Kaiser Permanente Georgia's Experience with Operation Zero: A Group Medical Appointment to Address Pediatric Overweight

CONTEXT

The rate of overweight (OW) in children in the United States has more than tripled since 1980. The health consequences of pediatric OW include type 2 diabetes and significant illness later in life. Treating pediatric OW is a necessity; however, health care clinicians have minimal access to successful and comprehensive treatment modalities for addressing it.

OBJECTIVE

Kaiser Permanente of Georgia (KPGA) offers a group medical appointment clinic, Operation Zero (O.Z.), as a referral program for preadolescent and adolescent patients who are in the 85th or higher percentile for body mass index (BMI) for their age. The eight-session clinic uses a family-oriented approach and provides a supportive group environment with interactive learning, games, physical activity, and creative problem solving. The goal of the program is to improve lifestyle behaviors for nutrition and physical activity. Clinically, meeting these goals can manifest as reductions in body fat (BF), waist size, and BMI-for-age percentile. Two implementation models help improve dissemination of the program within KPGA.

DESIGN

Baseline and eight-week postclinical outcomes for O.Z. participants were analyzed to determine program effectiveness. A retrospective analysis with a control group looked at long-term clinical outcomes to determine weight maintenance. Main outcome measures were weight, BMI-for-age percentile, waist size, and percentage of body fat (%BF).

RESULTS

At eight weeks after program completion compared with baseline, there were significant reductions in %BF and waist size for the total sample and specifically for adolescents, preteens, and participants who attended six or more sessions. Among O.Z. participants, there were insignificant increases in weight at six months after program participation and BMI-for-age percentile at one year after participation. At six months, the mean change in weight and BMI in the O.Z. group was statistically less than the mean change in the control group.

CONCLUSIONS

A structured, family-oriented weight management program is effective in changing measures consistent with improved weight management.

Evaluation of a training to improve management of pediatric overweight

INTRODUCTION

Despite widespread concern about pediatric obesity, health care professionals report low proficiency for identifying and treating this condition. This paper reports on the evaluation of pediatric overweight assessment and management training for clinicians and staff in a managed care system. The training was evaluated for its impact on assessment practices and utilization of management tools.

METHODS

A delayed-control design was utilized to measure the effects of two 60-minute interactive Continuing Medical education (CME) trainings for the pediatric health care teams. Chart abstraction was conducted at 0-, 3- and 6-months after training, recording the proportion of charts containing the recommended assessment methods and management tools.

RESULTS

The training was associated with a significant increase in the utilization of some tools and practices, including charting BMI-for-age percentile (p < 0.001) and using a nutrition and activity self-history form (p < 0.001). Overall, from baseline to 3-months post training, charting BMI-for-age percentiles increased from zero to 25.2% and utilization of the self-history form increased from zero to 35.3%. These increases were sustained at 6-months post training. Other tools guiding clinician counseling were less widely utilized, although a behavioral prescription pad was used with 20% of overweight patients.

DISCUSSION

A modest investment in clinician and staff training designed to be feasible in a clinical setting was associated with substantial increases in the use of appropriate tools and practices for the assessment and management of pediatric overweight. Such training may help to augment and improve the processes of pediatric health care delivery for addressing overweight. The training provides a viable model for future CME efforts in other health care settings.

Design and implementation of training to improve management of pediatric overweight

INTRODUCTION

Clinicians report a low proficiency in treating overweight children and using behavioral management strategies. This paper documents the design and implementation of a training program to improve clinicians' skills in the assessment and behavioral management of pediatric overweight.

METHODS

Two one-hour CME trainings were designed using published guidelines, research findings, and expert committee recommendations. The trainings were provided to clinicians of a managed care pediatric department, utilizing novel screening and counseling tools, and interactive exercises. Surveys and focus groups were conducted 3 and 6 months post intervention to examine clinician attitudes and practices regarding the screening and counseling tools.

RESULTS

Post intervention, the majority of clinicians agreed that the clinical practice guidelines (Pediatric Obesity Practice Resource) and BMI-for-age percentile provided useful information for clinical practice. Clinicians reported an increased utilization of the recommended screening tools and changes in office practices to implement these tools. They offered suggestions to improve the ease of use of the tools and to overcome perceived clinician and/or patient barriers.

DISCUSSION

A brief, cost effective, multi-faceted training and provision of counseling tools were perceived as helpful to clinical practice. Useful lessons were learned about tool design and ways to fit tools into practice. Training the entire health care team is advantageous to the adoption of new tools and practices.

Anti-atherosclerotic effect of simvastatin depends on the presence of apolipoprotein E

Low density lipoprotein receptor deficient (LDLR-KO) and apolipoprotein E deficient (apo E-KO) mice both develop hyperlipidemia and atherosclerosis by different mechanisms. The aim of the present study was to compare the effects of simvastatin on cholesterol levels, endothelial dysfunction, and aortic lesions in these two models of experimental atherosclerosis. Male LDLR-KO mice fed a high cholesterol (HC; 1%) diet developed atherosclerosis at 8 months of age with hypercholesterolemia. The addition of simvastatin (300 mg/kg daily) to the HC diet for 2 more months lowered total cholesterol levels by approximately 57% and reduced aortic plaque area by approximately 15% compared with the LDLR-KO mice continued on HC diet alone, P<0.05. Simvastatin treatment also improved acetylcholine (ACh)-induced endothelium-dependent vasorelaxation in isolated aortic rings, which was associated with an increase in NOS-3 expression by approximately 88% in the aorta measured by real time polymerase chain reaction (PCR), P<0.05. In contrast, in age-matched male apo E-KO mice fed a normal diet, the same treatment of simvastatin elevated serum total cholesterol by approximately 35%, increased aortic plaque area by approximately 15%, and had no effect on endothelial function. These results suggest that the therapeutic effects of simvastatin may depend on the presence of a functional apolipoprotein E.