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Body Mass Index (BMI)

• BMI kg/m2
• BMI adult 20-25 Normal
• 25-29 Overweight/at risk
• gt 30 Obese
• Obese I 30-34.9
• Obese II 35-39.9
• Extreme obese gt 40
• Super obese gt50
• Mega obese gt70

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Pediatric BMI Interpretation is Age-Dependent

• Pediatrics BMI
• 5-85 Normal
• 85-95 Overweight
• gt 95 Obesity

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Questions

• How do I calculate BMI and know its significance?
• - calculating BMI - interpreting BMI
• What is the link between lifestyle and obesity?
• - nutrition - (in) activity
• - environment - genetics
• What are the complications of obesity?
• - liver disease
• - metabolic syndrome definition and
  significance
• - cause and effect of endocrine issues
• What are the treatment options?
• - nutrition education - activity education
• - pharmacotherapy - surgical options
• What you can do?

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Obesity Causes
Intake Expenditure
Environment Genetics
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Questions

• How do I calculate BMI and know its significance?
• - calculating BMI - interpreting BMI
• What is the link between lifestyle and obesity?
• - nutrition - (in) activity
• - environment - genetics
• What are the complications of obesity?
• - liver disease
• - metabolic syndrome definition and
  significance
• - cause and effect of endocrine issues
• What are the treatment options?
• - nutrition education - activity education
• - pharmacotherapy - surgical options
• What you can do?

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Obesity Leads To
Coronary artery disease Type II diabetes Hypertension Cerebrovascular accident Osteoarthritis Sleep apnea Gastroesophageal reflux Depression Gallbladder disease (x4 more likely in obese than lean) Non-alcoholic fatty liver / steatohepatitis (NAFLD / NASH) Metabolic syndrome.
First generation to live sicker and die younger
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NAFLD and NASH

• NAFLD and NASH are common among obese children
  and can lead to progressive liver disease, even
  in childhood
• Prevalence in adults gt10 of general population
  and gt50 of obese persons
• Prevalence in children 3 of children and gt20
  of obese children

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Metabolic Syndrome

• Link between insulin resistance and hypertension,
  dyslipidemia, type 2 diabetes, and prothrombotic,
  inflammatory vascular environment
• Long-term complication is cardiovascular disease
  also consider liver disease, PCOS, premature
  puberty etc
• NHANES III (1988-1994) prevalence 6.8 in
  overweight adolescents and 28.7 in obese teens
• Males gt females ethnic differences

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Endocrine Causes of Obesity

• Growth hormone deficiency
• Hypothyroidism
• Hypercortisolism
• Primary hyperinsulinism
• Pseudohypoparathyroidism
• Acquired Hypothalamic

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Endocrine Effects of Obesity

• Type 2 Diabetes
• Insulin Resistance
• Acanthosis nigricans. May improve with improved
  insulin resistance

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Cardiovascular Health and Obesity

• AAP guidelines Lipid screening and
  cardiovascular health in childhood. Pediatrics
  July 2008

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Questions

• How do I calculate BMI and know its significance?
• - calculating BMI - interpreting BMI
• What is the link between lifestyle and obesity?
• - nutrition - (in) activity
• - environment - genetics
• What are the complications of obesity?
• - liver disease
• - metabolic syndrome definition and
  significance
• - cause and effect of endocrine issues
• What are the treatment options?
• - nutrition education - activity education
• - pharmacotherapy - surgical options
• What you can do?

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Modalities of Obesity Treatment
Pharmacotherapy
Lifestyle Modification
Surgery
Nutrition Therapy
? Physical Activity
Adherence to Improved Nutrition and Physical
Activity
Stunkard. Obes Res. 19964293
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Pharmacotherapy A Primer

• Should not be considered as short-term fix/sole
  Rx
• 2 main drug groups
• Lowered intake by appetite/ satiety, e.g.,
  sibutramine (approved gt16 years with program)
• Malabsorption, e.g., orlistat ( approved gt12
  years with program)
• Others
• Dietary supplements
• Drugs with Other Indications
• Investigational drugs

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Surgery A Primer

• Indications in Adults
• BMI ? 40
• BMI 35-40 with severe obesity-related disease and
  unable to lose weight with non-surgical therapy
• Pediatric indications consider for motivated
  teens with BMI gt 40, failure of organized weight
  loss attempts gt 6 months, near- complete skeletal
  maturity, and significant co-morbidities in a
  multidisciplinary experienced center.

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A Guide to Selecting Treatment
BMI category
Treatment
25-26.9
27-29.9
30-34.9
35-39.9
?40
Diet, physical activity, and behavior therapy
With co-morbidity




With co-morbidity



Pharmacotherapy
With co-morbidity

Surgery
The Practical Guide. 2000
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Questions

• How do I calculate BMI and know its significance?
• - calculating BMI - interpreting BMI
• What is the link between lifestyle and obesity?
• - nutrition - (in) activity
• - environment - genetics
• What are the complications of obesity?
• - liver disease
• - metabolic syndrome definition and
  significance
• - cause and effect of endocrine issues
• What are the treatment options?
• - nutrition education - activity education
• - pharmacotherapy - surgical options
• What you can do?

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Take Home Tips to Get Started

• Change full diary to low fat
• Change caloric beverages to those without
• Change from frying to baking, grilling, broiling
• Change sweet snacks to fruit crunchy/salty to
  veggies
• Eat at designated place with distraction
• Plan snacks into day not grab and go
• Active play daily break a sweat

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Recommendations for Obesity Prevention

• Limit sugar-sweetened beverages (CE)
• Encourage recommended servings of fruits and
  vegetables (ME)
• Limit screen time to 2 hours/day (CE)
• Remove screen from primary sleeping area (CE)
• Eat breakfast daily (CE)
• Limit restaurants especially fast foods (CE)
• Eat meals as family more appropriate choices
  (CE)
• Limit portion size (CE)
• Authoritative, not authoritarian parenting
• CE consistent evidence ME- mixed evidence

Davis MM, Pediatrics 2007
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References

• Barlow SE and Dietz WH. Obesity evaluation and
  treatment expert committee recommendations.
  Pediatrics 1998102E29.
• Baker S, Barlow S, Cochran W et al. Overweight
  children and adolescents a clinical report of
  the North American Society for Pediatric
  Gastroenterology, Hepatology and Nutrition. J
  Pediatr Gastroenterol Nutr 200540533-543
• Diets WH and Robinson TN. Overweight children and
  adolescents. N Engl J Med 20053522100-9
• Barlow SE and Dietz WH. Obesity Evaluation and
  Treatment Expert Committee Recommendations.
  Pediatrics 2007102, S164
• Committee on Nutrition American Academy of
  Pediatrics. Prevention of pediatric overweight
  and obesity. Pediatrics 2003112424-430.
• Weiss R, Dziura J, Burgert TS et al. Obesity and
  the metabolic syndrome in children and
  adolescents. N Engl J Med 20043502362-2374.
• Inge TH, Krebs NF, Garcia VF et al. Bariatric
  surgery for severely overweight adolescents
  concerns and recommendations. Pediatrics
  2004114217-223.
• www.nichq.org Expert Recommendations

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Psychology and Obesity

• Ann M. Lagges, Ph.D., H.S.P.P.
• Assistant Professor of Clinical Psychology in
  Clinical Psychiatry
• Indiana University School of Medicine

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Stradmeijer, Bosch, Koops and Sedell (2000)

• Compared 73 overweight and 70 normal weight
  children ages 10-16.
• Results
• Overweight higher Total Problem Behavior scores
  on the Child Behavior Checklist (CBCL) as
  reported by mothers and teachers
• This difference between overweight and normal
  weight children was more marked for children
  under 13.
• Overweight children had lower self-competence
  scores on physical appearance, athletic
  competence, social acceptance and global
  self-worth.

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Falkner et al (2001)

• Compared 4742 male and 5201 female students in
  7th, 9th and 11th grades
• Obese girls compared to normal weight girls
• 1.63 times less likely to hang out with friends
  in past week
• 1.49 times more likely to report serious
  emotional problems in the past year
• 1.79 times more likely to report hopelessness
• 1.73 times more likely to report a suicide
  attempt
• 1.51 times more likely to report being held back
  a grade
• 2.09 times more likely to consider themselves
  poor students.

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Falkner et al (2001)

• Obese boys compared to normal weight boys
• 1.91 times less likely to hang out with friends
  in the past week
• 1.34 times more likely to report friends dont
  care about them
• 1.38 times more likely to report emotional
  problems in the past year
• 1.46 times more likely to consider themselves
  poor students
• 2.18 times more likely to expect to quit school

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Pearce, Boergers, and Prinstein (2002)

• 416 students in 9th to 12th grade
• Obese boys reported more overt victimization than
  average weight peers
• Obese girls reported more relational
  victimization than average weight peers
• Obese girls are less likely to date than average
  weight peers
• Obese boys and girls are more dissatisfied with
  their dating status than average weight peers

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Morgan et al (2002)

• Studied relationship between loss of control over
  eating and psychological distress in a sample of
  112 overweight children (ages 6-10)
• Overweight children reporting loss of control
  over eating had greater severity of obesity and
  higher levels of anxiety, depressive symptoms and
  body dissatisfaction

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Decaluwe, Braet, Moens Vlierberghe (2006)

• 196 Belgian families with an overweight 10 16
  year old
• Child Behavior Checklist
• Internalizing problems boys 49.3, girls 53.1
• Externalizing problems boys 42.7, girls 41.4
• Maternal and Paternal psychopathology were
  associated with greater psychopathology in the
  kids
• Compared to a normative group, parents of
  overweight kids were more likely to show less
  positive parenting and more ineffective parenting
  (such as inconsistent discipline)

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Jelalian, et al (2007)

• Review of the literature indicates higher levels
  of depressive disorders and anxiety disorders in
  obese children and adolescents
• Binge eating is also more common in obese
  children and adolescents
• Presence of a psychiatric disorder can complicate
  interventions for obesity and will need to be
  addressed if interventions for obesity are to
  have the best chance of succeeding.

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Psychosocial Treatment for Obesity in Children
and Adolescents
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Jelalian and Saelens (1999)

• Meta-analysis of 42 studies of randomized,
  non-school based studies of obesity intervention
  programs.
• For children (12 and younger)
• Behavior modification of eating and physical
  activity superior to education alone and wait
  list control
• Most behavioral interventions result in a 5-20
  decrease in overweight (short-term)
• Little evidence to suggest that exercise
  interventions without dietary changes will result
  in decrease in overweight

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Jelalian and Saelens (1999)

• Components of successful programs for children
• Self-monitoring of diet and activity
• Stimulus control strategies
• Contingency management
• There is not enough data to determine which
  component is most crucial

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Jelalian and Saelens (1999)

• Long-term maintenance
• Minimal long-term data - a few studies show 30
  achieving non-obese status at 5 and 10 year
  follow-up
• Parent involvement appears to be crucial
• Specifically, the critical factor may be that
  parents serve as models for eating and activity

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Epstein, Paluch, Kilanowski Raynor (2004)

• Children aged 8-12
• Stimulus control programs and positive
  reinforcement programs with goal of reduction in
  sedentary activity produced equal and significant
  reductions in sedentary activity
• When combined with diet change program using the
  Traffic Light Diet resulted in significant
  decreases in BMI.

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Saelens et al (2002)

• A controlled study of adolescent obesity
  treatment
• 44 overweight adolescents randomly assigned to
  multiple component behavioral weight intervention
  (Healthy Habits - HH) or to single session
  physician counseling (Typical Care -TC)
• Healthy Habits program
• 4 month program
• 11 planned telephone contacts by bachelors level
  counselor each lasting 15-20 minutes
• Mail contact
• Phone conversations and mailed materials
  addressed behavioral skills including
  self-monitoring, goal setting, problem solving,
  stimulus control, self-reward and pre-planning

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Saelens et al (2002)

• Results
• HH program resulted in better change in BMI
  z-scores than TC at post-treatment and 3- month
  follow up
• HH adolescents displayed higher use of behavioral
  skills

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Herrera, Johnston Steele (2004)

• Ages 6-18 with no effect found for age
• Base intervention nutritional education,
  exercise education and goal instruction
• 3 groups
• Base intervention alone
• Base intervention plus cognitive intervention
  (monitoring negative thoughts, restructuring
  negative thoughts, self-reinforcement)
• Base intervention plus behavioral intervention
  (self-monitoring, praise and modeling,
  reinforcement and contracting)

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Herrera, Johnston Steele (2004)

• Results
• Behavioral intervention was associated with
  greater reduction in percentage over ideal BMI
• Not clear that the cognitive intervention
  produced superior results than the base
  intervention alone
• Study did not address if adding cognitive
  interventions to the behavioral plus base
  intervention condition would lead to even greater
  improvement.

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Lifestyle Education (Physical Activity)

• Anne Graves, BS, ACSM HFS
• Clarian Health
• Senior Program Coordinator / POWER Exercise
  Physiologist

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1. Understand Physical inactivity and effect on
youth2. Establish an awareness of physical
activity guidelines for youth.3. Identify and
Examine approaches to increasing physical
activity in youth. 4. Use available research
to create a plan for working with children to
increase time spent in physical activity
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Where are we at?

• Although Children are naturally active, a
  significant amount of children are considered to
  get inadequate amounts of physical activity
  everyday.

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Physical Inactivity
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Why Has Energy Expenditure Decreased?

• Fewer physical household chores
• Less need and opportunities for manual
  transportation (walking, biking)
• More attractive sedentary leisure-time activities
  
• Less school physical education and other physical
  activity
• More people who model decreased physical activity
• Increased percentage of households where both
  parents work.

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Causes
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Importance of Physical Activity in Youth
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Can an Exercise Plan make a difference?

• Caloric expenditure by improving daily activities
  is small, but accumulative.
• Studies have shown that exercise plus diet is
  more effective in weight loss than diet alone.
• Regular exercise for a child with obesity has
  been shown to increase lean muscle mass, reduce
  blood pressure and improve psychological health.
• Regular exercise can result in a decreased risk
  for cardiovascular disease, diabetes,
  osteoporosis, COPD and even some cancers.

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Children are not simply small adults when it
comes to activity.
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Considerations

• Children who are overweight and obese are
  developing adult disorders such as CVD, Diabetes,
  Musculoskeletal, Metabolic Syndrome which makes
  it increasingly important to do a proper health
  risk assessment prior to planning exercise.
• Risks to exercise can be managed by proper risk
  stratification.

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The Recommendations

• According to the 2008 ACSM Guidelines for
  Exercise Testing and Prescription the Guidelines
  for Activity in Youth are
• 30 minutes of moderate intensity exercise 5-7
  (preferably 7) days per week
• 30 minutes of vigorous intensity exercise 5-7
  (preferably 7) days per week
• Supervised resistance training (within
  guidelines) can safely be included as a part of a
  complete exercise program.

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Motivating Kids Approaches to implementing the
recommendations with children
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Strategies

• Adult Prescription Model
• the traditional approach to activity, this
  involves use of the FITT principle of Frequency,
  Intensity, Time and Type.
• Decreasing Sedentary Time
• backward approach this is basically taking TV,
  Computer, Video Games, and can include replacing
  these activities with more active choices.
• Lifestyle Activity
• Activities of daily living parking in the
  farthest spot, taking a walk with family, playing
  in the back yard, chores like mowing the yard,
  creating active play areas.

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Decreasing Sedentary Time
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Percent Increase Above Resting Energy Expenditure
Foster, L., Jensen, T.B., Foster, R.C., Redmond,
A.B., Walker, B.A., Heinz, D., Levine, J.A.,
Energy Expenditure of Sedentary Screen Time
Compared With Active Screen Time for Children
Pediatrics 118 (2006) 1831-1835.
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Lifestyle Activity vs. Traditional Exercise
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Lifestyle vs Structured Exercise 24 month
adjusted mean change
Lifestyle Structured
Body Fat -2.39 -1.85
Weight (kg) -.05 .69
Total Cholesterol (mg/dL) -.11 -.13
Systolic BP (mmHg) -3.63 -3.26
Diastolic BP (mmHg) -5.38 -5.14
Dunn, A.L., Marcus, B.H., Kampert, J.B.,
Comparison of Lifestyle and Structured
Interventions to Increase Physical Activity and
Cardiorespiratory Fitness A Randomized Trial
Journal of the American Medical Association 2814
(1999) 327-334
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Relative Weight Changes for Children in a 24
month activity intervention
Epstein, L.H., Wing, R.R., Koeske, R., Valoski,
A., A comparison of Lifestyle Exercise, Aerobic
Exercise, and Calisthenics on Weight Loss in
Obese Children Behavior Therapy 16 (1985)
345-356.
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The Right Prescription

• The body of research is growing, pointing to
  specific program components that seem to predict
  success.
• Fun
• Comfort (not embarrassed)
• Non competitive environment
• Social support
• Reward system (success)

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Referral Options

• Medically supervised program
• Fitness Facility
• Ensure the facility employees qualified trainers
• Qualified exercise professionals
• Many certifications, the gold standard
  especially for those working with individuals
  with chronic disease is ACSM.
• Minimum of 4 year degree in Exercise Science
• ACSM HFS
• ACSM ES
• ACSM RCEP

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Resources

• American College of Sports Medicine. Guidelines
  for Exercise Testing and Prescription. 7th ed.
  Baltimore, MD Williams Wilkins 1995.
• Bowdoin, J. A Response to the Expert Committees
  recommendations on the Assessment, Prevention,
  and Treatment of Child and Adolescent Overweight
  and Obesity. Pediatrics. Apr. 2008121,4,833-834.
  
• Council on Sports Medicine and Fitness. Strength
  Training by Children and Adolescents.
  Pediatric., Apr 2008 1214835-840
• Davis et al. Recommendations for Prevention of
  Childhood Obesity Pediatrics. Dec 2007
  4s229-s253
• Downs, A., Pediatric Physical Activity and
  Fitness. Cardiopulmonary Physical Therapy
  Journal. Jun. 2005
• Roland, T., Prescribing Exercise for Obese Youth
  in the Primary Care Setting. Obesity Management.
  Aug 2008
• Faignebaum AD. Wescott WL. Resistance training
  for obese children and adolescents. Pres Council
  Phys Fitness Sports Res Dig. 200781-8

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Nutrition Counseling in 5 Minutes

• Heather Cupp, RD, CD
• Clinical Dietitian Riley POWER Program
• Clarian Health Promotions and Community Relations

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Calories in Calories out

• Excess calories (even from healthy foods) store
  as FAT
• carbohydrate - 4 calories/gram
• protein - 4 calories/gram
• fat - 9 calories/gram

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www.mypyramid.gov
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History

• Meals and Snacks per day
• Who does grocery shopping/cooking
• Fruits/Vegetables per Day
• Sweetened Beverages
• Type of Dairy (whole milk, 2, Skim)
• Eating at Restaurants
• Meals eaten at Table
• Sneaking/Hiding Foods

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Meal Patterns

• Skipping Meals
• Metabolism
• Intake
• Snacking
• Healthy snacks are key

?
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Fruits and Vegetables

• Where are they???

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What our meals should look like
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Beverages

• Not just a drink any more..

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MilkThe real difference

• Whole 147 cal/8 oz
• 2 - 123 cal/8 oz
• 1 - 105 cal/8 oz
• Skim 91 cal/8 oz
• 1 chocolate milk
• 158 calories/8oz

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Meal Planning

• Are the children involved
• Meal planning
• Letting kids assist with choosing food items will
  make them more likely to eat or try foods
• Grocery shopping
• Avoid junk foods at home by not purchasing
• Encourage children to pick out healthier snack
  items
• Encourage buying more produce
• Meal preparation
• Involving kids in meal preparation will make them
  more likely to eat or try foods

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Take a Look

• Serving Size
• Calories
• Ingredients
• Fiber
• Fat
• Sugars
• Nutrients
• Vitamin A, C, Calcium, iron

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Portion Sizes
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Meal Time

• What are the parents eating?
• Is the family eating together?
• Are they eating at the table or in front of the
  TV?
• Portion control
• Activity for 15 minutes before 2nd helping
• Second helping of fruits and vegetables only

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Rewards

• Reward foods preferred foods
• forbidden foods overeating eating when not
  hungry
• Encourage rewarding without food items (movie
  night, family fun time, friend time, money)

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Take Home Tips

• Avoid skipping meals
• Plan meals and snacks not grab and go
• Eat at least 1 fruit and/or vegetable with each
  meal
• Change to nonfat or low fat dairy products
• Change to unsweetened beverages
• Change from frying to baking, grilling, broiling
• Change snack items to low fat items and
  fruits/vegetables
• Eat at a designated place without distractions
• Limit eating at restaurants

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References

• United States Department of Agriculture.
  MyPyramid Food Intake Patterns data file
• Retrieved from
• http//www.mypyramid.gov/downloads/MyPyramid_Food
  _Intake_Patterns.pdf
• United States Department of Agriculture. Food
  Intake Pattern Calorie Levels data file
  Retrieved from
• http//www.mypyramid.gov/downloads/MyPyramid_Calo
  rie_Levels.pdf
• Jennifer S. Savage, Jennifer Orlet Fisher, and
  Leann L. Birch Parental Influence on Eating
  Behavior Conception to Adolescence J Law Med
  Ethics. 2007 35(1) 2234.
• D Benton Role of parents in the determination of
  the food preferences of children and the
  development of obesity International Journal of
  Obesity (2004) 28, 858869.

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Weight Management Toolkit
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Getting Started Tab What to do with all
children in Your Office

• Calculate and interpret BMI
• Start early age 2 years on
• Talk to families Use motivational interviewing
• Use evidence based messages

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Underweight

• Under the 5ile

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Normal Weight

• 5th 85th ile BMI
• Patient/Family education materials
• Nutrition Education
• Physical Activity Education
• Community Resources

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Overweight

• 85-94ile BMI
• Committed to Kids Health
• Local Community Programs
• Indiana Health Connect
• In Office Education
• Healthy Family Home Starter Kit
• Nutrition Education
• Physical Activity Education
• Community Resources

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Obese and Severely Obese

• Over the 95ile BMI
• According to NICHQ treatment could range from
  Primary Care Office to Tertiary care center.
• Information in previous tabs
• Committed to Kids
• Local Community Programs
• Riley POWER Clinic

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Resources Sections

• Community Resources
• Community programs you can use for patient
  education or referral
• Physician Resources
• Additional research and resources to expand your
  understanding of youth obesity
• Physical Activity Resources
• Resources to aid in exercise recommendations or
  to print as educational material for families
• Nutrition Resources
• Resources to aid in nutrition recommendations or
  to print as educational material for families

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POWERPediatric Over Weight Education and Research
93

• The Riley P.O.W.E.R. program is a partnership
  between Clarian Health and Riley Hospital for
  children to deliver a comprehensive youth obesity
  program to Indiana children and their families.

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POWER
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POWER Clinic

• Perfect Candidate over the 95ile BMI with
  complications and referral from primary care
  physician. Strict intake criteria not set. Each
  case is individual so POWER will take patients
  upon referral from primary care physician.

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POWER Clinic Logistics

• Referral and Intake procedure
• 12 month program
• 3 hour initial visit
• POWER Team Physician, Exercise Physiologist,
  Dietitian, Psychologist
• Lab Work (repeat as necessary)
• Fitness Assessments (repeat at 4th and 12th
  month)
• 12 week intensive (every other week)
• 12-26 weeks (monthly group sessions) 6 month
  point
• 27-52 weeks (bi-monthly group sessions)
• 12 month point discharge and community programs

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How to Refer to the POWER Clinic

• Complete the referral form located in the POWER
  toolkit, or on line at www.rileyhospitalforchildre
  n.org 317-274-8521 and fax to or call
  317-274-3774 for patient referrals.

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For more information on prevention and treatment
in your office

• Physician Resources Tab
• Academy of Pediatrics 2008 Report.
• Barlow, S. E., Dietz, W. H. (2007, December).
  Obesity Evaluation and Treatment Expert
  Committee Recommendations. Pediatrics, 102, S164.
• NICHQ 2007 Expert Committee Recommendations
  Implementation Guide
• http//www.nichq.org/NR/rdonlyres/7CF2C1F3-4DA3-4A
  00-AE15-4E35967F3571/5316/COANImplementationGuide6
  2607FINAL.pdf

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