SummaryPediatric practices throughout Maine have adopted the Maine Youth Overweight Collaborative's framework and tools, with most adapting the program to the unique features of their practice. The program provides education and practical tools (e.g., body mass index assessments, algorithms, motivational interviewing techniques, patient registries) to help pediatric practices assess and manage obesity in their patient populations. A quasi-experimental evaluation found that the program increased provider knowledge and confidence in behavioral management, which, in turn, led to more frequent assessment and tracking of body mass index, discussions with families about nutrition and physical activity, and counseling regarding behavior change. Although body mass index levels declined among patients participating in the collaborative, the level of decline was similar to that found in a control group and in national trends.1Moderate: The evidence consists of before-and-after comparisons of the provision of key services related to behavioral management, including weight measurement, provider discussions with families about nutrition, physical activity and screen time, and counseling regarding behavior change.
Developing OrganizationsMaine Center for Public Health; Maine Chapter, American Academy of Pediatrics; Maine Harvard Prevention Research Center; Winthrop Pediatrics and Adolescent Medicine
Use By Other OrganizationsApproximately 25 states have adopted the Maine Youth Overweight Collaborative's “5-2-1-0” message.
Date First Implemented2004
Patient PopulationPractices in the collaborative serve a range of communities throughout Maine. For example, Winthrop Pediatrics and Adolescent Medicine, with three physicians, serves a population of approximately 3,000 babies, children, and adolescents in rural Winthrop, Maine, and surrounding areas.Vulnerable Populations > Children
Problem AddressedChildhood obesity is a widespread, growing problem that has serious health consequences. Providers who care for children and adolescents have not yet developed effective strategies to treat this growing epidemic and often do not address behavior change with their overweight and obese patients.1
- A growing epidemic: Data from National Health and Nutrition Examination Surveys show that, between the 1971–1974 survey and the 2007–2008 survey (the most recently available published data), the prevalence of obesity increased among all childhood age groups—including from 5.0 to 10.4 percent among those ages 2 to 5 years, from 4.0 to 19.6 percent among those ages 6 to 11 years, and from 6.1 to 18.1 percent among those ages 12 to 19 years.2 The 2009 Maine Youth Risk Behavior Survey found that 13 percent of Maine high school students were obese.3
- Severe health consequences: In a population-based sample, approximately 60 percent of obese children between the ages of 5 and 10 years had at least one risk factor for cardiovascular disease, such as elevated total cholesterol, triglycerides, insulin, or blood pressure, whereas 25 percent had two or more cardiovascular disease risk factors.4 Overweight and obesity put children at current and future risk of a number of serious health problems, including cardiovascular disease, type 2 diabetes, and mental health conditions such as anxiety and depression. Type 2 diabetes now accounts for up to one-half of all new pediatric cases of diabetes, compared with less than 4 percent before 1990.5
- Unrealized potential of pediatric practices to address weight management: Despite the fact that pediatric providers can leverage opportunities to create awareness and motivate behavior change, most do not measure body mass index (BMI) percentiles, deliver preventive messages, or provide appropriate medical evaluation for obesity. Providers may lack awareness regarding their role in behavior modification, or they may lack confidence in addressing obesity and lifestyle issues with children and families.1 For example, at Winthrop Pediatrics and Adolescent Medicine in Maine, physicians addressed obesity inconsistently and reported feeling uncomfortable addressing weight issues with patients.
Description of the Innovative ActivityA number of pediatric and family practices have adopted the Maine Youth Overweight Collaborative framework and tools, with most adapting the program to the unique features of the practice, including location, demographics, and other characteristics. Winthrop Pediatrics and Adolescent Medicine, for example, adopted use of a behavioral screening tool, BMI assessments, clinical assessment, and management using motivational interviewing and an algorithm, a registry, team-based care management, and community outreach and collaboration. Key elements of the program at Winthrop include the following:
- “5-2-1-0” framework: The practice’s obesity interventions are based on the collaborative's “5-2-1-0” framework, which supports encouraging 5 or more servings of fruits and vegetables on most days; limiting screen time to 2 hours or less each day; participating in at least 1 hour of physical activity daily; and avoiding (i.e., consuming "0") sugar-sweetened beverages.
- Behavioral screening tool: When patients arrive for the annual well-child visit, the practice’s receptionist hands out a “5-2-1-0” behavioral screening tool, a one-page survey for parents or adolescents to complete in the waiting room that includes specific questions about daily diet, beverage consumption, screen time, and physical activity.
- Initial BMI assessment: In the examination room, the medical assistant obtains the patient’s height and weight and calculates BMI. The medical assistant charts the BMI on a graph (either by hand or electronically) to track trends over time. Ideally, tracking begins at age 1 or 2 years.
- Clinical assessment and management: Clinical assessment and management by the physician includes the following components:
- Discussion of BMI: If appropriate, the physician discusses the BMI results with the child and parent(s), including any changes that have occurred since the last visit.
- Motivational interviewing: The physician uses the completed “5-2-1-0” screening tool as a guide for motivational interviewing, goal setting, behavioral modification, and general discussions with the patient.
- Algorithm for management: The physician uses a clinical decision support tool known as the Pediatric Obesity Clinical Decision Support Chart, which includes an algorithm and guidelines for overweight prevention and management based on the “5-2-1-0” framework. Specifically, the tool includes guidelines for medical evaluation of overweight patients (e.g., checking fasting lipid profiles and conducting a liver function panel for overweight patients aged 10 years or older, and checking fasting blood sugar if the patient has more than one risk factor for diabetes); guidelines for hypertension management; reference lab values; blood pressure and BMI percentile charts; and guidelines for effective communication with families.
- Patient registry: The practice has created a patient registry through its electronic medical record that tracks key indicators for overweight patients, thus identifying those who require preventive weight management interventions. (Other participating sites that do not have such a system often use an Excel or Access-based overweight population registry provided by the collaborative.)
- Counseling and self-management tools: The practice uses counseling and self-management tools provided by the collaborative, including the Keep ME Healthy poster for waiting rooms and offices, goal setting worksheets, goal trackers, and parent/child flip charts with healthy lifestyle tips. Content centers on appropriate fruit and vegetable intake; family meals; daily breakfast; television and other screen time; physical activity; and consumption of sugary drinks, milk, and fast food. Physicians and nurses use these tools to frame counseling interventions and other self-management support.
- Team approach to patient management: Clinicians within each collaborative practice site create a team that typically includes a physician, a second clinician (often a nurse), and an administrative staff leader. Teams jointly provide care for overweight patients by planning followup visits and using other strategies, such as telephone followup or group visits. Team members routinely confer on topics such as patient tracking, assessment, education, and followup.
- Community outreach and collaboration: The clinical team also works with schools and other community organizations involved in healthy lifestyles for children. For example, Winthrop Pediatrics and Adolescent Medicine worked with a high school nurse, a therapist, and the local YMCA to hold a 6-week course at the school’s student-based health center targeted at the female nonathlete. The course covered topics and activities such as nutrition, yoga, relaxation therapy, kickboxing, Pilates, and hip-hop dancing. Participants and their families received free 3-month YMCA memberships.
Context of the InnovationThe Maine Harvard Prevention Research Center and the Maine Center for Public Health, in collaboration with the Maine Chapter of the American Academy of Pediatrics, established the Maine Youth Overweight Collaborative in 2004 to improve care and outcomes for youth who are overweight or obese, and to reduce risk factors (e.g., poor nutrition, lack of physical activity, and excessive screen time) for obesity among all youth. The collaborative came into being as a result of a conference held in September 2003 that centered on clinical approaches to addressing overweight individuals in the primary care setting; participants believed that the Institute for Healthcare Improvement model for collaborative change, used for developing innovative approaches to managing other chronic diseases, could be adapted for obesity prevention and management. At present, more than 100 providers across more than 30 sites treat approximately 200,000 children and adolescents. Sites are quite diverse in terms of practice size and geographic location. Although funding for the collaborative ended, the collaborative's initiatives have become routine as a standard of care at the participating sites.
ResultsA quasi-experimental, pre- and post-implementation analysis found that the program increased provider knowledge and comfort in addressing lifestyle, which, in turn, led to more frequent assessment and tracking of BMI, discussions with families about nutrition and physical activity, and counseling regarding behavior change. Although BMI levels declined among patients participating in the collaborative, the level of decline was similar to that found in a control group and in national trends.1 Specific results are as follows:
Moderate: The evidence consists of before-and-after comparisons of the provision of key services related to behavioral management, including weight measurement, provider discussions with families about nutrition, physical activity and screen time, and counseling regarding behavior change.
- Greater provider knowledge and confidence: Both new and veteran providers at participating sites reported increased knowledge, better attitudes, and higher levels of confidence and self-efficacy in addressing weight management issues, along with increased use of medical evaluation of overweight patients, patient counseling, goal setting, and motivational interviewing.
- More frequent assessment and tracking of BMI: Chart reviews at participating sites show that 94 percent of patients received BMI assessments after implementation, up from 38 percent before. Assessment of BMI percentile for age and gender increased from 25 to 89 percent, use of the “5-2-1-0” behavioral screening tool increased from 0 to 82 percent, and classification of weight (i.e., as underweight, normal weight, overweight, or obese) increased from 19 to 75 percent.
- More discussions with families: Parent surveys indicate that providers in participating sites were more likely than their peers in comparison group sites to engage in discussions with patients on topics such as nutrition (odds ratio of 4, indicating a 4 times greater likelihood of this discussion taking place), television time (2.7), physical activity (2.1), and sugar-sweetened drinks (3.7).
- Increased use of behavior change counseling: Compared with patients in comparison group sites, children who received care at participating sites (and their parents) were more likely to receive counseling during a well-child visit about eating fruits and vegetables (odds ratio: 2.1), physical activity (1.9), reducing television time (2.8), and reducing consumption of sugary drinks (2.63).
- Declines in BMI, but no greater than in control group or national trends: Chart reviews of 1,178 intervention and 1,260 comparison group participants at 9 participating and 10 nonparticipating sites found that average BMI declined since the inception of the program in both groups, with no meaningful difference between the two. Adoption of the program throughout the state and community activities associated with “5-2-1-0” interventions may have positively influenced BMI trends among patients at comparison group sites. However, because national BMI rates also declined during the same time period, it is unclear whether this program led to the declines experienced in Maine.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Toolkit development: Collaborative partners brought in local and national clinical experts with expertise in the Institute for Healthcare Improvement model to develop a strategy for addressing youth obesity. These experts worked with collaborative representatives to develop the “5-2-1-0” framework and an early version of a toolkit based on existing publicly available educational materials.
- Learning sessions: The collaborative held three 1.5-day learning sessions with clinical teams from the practice sites. At the first session, collaborative representatives introduced the teams to the “5-2-1-0” behavioral assessment tool, emphasized the importance of BMI calculation, and discussed healthy lifestyle habits and the treatment of obesity in a pediatric population. During the second learning session, collaborative representatives taught the teams the skills necessary to conduct motivational interviewing. The third session covered issues related to followup care, including key metrics and clinical decision support tools.
- Toolkit and training refinement: After a pilot test at the initial sites, the team refined the toolkit and the training sessions.
Resources Used and Skills Needed
- Staffing: The program requires no new staff at the practice sites, as existing clinicians incorporate it into their daily routines.
- Costs: More than $700,000 of in-kind donations and grants funded the development of the collaborative, tools, and training over the 5 years of the project. Costs to the practices involved a time commitment, as physicians conducted internal chart reviews and met with staff to discuss process changes related to addressing obesity. All program tools and training were provided free of charge to the practices. Learning sessions cost approximately $8,000 each.
Funding SourcesCenters for Disease Control and Prevention; Maine Health Access Foundation; Betterment Fund; MaineHealth; Jessie B. Cox Charitable Trust; Maine Harvard Prevention Research Center; Bingham Program; Eastern Maine Healthcare
The Maine Health Access Foundation provided initial funding for the program via a 2-year grant. Additional funding sources include the Bingham Program, the Jessie B. Cox Charitable Trust, MaineHealth, Eastern Maine Healthcare, The Betterment Fund, the Harvard Prevention Research Center, and the Centers for Disease Control and Prevention. The Maine Harvard Prevention Research Center conducted the program evaluation as an in-kind donation.
Tools and Other ResourcesThe Maine Youth Overweight Collaborative toolkit (“Keep ME Healthy”), the Pediatric Obesity Clinical Decision Support Chart, and other intervention materials are available at: http://www.hsph.harvard.edu/research/prc/projects/clinical-interventions-to-prevent-childhood-overweight/index.html.
A national version of the Pediatric Obesity Clinical Decision Support Chart is available on the American Academy of Pediatrics Web site: https://www.nfaap.org/netforum/eweb/dynamicpage.aspx?site=nf.aap.org&webcode=aapbks_productdetail&key=3ffed110-2471-40f3-9547-61666fa5b6ed.
Getting Started with This Innovation
- Engage frontline staff: All practice staff, including physicians, nurses, medical assistants, office managers, and receptionists, should be engaged in the process change, including deciding on the best way to implement the program and being educated on their specific roles in the new process. To secure buy-in, all individuals should also receive education about the long-term complications associated with obesity.
- Provide training: Downloading tools is not sufficient to generate clinician engagement. To ensure effective implementation, provide training on the need to focus on obesity and use of program tools (including motivational interviewing).
- Use electronic medical records when possible: Although not required for program adoption, electronic medical records facilitate data tracking and make it easier to incorporate discussions of BMI and other weight-related issues into the medical visit.
Sustaining This Innovation
- Develop outreach efforts to engage late adopters: Early adopters may be more inclined to take time away from their practices to attend learning sessions and implement office system change. Later adopters have necessitated more site visits and supplements to the toolkit (e.g., office flow framework) that they can use to spread Maine Youth Overweight Collaborative innovations throughout their practice sites.
Use By Other OrganizationsApproximately 25 states have adopted the Maine Youth Overweight Collaborative's “5-2-1-0” message.
Contact the InnovatorCarol Mansfield, MD
Winthrop Pediatrics and Adolescent Medicine
149 Main Street
Winthrop, ME 04364
Phone: (207) 377-2114
Innovator DisclosuresDr. Mansfield has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesPolacsek M, Orr J, Letourneau L, et al. Impact of a primary care intervention on physician practice and patient and family behavior: Keep ME Healthy – The Maine Youth Overweight Collaborative. Pediatrics 2009;123:S258-66. [PubMed]
Polacsek M. Final report: the Maine Youth Overweight Collaborative 3. October 2009.
Polacsek M. Final report: the Maine Youth Overweight Collaborative 2. November 2008.
1 Polacsek M, Orr J, Letourneau L, et al. Impact of a primary care intervention on physician practice and patient and family behavior: Keep ME Healthy—The Maine Youth Overweight Collaborative. Draft Manuscript.
Skelton JA, DeMattia LG, Flores G. A pediatric weight management program for high-risk populations: a preliminary analysis. Obesity (Silver Spring). 2008;16(7):1698-701. [PubMed]
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Original publication: September 30, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 29, 2013.
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