Family-Oriented Program Combines Medical Care and Behavioral Counseling, Leading to Health Improvements in Obese Children and Adolescents
Family-Oriented Program Combines Medical Care and Behavioral Counseling, Leading to Health Improvements in Obese Children and Adolescents
The Brenner Children's Hospital's Families-in-Training (BrennerFIT) Program is an intensive, holistic treatment program for the families of obese children and adolescents between the ages of 2 and 18 years old with at least one medical complication of obesity. Throughout the 1-year program, a multidisciplinary team of professionals implements family-focused and family-centered behavior modification techniques and emphasizes improved nutrition and physical activity to encourage the development of healthier lifestyle habits. Community and group programming allow for experiential learning and peer support. Outcomes evaluation suggests that BrennerFIT participants have reduced their body mass index and cardiovascular risk factors, while post-implementation data and surveys show a low dropout rate and high levels of patient/family satisfaction with the program.
Date First Implemented
Childhood obesity is a widespread, growing problem that has devastating health consequences. Primary care providers and hospital-based clinicians have not yet developed effective strategies to treat this growing epidemic.
- A growing epidemic: Data from National Health and Nutrition Examination Surveys show that the prevalence of overweight among children aged 2 to 5 years old increased from 5 to 10.4 percent from the 1976-1980 to 2007-2008 period; for those aged 6 to 11 years old, prevalence increased from 6.5 to 19.6 percent; and for those aged 12 to 19 years old, prevalence increased from 5 to 18.1 percent. North Carolina ranks fifth among all states in the prevalence of childhood obesity. In Brenner Children's Hospital's 19-county referral area, approximately 1 in 5 (or roughly 100,000) children are obese.
- Severe health consequences: In a population-based sample, approximately 60 percent of obese children between the ages of 5 and 10 years old had at least one risk factor for cardiovascular disease, such as elevated total cholesterol, triglycerides, insulin, or blood pressure, while 25 percent had two or more risk factors. 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 of cases before 1990.
- High program dropout rates: According to a literature review, the typical pediatric weight management program, which tends to be based on an adult model of weight loss and exercise, experiences a dropout rate of approximately 50 percent (ranging from 35 to 80 percent) ; a more recent review estimates this range as 27 to 73 percent. A multidisciplinary program that addresses the patient's lifestyle more comprehensively and that builds a connection between the patient, family, and treatment team can reduce dropout rates.
- Family involvement critical to success: Traditional weight loss efforts, particularly those that are not age specific, do not involve families in the process; however, research has shown that family-based weight management programs are more successful at helping children achieve improvements in BMI than are traditional weight loss approaches , and that family members exert a strong influence on weight loss efforts for adolescents.
Description of the Innovative Activity
The Brenner Children's Hospital's Families-in-Training (BrennerFIT) Program consists of a multidisciplinary team of professionals that implements family-based behavior modification techniques and emphasizes improved nutrition and physical activity to encourage the development of healthier lifestyle habits for obese children and their families. Key elements of the program include the following:
- Referrals: Patients, aged 2 to 18 years old, must be referred to the program by a primary care physician, pediatrician, or subspecialist. Eligible patients are obese (defined as a BMI above the 95th percentile for age and gender) and have at least one medical comorbidity (e.g., high cholesterol, high blood pressure, type 2 diabetes, asthma, or musculoskeletal problems) associated with obesity.
- Program orientation: Before enrolling, prospective families are provided with information that describes the program and sets expectations for family involvement via a “see it, read it, hear it” approach that includes an in-person orientation, reading a one-page description of the program, and having a telephone conversation with a BrennerFIT “Phone Coach” that ensures family understanding of the program and any potential barriers to participation.
- Data gathering: The family completes a data sheet that summarizes the health and weight problems faced by the child/adolescent and family and past approaches to nutritional and weight management. The family also completes a sample daily schedule that profiles foods eaten during the day, where and with whom the food was eaten, the child's school schedule, and the parents' work schedules. This information is mailed to BrennerFIT.
- Intake meeting: The family meets with the BrennerFIT clinicians during a 2-hour intake meeting held at the hospital. Four BrennerFIT clinicians attend this meeting: the program physician, a dietitian, a family counselor (a licensed clinical social worker or marriage and family therapist), and a physical therapist or exercise specialist.
- “Game plan”: After a break in the meeting, during which the team synthesizes the information, the team presents the family with a “game plan” for developing healthier habits, such as eating five to nine servings of fruits and vegetables daily, keeping “screen time” to no more than 2 hours daily, and avoiding sugar-sweetened beverages. The game plan includes both short- and long-term goals, outlines resources to support attainment of these goals, and addresses existing or anticipated barriers based on the team's evaluation of the family. A written document delineating the game plan is presented to the family for approval.
- Motivational Interviewing: BrennerFIT employs a unique form of motivational interviewing, with multiple clinicians (i.e. dietitian, family counselor, physical therapist) engaging families (vs. individual patients).
- Other Treatment Approaches: BrennerFIT staff have been trained in other disciplines key to implementing healthy lifestyles, such as parenting, picky eating, and mindfulness.
- Special Programs: BrennerFIT has established two programs that address treatment challenges encountered by specific populations. Mejor Salud Mejor Vida (Better Health Better Life) assists Spanish-speaking families. An initial outcomes assessment identified that few Spanish-speaking families enrolled into treatment. This program is led by a case manager, who coordinates visits, provides on-going support, links families to other resources, and teaches group educational programs. An outcomes assessment has demonstrated that the program has a low dropout rate and equivalent outcomes in BMI z-score change. To address families living in rural areas having to drive long distances, TeleFIT was developed, which places telemonitors in select practices throughout Northwest North Carolina. Families still come to BrennerFIT for their first visit, and for three additional visits throughout the year to see the physician, but the rest of their care is delivered by telemonitors. An initial outcomes evaluation demonstrates that the program has a comparable effectiveness.
- Followup visits: Throughout the 1-year program, followup visits are scheduled as follows:
- Phase 1: Visits occur every 2 weeks for the first 4 months; the BrennerFIT clinicians participating in these visits vary according to the family's needs; for example, the physical therapist will be involved in visits with children who have physical problems. Typically, at least two clinicians participate in each visit. The team addresses barriers and challenges faced by the family and suggests small but meaningful changes in habits.
- Phase 2: Visits with the team continue monthly for the subsequent 4 months, with interim telephone followup to reinforce the positive momentum between visits. Children may also attend BrennerFIT group classes during this time.
- Phase 3: Visits during the final 4 months of the program are scheduled according to the family's needs and may range from as frequently as every 2 weeks to as little as just one visit during the entire period. The family also continues with group classes during this time and may begin using community resources (e.g., the YMCA) for physical activity.
- Medical evaluations: Medical evaluations by the BrennerFIT physician are performed at months 4, 8, and 12 and include blood work to measure indicators such as cholesterol levels. The BrennerFIT physician also communicates with the child's regular physician(s) to ensure coordinated medical care.
- Wrap-up visit: A visit with the whole team is held after 12 months in the program. Families may “graduate” or extend program participation if needed.
- Alumni club: An alumni club provides ongoing support and education and offers a connection to Brenner FIT in the case of substantial weight gain upon graduation.
Context of the Innovation
The Brenner Children's Hospital is a 160-bed facility that is part of Wake Forest University Baptist Medical Center, an academic health system that also includes North Carolina Baptist Hospital and Wake Forest University Health Sciences, which operates the university's medical school. The hospital treats approximately 4,200 inpatient admissions and 46,000 outpatient visits annually. Hospital administrators and community pediatricians were concerned about the high rates of pediatric obesity in North Carolina and an observed rise in complications associated with childhood obesity (including sleep apnea, type 2 diabetes, musculoskeletal problems, and worsening asthma). These concerns spurred interest in developing a comprehensive, practical program to address the problem. The hospital recruited Joseph Skelton, MD, a pediatric gastroenterologist, to develop and lead the initiative; Dr. Skelton had previously developed a successful family-oriented program to address pediatric obesity (called the NEW Kids Program) at the Children's Hospital of Wisconsin.
Outcomes analysis suggests that BrennerFIT participants have reduced their BMI and cardiovascular risk factors, and post-implementation data and surveys show a low dropout rate and high levels of patient/family satisfaction with the program. Two-thirds of participants have been shown to decrease their BMI z-score (a measure designed to account for change in age) after 4 months of participation, and this decrease continues throughout the year of treatment. Approximately 32 percent of families drop out in the first 4 months of treatment (the most intensive phase). The BrennerFIT Program has particular success in its Spanish-language program (Mejor Salud Mejor Vida, which uses a case-manager approach), with 70 percent of participants completing a year of treatment, and nearly 70 percent improving their weight status.
- Lower body mass index: An analysis of program outcomes in 2010 revealed that 74 percent of patients improved their weight status as measured by a change in BMI z-score. This improvement occurred regardless of distance from program, race/ethnicity, or insurance status. Information provided in 2011 showed that two-thirds of participants decreased their BMI z-score after 4 months of participation, and that this decrease continued throughout the year of treatment. In addition, nearly 70 percent of participants in BrennerFIT's program for Spanish speakers improved their weight status. Information provided in March 2012 indicates that ongoing twice-yearly analysis of outcomes shows consistent levels of improvement.
- Reduced cardiovascular risk factors: Anecdotal evidence suggests that participants have reduced their cholesterol levels and resistance to insulin. Blood pressure reductions have not yet been observed.
- High patient satisfaction: Satisfaction surveys administered after the initial intake visit and every 4 months indicate high levels of patient and family satisfaction (all 4's and 5's on a 5-point Likert scale). Anecdotal reports from patients and families suggest that they feel they are being “listened to” by clinicians, who are viewed as being highly supportive and caring.
- Low dropout rate: As of March 2011, the dropout rate at 4 months was 32 percent. Ongoing program analysis has revealed that some families continue to drop out of the program and quality improvement efforts are focused at keeping families engaged in treatment.
Planning and Development Process
Key elements of the planning and development process included the following:
- Adapting program and materials: The physician program leader developed BrennerFIT and associated materials based on the program he previously designed at the Children's Hospital of Wisconsin.
- Agreeing on billing and reimbursement issues: The physician program leader and hospital administrators came to an agreement on which services would be billed to insurers (based on likelihood of reimbursement) and which services would be funded by the hospital, given that certain services (e.g., the counseling component) would not be reimbursable. Ultimately, the program will use outcomes data to lobby insurers for reimbursement for all services.
- Gathering a team of interested clinicians: The physician program leader interviewed and hired professionals who were willing to work full time on the program.
- Contacting referral sources: Community physicians and hospital subspecialists were notified of the BrennerFIT program via personal discussions with BrennerFIT staff, continuing medical education presentations, online advertising, and reference in hospital advertising. In addition, a news release was provided to the local media, which resulted in two television news interviews and a print media interview.
- Performing community outreach: The physician program leader contacted administrators of community organizations, such as the local YMCA to discuss opportunities to work together to address childhood obesity; in 2011 outreach efforts expanded to the YWCA and schools.
Resources Used and Skills Needed
- Staffing: As of 2011, the program is staffed by a full-time physician, two dietitians, a physical therapist, two family counselors (LCSW and Marriage and Family Therapist), an exercise specialist, and a secretary/coordinator.
- Costs: Total annual costs are not available; salaries represent the largest budget item. At startup, the hospital spent approximately $5,000 to convert unused space into a room where family meetings could be held; purchases for this space included bariatric furniture, a refrigerator, and other decorative touches.
A Duke Endowment grant allowed the program to expand outreach activities and add a second dietitian; information provided in March 2011 indicates that the program received funding from the Kate B. Reynolds Charitable Trust to increase the clinical capacity of the program and from the Winston-Salem Foundation to expand community outreach. Other grants from local foundations are being pursued or are pending.
Getting Started with This Innovation
- Elicit senior management support: The support of senior management is critical to ensuring appropriate funding and cooperation of other hospital departments.
- Hire full-time (rather than part-time) staff: Some professionals may want to spend only a portion of their time working for the program, but having full-time staff ensures that professionals can immerse themselves in issues related to childhood obesity, that families have continuity of providers, and that staffing is adequate to respond to high patient demand, community inquiries, and outreach activities.
- Set family expectations: Families may have many misconceptions about the program based on previous participation in weight management programs. Families should understand that the program is not simply a diet and exercise program but focuses on building healthier lifestyle habits.
- Cultivate communication among team members: Professionals who are used to working independently need to learn how to work as a team; clearly delineated roles for each team member will help in creating this team-based approach.
- Understand reimbursement issues: Knowing up front what services are reimbursable will help to determine what aspects of the program must be funded internally. This information also helps provide a focus for grant proposals.
Sustaining This Innovation
- Be sensitive to the family's time and costs: Each visit requires parents and children to miss work/school; parents also have to travel to the hospital, pay for parking, and pay a copayment. To reduce these logistic and financial problems, programs should consider incorporating flexible strategies, such as telephone followups and telemedicine.
- Track outcomes: Ongoing monitoring allows for program refinements. In addition, being able to document improvements in health can help to encourage insurers to reimburse for services.
- Consider developing a community component: Partnering with community organizations such as the YMCA can offer other avenues for addressing pediatric obesity.
Contact the Innovator
Note: Innovator contact information is no longer being updated and may not be current.
Joseph A. Skelton, MD
Brenner Children's Hospital/Wake Forest University School of Medicine
Medical Center Boulevard
Winston-Salem, NC 27157
Dr. Skelton has not indicated whether he 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.
Irby MB, Boles KA, Jordan C, Skelton JA. TeleFIT: Adapting a multidisciplinary, tertiary-care pediatric obesity clinic to rural populations. Telemedicine and E-Health. April 2012;18(3):1-3.
Guzman A, Irby MB, Pulgar C, Skelton JA. Adapting a tertiary-care pediatric weight management clinic to better reach Spanish-speaking families. J Immigrant Minority Health. Published online 11 Sept 2011.
Skelton JA, Beech BM. Attrition in paediatric weight management: a review of the literature and new directions. Obesity Reviews. 2010 Sept 29. Epub ahead of print. [PubMed]
Irby M, Kaplan S, Garner-Edwards D, et al. Motivational interviewing in a family-based pediatric obesity program: a case study. Fam Syst Health. 2010;28(3):236-246. [PubMed]
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. Epub 2008 Apr 24. [PubMed]
Wake Forest University Baptist Medical Center. Pediatric obesity program effectively improves outcomes for kids. May 14, 2008.
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U.S. Centers for Disease Control and Prevention. Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963-1965 Through 2007-2008. June 4, 2010. Available at:http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm
Interview with Dr. Joseph Skelton, October 14, 2008.
Institute of Medicine of the National Academies. Childhood obesity in the United States, facts and figures. September 2004.
Skelton JA, Beech BM. Attrition in paediatric weight management: a review of the literature and new directions. Obes Rev. 2010 Sept 29. Epub ahead of print. [PubMed]
Skelton JA, DeMattia LG, Flores G. A pediatric weight management program for high-risk populations: a preliminary analysis. Obesity (Silver Spring). 2008 Jul;16(7):1698-701. Epub 2008 Apr 24. [PubMed]
Sharma S. Family-based weight loss program effective for children and teens. June 26, 2007. Available at:http://insidermedicine.com/archives/Family-based_weight_loss_program_effective_for_children_and_teens__1251.aspx
Savoye M, Shaw M, Dziura J, et al. Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial. JAMA. 2007;297(24):2697-704. [PubMed]
White MA, Martin PD, Newton RL, et al. Mediators of weight loss in a family-based intervention presented over the internet. Obes Res. 2004;12:1050-9. [PubMed]
Irby M, Kaplan S, Garner-Edwards D, et al. Motivational interviewing in a family-based pediatric obesity program: a case study. Fam Syst Health. 2010;28(3):236-46. [PubMed]
Guzman A, Irby MB, Pulgar C, Skelton JA. Adapting a Tertiary-Care Pediatric Weight Management Clinic to Better Reach Spanish-Speaking Families. Journal of Immigrant and Minority Health. Epub 2011 Sept 11.
Irby MB, Boles KA, Jordan C, Skelton JA. TeleFIT: Adapting a Multidisciplinary, Tertiary-Care Pediatric Obesity Clinic to Rural Populations. Telemedicine and e-Health. 2012;18(3): In Press.
Interdisciplinary Family-Oriented Programs Target Childhood ObesityJonathan D. Klein, MD, MPH, FAAP
Director, Julius B. Richmond Center
Associate Executive Director, American Academy of Pediatrics
Obesity and its complications are major health concerns facing children and families. Obesity in childhood leads to childhood and adult type 2 diabetes, heart disease, asthma, sleep apnea, hypertension, and orthopedic problems. Psychological problems can also result, leading to low self-esteem, discrimination, depression, negative body image, and teasing and bullying.
Parents, in collaboration with health care providers, can address this unhealthy trend. Genetic, behavioral, and environmental factors contribute to children becoming overweight. However, the most common reason for unhealthy weight gain is too many calories of food and a lack of exercise. The American Medical Association/Centers for Disease Control and Prevention expert committee recommendations for childhood obesity interventions, 1 the American Academy of Pediatrics guidelines, and the Institute of Medicine report calling for interventions based on the best available evidence 2 underscore the importance and urgency of responding to this epidemic. The U.S. Preventive Services Task Force childhood obesity counseling recommendations call for moderate intensity counseling for obese children age 6 and up, recognizing the efficacy of prevention in improving children's health.
These three innovation profiles from academic medical centers in Kansas City, KS, Wake Forest, NC, and Boston, MA, provide models of effective, family-oriented counseling programs for reducing obesity among children and youth. These programs provide moderate to intense multidisciplinary one-on-one and group education and counseling sessions for up to 1 year. Patients may be referred to these counseling programs by primary care providers, and, in some cases, they may be offered specialty obesity intervention services and ongoing primary care linked to the specialty program. For example, the Boston Children's Optimal Weight for Life program involves primary care clinician referral of overweight or obese patients. A physician, dietitian, and psychologist provide medical evaluation, treatment and referral, nutritional counseling focusing on healthy eating and dietary modification, and behavior modification.
These programs all include important elements of successful quality improvement interventions: leadership support, engaged teams, and engaged motivated families and patients. All use some variation of multidisciplinary teams and staged approaches with increasingly intense patient and family activities to ensure engagement of motivated participants. Each program has demonstrated effectiveness in helping overweight children lose weight through developing lifestyle and food changes for children and families. The Kansas Healthy Hawks program has specific outcome data, and the Boston Children's Optimal Weight for Life program has a randomized controlled trial and retrospective cohort data that shows positive effects of their low glycemic index diet on body mass index (BMI), fat mass, body weight, and insulin resistance. Wake Forest's BrennerFIT program is based on a previously successful model that combines medical care with behavioral counseling and practical strategies. Its efficacy has been tested in other settings.
Children who complete the full course of sessions (and there is substantial attrition), usually experience a reduction in calorie intake and BMI. Parents, when assessed, are satisfied with these programs. This is important because family members exert a strong influence on weight loss efforts for children and adolescents. Moreover, family-based weight management programs are more successful at helping children achieve improvements in BMI than more traditional approaches.
Continued evolution of guidelines for child obesity screening and treatment may help raise clinician's awareness of and community support for intervention programs that can influence food and lifestyle choices and reduce obesity complications. Numerous resources are available to help change both practice and policy for children's health. As screening for unhealthy weight becomes a routine part of child health supervision, these programs provide encouraging evidence of the role of obesity treatment referral programs in overcoming the barriers to promoting healthy nutrition and physical activity to children and youth.
1 Davis MM, Gance-Cleveland B, Hassink S, et al. Recommendations for prevention of childhood obesity. Pediatrics. 2007 Dec;120 Suppl 4:S229-S253. [PubMed]
2 Koplan JP, Liverman CT, Kraak VI, eds. Preventing childhood obesity: health in the balance. Institute of Medicine, National Academies Press, 2005.
Disclosure Statement: Dr. Klein has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this article.