# Presentation: 136989

## FLAIRFamily 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@aecom.yu.edu

## 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

**Notes:**
In urban poor communities, Hispanic children are 3 times as likely to be overweight at age 3 than white or black children.
[Whitaker RC, Orzol SM. Obesity among US urban preschool children. Arch Pediatr Adolesc Med 2006;160:578-84.]

## RWJ Prescription for Health

- 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

## 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

## FLAIR Team

- 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?

- 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?

## Montefiore Medical Center Initiatives

- 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

## Practical Approaches to Child and Adolescent Obesity in the Bronx

- 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

- 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

## 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.

## MPOP Workgroup Activities

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

## 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

## FLAIR Tools

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

## 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

## Adoption of Intervention by Primary Care Providers

- Initial Chart Review (n=80)
- 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%

## 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

## FLAIR Screening

- 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

## 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

## Referrals (n=79)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

## MPOP School-Based HealthObesity 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

## 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!

## 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