Roadmap for implementing the Chronic Care Model for weight management: Healthcare Institution's Response to Obesity (HIRO)

Background. Excess weight and obesity are at epidemic proportions in the United States and place individuals at increased risk for a variety of chronic conditions. Rates of diabetes, high blood pressure, coronary artery disease, stroke, cancer, and arthritis are all influenced by the presence of obesity. Small reductions in excess weight can produce significant positive clinical outcomes. Healthcare organizations have a vital role to play in the identification and management of obesity. Currently, healthcare providers do not adequately diagnose and manage excess weight in patients. Lack of skill, time, and knowledge are commonly cited as reasons for non-adherence to recommended standards of care. The Chronic Care Model offers an approach to healthcare organizations for chronic disease management. The model consists of six elements that work together to empower both providers and patients to have more productive interactions: the community, the health system itself, self-management support, delivery system design, decision support, and clinical information systems. The model and its elements may offer a framework through which healthcare organizations can adapt to support, educate, and empower providers and patients in the management of excess weight and obesity. Successful management of excess weight will reduce morbidity and mortality of many chronic conditions. Purpose. The purpose of this review is to synthesize existing research on the effectiveness of the Chronic Care Model and its elements as they relate to weight management and behaviors associated with maintaining a healthy weight. Methods: A narrative review of the literature between November 1998 and November 2008 was conducted. The review focused on clinical trials, systematic reviews, and reports related to the chronic care model or its elements and weight management, physical activity, nutrition, or diabetes. Fifty-nine articles are included in the review. Results. This review highlights the use of the Chronic Care Model and its elements that can result in improved quality of care and clinical outcomes related to weight management, physical activity, nutrition, and diabetes. Conclusions. Healthcare organizations can use the Chronic Care Model framework to implement changes within their systems to successfully address overweight and obesity in their patient populations. Specific recommendations for operationalizing the Chronic Care Model elements for weight management are presented.^

Descriptive analysis of Ben Taub Pediatric Weight Management Program

The purpose of this study is to descriptively analyze the current program at Ben Taub Pediatric Weight Management Program in Houston, Texas, a program designed to help overweight children ages three to eighteen to lose weight. In Texas, approximately one in every three children is overweight or obese. Obesity is seen at an even greater level within Ben Taub due to the hospital's high rate of service for underserved minority populations (Dehghan et al, 2005; Tyler and Horner, 2008; Hunt, 2009). The weight management program consists of nutritional, behavioral, physical activity, and medical counseling. Analysis will focus on changes in weight, BMI, cholesterol levels, and blood pressure from 2007–2010 for all participants who attended at least two weight management sessions. Recommendations will be given in response to the results of the data analysis.^

Correlates of post-diagnosis weight management among female breast cancer survivors: An Internet survey

Objective. Weight gain after cancer treatment is associated with breast cancer recurrence. In order to prolong cancer-free survivorship, interventions to manage post-diagnosis weight are sometimes conducted. However, little is known about what factors are associated with weight management behaviors among cancer survivors. In this study, we examined associations of demographic, clinical, and psychosocial variables with weight management behaviors in female breast cancer survivors. We also examined whether knowledge about post-diagnosis weight gain and its risk is associated with weight management behaviors. ^ Methods. 251 female breast cancer survivors completed an internet survey. They reported current performance of three weight management behaviors (general weight management, physical activity, and healthy diet). We also measured attitude, elf-efficacy, knowledge and social support regarding these behaviors along with demographic and clinical characteristics. ^ Results. Multiple regression models for the weight management behaviors explained 17% of the variance in general weight management, 45% in physical activity and 34% in healthy dieting. The models had 9–14 predictor variables which differed in each model. The variables associated with all three behaviors were social support and self-efficacy. Self-efficacy showed the strongest contribution in all models. The knowledge about weight gain and its risks was not associated with any weight management behaviors. However, women who obtained the knowledge during cancer treatment were more likely to engage in physical activity and healthy dieting. ^ Conclusions. The findings suggest that an intervention designed to increase their self-efficacy to manage weight, to be physically active, to eat healthy will effectively promote survivors to engage in these behaviors. Knowledge may motivate women to manage post-diagnosis weight about risk if information is provided during cancer treatment.^

Long-term impact of a weight management summer camp on obese children

Background: interventions that focus on improving eating habits, increasing physical activity, and reducing sedentary behaviors on weight status and body mass index percentile and z-scores in youths have not been well documented. This study aimed to determine the short and long term effects of a 2-week residential weight management summer camp program for youths on weight, BMI, BMI percentile, and BMI z-score. ^ Methods: A sample of 73 obese multiethnic 10-14 years old youths (11.9 ± 1.4) attended a weight management camp called Kamp K'aana for two weeks and completed a 12-month follow-up on height and weight. As part of Kamp K'aana, participants received a series of nutrition, physical activity and behavioral lessons and were on an 1800 kcal per day meal plan. Anthropometric measurements of height and weight were taken to calculate participants' BMI percentiles and z-scores. Paired t-tests, chi square test and ANCOVA, adjusting for age, gender, and ethnicity were used to assess changes in body weight, BMI, BMI percentiles and BMI z-scores pre to two-weeks post-camp and 12 months post-camp. ^ Results: Significant reductions in body weight of 3.6 ± 1.4 (P = 0.0000), BMI of 1.4 ± 0.54 (P = 0.0000), BMI percentile of 0.45 ± 0.06 (P = 0.0000), and BMI z-score of 0.1 ± 0.06 (P = 0.0000) were observed at the end of the camp. Significant reductions in BMI z-scores (P < 0.001) and BMI percentile (P < 0.001) were observed at the 12-month reunion when compared to pre- and two-weeks post camp data. There was a significant increase in weight and BMI (P = 0.0000) at the 12-month reunion when compared to pre and post camp measurements. ^ Conclusion: Kamp K'aana has consistently shown short-term reductions in weight, BMI, BMI percentile, and BMI z-score. Results from analysis of long-term data suggest that this intervention had beneficial effects on body composition in an ethnically diverse population of obese children. Further research which includes a control group, larger sample size, and cost-analysis should be conducted.^

"Teens talk healthy weight": A video technology project

Purpose. The purpose of this study was to investigate the impact of a motivational weight management DVD on knowledge of obesity related diseases, readiness, motivation, and self-efficacy to lose weight, connectedness to their care provider, and patients return to clinic. Design. A randomized control trial was conducted in which 40 overweight/obese adolescents and their parents/caregivers were randomly assigned to standard care alone or standard care plus DVD. Subjects completed a set of pre- and post-questionnaire measures. A group of 22 patients was also formed as a historical control group in order to account for the potential effect of extra attention given to subjects prospectively enrolled. Methods. The adolescents and their parent/caregiver were placed into a patient room. Consent was obtained and a set of written pre-questionnaires were given to both the parent and the adolescent. Standard care was provided to all patients by the Registered Dietitian and physician; the DVD was shown in addition to standard care among the intervention group. A set of post-questionnaires were given and compensation was provided. Analysis. Groups were compared to determine equivalence at baseline. Analysis of covariance was used to evaluate changes over time, while controlling for pre-test scores and race/ethnicity. Results. Parents who viewed the DVD experienced greater changes in correct knowledge as compared to parents who did not view the DVD. Conclusion. Our study found only one substantial benefit of the DVD beyond standard clinical practices. This is an important area for change as it increased awareness of obesity as a serious disease and has future clinical implications.^

A formative evaluation of the American Diabetes Association's Choosing Health and Sensible Exercise childhood obesity intervention

Background. The increasing prevalence of overweight among youth in the United States, and the parallel rise in related medical comorbidities has led to a growing need for efficient weight-management interventions. Purpose. The aim of this study was to evaluate the effects of the Choosing Health and Sensible Exercise (C.H.A.S.E.) childhood obesity prevention program on Body Mass Index (BMI), physical activity and dietary behaviors. Methods. This study utilized de-identified data collected during the fall 2006 session of the C.H.A.S.E. program. A total of 65 students at Woodview Elementary School and Deepwater Elementary School participated in this intervention. The C.H.A.S.E. program is a 10-week obesity prevention program that focuses on nutrition and physical activity education. Collection of height and weight data, and a health behavior survey was conducted during the first and last week of the intervention. Paired t-tests were used to determine statistically significant differences between pre- and post-intervention measurements. One-way analysis of variance was used to adjust for potential confounders, such as gender, age, BMI category ("normal weight", "at risk overweight", or "overweight"), and self-reported weight loss goals. Data were analyzed using STATA, v. 9.2. Results. A significant decrease in mean BMI (p< 0.05) was found after the 10-week intervention. While the results were statistically significant for the group as a whole, changes in BMI were not significant when stratified by age, sex, or ethnicity. The mean overall scores for the behavior survey did not change significantly pre- and post-intervention; however, significant differences were found in the dietary intention scale, indicating that students were more likely to intend to make healthier food choices (p<0.05). No statistically significant decreases in BMI were found when stratified for baseline BMI-for-age percentiles or baseline weight loss efforts (p>0.05). Conclusion. The results of this evaluation provide information that will be useful in planning and implementing an effective childhood obesity intervention in the future. Changes in the self-reported dietary intentions and BMI show that the C.H.A.S.E. program is capable of modifying food choice selection and decreasing BMI. Results from the behavior questionnaire indicate that students in the intervention program were making changes in a positive direction. Future implementation of the C.H.A.S.E. program, as well as other childhood obesity interventions, may want to consider incorporating additional strategies to increase knowledge and other behavioral constructs associated with decreased BMI. In addition, obesity prevention programs may want to increase parental involvement and increase the dose or intensity of the intervention. ^

Pediatric obesity: Managed care collaborating with providers to improve diagnosis and treatment

Child overweight and obesity reaches across ethnic, cultural, socioeconomic and regional barriers. It must be assessed, diagnosed and treated to help families make sustainable behavior changes. Treatment recommendations have been made to address pediatric overweight and obesity. They include screening for risk factors, monitoring BMI trends and educating patients and families to make small sustainable changes. Health insurance companies can play a meaningful role in supporting and facilitating provider education and behavior change to diagnose, treat and prevent pediatric overweight and obesity.^ The aims of this thesis were: (1) Describe a disease management program that uses evidence-based practices to create provider behavior change related to pediatric obesity screening, diagnosis and treatment. (2) Identify ways to improve the implementation of the program based on the perceptions of participating clinicians.^ A literature review was completed to evaluate current recommendations for screening and treating pediatric obesity using the Ovid data base. The evidenced-based recommendations were compared against the practices of the Healthy Lifestyles Program (HeLP). The literature confirmed that HeLP is following evidence-based recommendations for assessment, diagnosis and treatment of pediatric obesity.^ A Children’s Mercy Family Health Partners focus group was convened to create a provider survey. The goals of the survey were to assess providers’ perception of the Healthy Lifestyles Program (HeLP). The survey was sent out through email using Survey Monkey. All survey responses were anonymous. The survey was sent to a total of 80 providers who had completed HeLP. Twenty-five percent responded. The survey results were evaluated to make recommendations for HeLP.^ Results of the survey included motivating factors for participation in HeLP. Concern about the increasing prevalence of pediatric obesity was a frequent motivator for participation. Provider barriers to obesity diagnosis were evaluated. Lack of time during clinic visits a frequent barrier to obesity diagnosis. ^ In conclusion several recommendations for the HeLP were made based on survey results. It is recommended that the program evaluate methods and tools for facilitating effective weight management follow up visits. Promotional materials should highlight the increasing prevalence of pediatric obesity when advertising HeLP. These recommendations will be used to refine the current Healthy Lifestyles Program.^

Risk factors for metabolic syndrome among overweight and obese Hispanic children attending a pediatric clinic in New Braunfels, Texas

Childhood obesity is a persistent problem in the U.S., especially among Hispanics. Health complications like hypertension, type II diabetes, and metabolic syndrome (Met-S) are being seen at younger ages, and current screening procedures may be inadequate. This study sought to describe the risk factors for Met-S present in a sample of 106 overweight and obese Hispanic children, aged 5-14 years, participating in Nutrition and Exercise Start Today (NEST), a randomized weight management intervention trial at a rural health clinic in New Braunfels, Texas; and to determine associations between these factors and other clinical and socio-demographic characteristics linked to obesity. Baseline data was analyzed for the prevalence of large waist circumference (WC), elevated blood pressure (BP), high fasting serum glucose and serum triglycerides (TG), and low serum HDL cholesterol, in relationship with selected sample characteristics. Main findings included high baseline prevalence rates of large WC (77%), reduced HDL (57%), and elevated BP (30%). WC was significantly associated with BMI percentile and the serum liver function test alanine aminotransferase (ALT) by Fisher's exact test (p<0.001 and p=0.032, respectively), while there were significant relationships between HDL and both female gender and ALT. BMI percentile and ALT were associated with all sets of Met-S diagnostic criteria examined. BMI percentile also had a strong association (p=0.005) with total number of Met-S risk factors, while ALT had a weaker association (p=0.093). WC is a low-cost, simple measure whose use may improve clinic surveillance for childhood obesity and complications like Met-S. WC, BP, HDL and ALT may be used as part of targeted screening for obesity complications like Met-S, particularly in situations where resources are limited.^

Food intake in nonpurging obese women who binge eat before and after a behavioral weight loss program

Little is known about the impact of behavioral programs to decrease binge eating in obese persons who do not purge. This study was conducted to compare the amount of change in the reduction of binge days and selected nutrients in women who had joined a behavioral weight loss program. Forty-six women in the behavioral self management (BSM) group and thirty-six women in the Wait List Control (WLC) groups completed seven day food records at baseline and six months. These records were analyzed for calories, percentage of calories from protein, carbohydrate, fat and dietary fiber/ 1000 calories and were marked as "binge" or "nonbinge" days. Foods were also divided into 12 food groups but only six contributing to fat intake were chosen for analysis: dairy; fat; grains and starchy vegetables; meat, fish, and poultry; meat, fish, and poultry combinations; snacks and desserts. At six months, there was no difference in the amount of change in any of the selected nutrients between the BSM and WLC groups or in the amount of change within each food group except in the meat, fish, and poultry combination and in the snacks and desserts groups because both groups experienced similar changes at six months. Binge and nonbinge day nutrient analysis by BSM and WLC showed that at baseline and six months within the BSM group, calories increased significantly on binge days. Within the WLC group at six months, percentage of calories from protein was significantly decreased on binge days.^ The significant finding of this study was the reduction in the amount of change in the number of binge days at six months between the BSM and WLC groups ($-$2.2 versus $-$1.1 respectively). These data suggest that behavioral programs can successful reduce binge days, but that significant change in food intake may require more intensive treatment. ^