Making the Assessment, Management and Treatment of Obesity Come Alive in Your...

What I'm gonna do for the next probably 30 to 45 minutes to talk to you about um making assessment and management and treatment of childhood obesity come alive in your practice using a new algorithm that we developed at the institute, um, and so it's being first, uh, unveiled here, so pretty exciting. So Stephanie's already introduced me, so here I am with the things that I do. Um, here is the Institute for a Child Healthy Weight. Our vision is to serve as a translational engine for pediatric obesity prevention, assessment, management, and treatment, and we hope to move policy and research from theory into practice in American healthcare communities and homes. The mission that we do at the institute, um, we hope to empower pediatricians, families, and children to better prevent, assess, and treat obesity and its comorbidities, and that's going to be an important point today because I'm going to be talking a lot about the comorbidities. We also hope to enhance partnerships with families to find and navigate pathways to healthy, active living, individual pathways. We hope to also catalyze stakeholders and communities to build an enhanced capacity for health of active, active living. The learning objective today is to explain a new obesity algorithm, define the potential conditions associated with childhood obesity, review the obesity-specific review of systems, PE, and family history. It's a new concept for some of us. And then also to define reading laboratory tests, we all seem to always want to know. That clarify the stages of management and treatment. So why a new algorithm? We seem to have lots of different tools, and I know Chris is going to be talking about this later. But over the last few years, there's been an increased understanding and research that children with overweight and obesity may be sick, and oftentimes those children are not being appropriately screened for comorbidities. So as providers, we want to be able to help keep our patients in the medical homes by managing and treating them in our offices. And we also developed this because providers have continued to ask for guidance around this. So how do we develop the algorithm? We had a small group of experts, primary care docs and self-specialists who get together over email and phone calls, um, and were incredibly patient with me as I pushed them to make sure that we got the words missing correct and put the commas in the right place and, and fasting and non-fasting labs. So they were incredibly patient. Um, we relied on existing guidelines, which is very, very important for us, the 2007. Committee recommendations, the US Department of Health and Human Services cardiovascular guidelines, and the American Diabetes Association guidelines. We also looked at new research, new research around crossing growth percentiles, type 2 diabetes, preventing weight bias, which I know we're going to hear about in a bit, motivational interviewing and obesity treatment, and we looked at new consensus statements around comorbidities and pre-diabetes. All of these references are on the back page of the algorithm and they're also at the end of my presentation. So a few points about the algorithm, excuse me, the algorithm. There's a lot of information in the algorithm, some old and some new. The algorithm starts at the well trial visit and continues on with planned follow-up visits as determined by the patient, family, and provider. Really important that the patient's family gets to decide their path through this. The algorithm is not a protocol. It's a suggested course of action that provides guidance to be used with clinical judgment. Again, critically important. So here it is. As I said, a lot of information. The front page that you're looking at here that's forward to you is um all around the assessment, and it's the assessment and management of childhood obesity in patients 2 years and older. It's critically important, as we heard earlier in the conversation, to think about the early days from. Birth, even prenatal, but birth to the age of 2. This algorithm doesn't address that. Maybe in the future, but this algorithm is just about patients 2 years and older. So the first page is all about assessment, everything from behaviors to weight to labs to comorbidities, and I'll walk you through each of those stages. The second page is all about the management and treatment. So here's the first thing that we need to be really thinking about. Wait one second, I'm gonna just change it to something on my screen. See if I can. I think it's great. So the first thing in assessing behaviors, you want to assess healthy eating and active living behaviors, and some examples are fruit and veggie consumption, sugar drink consumption, physical activity, screen time, and sleep. Really important to be thinking about behaviors, and we heard that earlier from what Lisa and Kathleen said. Really, we want to be focusing on behaviors and not weight. There we go. I've got it. So, um, this is going about adjusting the healthy habits, um, and how do you want to do this. This is what we do here in Maine. We use something called the Healthy habits Questionnaire. It's the 52 and 0, questionnaire. It asks a series of 10 questions. The last question is really the 1st 9 questions are about the typical fruits and veggies. Consumption, physical activity, sleep, eating out, a number of things like that. The 10th question is critically important because if asked, do you have one thing that you want to be working with your child on that that he or she may want to change. For older kids, we have them fill it out and we ask them, is there something you would like to work on changing. The important point about this questionnaire is it gets the conversation started between the parents and the child in the waiting room. We use this as an old fashioned way as a paper and pencil or pen. Uh, it keeps the conversation going throughout the appointment because the CNA or MA uh can also ask, um, The patient and the family, hey, how did you, do you have any questions about the healthy habits questionnaire? Oh, I see you're doing a really great job on screen time and you're doing a great job in getting that physical activity. And then it tracks through to the nurse, to the primary care doc. It can also be used as a quality indicator for healthy eating and active living. Oh, sorry, wait a minute. So this, um, the next stage in the, uh, algorithm is determine weight classification, and many of you all know this. We do this by accurately determining weight and height, calculating and plot the body mass index, and determining the BMI percentile. And from there, we have 3 categories that we're going to be talking about in this algorithm. On the left-hand side of the algorithm is the healthy weight category. That's for patients between the 5th and the 84th percentile. And then the middle category is the overweight category, and this is for patients between the eighty-fifth and ninety-fourth percentile, and the obese category for the BMI that is greater than or equal to the 95th percentile. So let's start over here on the left-hand side of the category. These are patients whose BMI have put them in this category. And so what you're gonna do, um, on this, again this is at a well child visit, you'll do a family history, a review of systems, and physical exam. And in most circumstances you just will end up doing routine care, preventive counseling. We use the 52 and 0 mnemonic, which many folks use across the country, and that stands for 5 or more fruits and vegetables a day, 2 hours or less of screen time, 1 hour more of physical activity, and zero sugary drinks. You also want to think about screening for genetic dyslipidemia to obtain a non-fasting lipid profile for children between the ages of 9 and 11, and then you do it again between the ages of 18 and 21. I'm going to pause here for a minute because this is not screening for lipid abnormalities associated with obesity. This is part of the the cardiovascular guidelines that came out about 3 years ago, so you should be doing this on all patients irrespective of their weight. And then you do follow up as needed. So now let's go into the middle category. So these are patients whose BMIs have put them in the overweight category. The BMI is between 85th and 94th. This is where it gets exciting, and this is what something's very different. This has been around for a while. Uh, it's been recommended in the 2007 Expert Committee recommendations that for patients who um BMI is over the 85th percentile, we should be thinking differently about them. We should be having a pausing moment. And I'm gonna come to that. So this pausing moment is because these children could be sick, and we don't know it. As you know, kids greater than the eighty-fifth percentile don't necessarily have some big sign on them saying like, hey, I might be sick, screen me. And so what we need to do is we need to think about how do we ask a couple of questions and fine tune and augment our assessment of these children. So what we're asking the Primary care providers to do is do a little more in-depth review of systems, physical exam, and family history. And if you do those three things, and again, it shouldn't take you much more time than you normally do on your well child visit anyway, if you do those three things, you may be able to determine for kids who are in the overweight category if they're at increased risk for comorbidities associated with their obesity. Let's go through that. So this is the review of systems. So the review of systems, when you're thinking about uh the things that would make you, uh, think more like this child might be at risk, are they snoring? Do they have sleep disturbances? Do they have abdominal pain, menstrual irregularities, hip or knee or leg pain, polyuria, polydipsia, depression? Any of these positive symptoms could put them at risk for an underlying comorbidity. This is a great graph, which it may be difficult to read here. However, it's in the 2007 Expert Committee recommendations. It's Table 5, and they have the review of systems, the symptoms on the left hand side and then on the right hand side of the possible causes. So for things like snoring, you could be thinking about obstructive sleep apnea. For abdominal pain, you might think about gastroesophageal reflux, constipation, very common in these kids, gallbladder disease, or non-alcoholic fatty liver. Things like nocturnal auresis, we might be, or in polyuria or polydipsy, you might be thinking about type 2 diabetes. So the next piece of this augmented um uh look that we're going to do with these kids is the physical exam. And again, this isn't anything different than you would do in your normal well child visit. It's just, just a little closer look with these kids, right? You want to clearly be looking at the blood pressure. Are they, do you have pre-hypertension or hypertension? It's the correct cuff size. It's critically important for these kids. You want to be looking to see if any of that dark discoloration of skin, the acanthosis magabands, do they have tonsillar hypertrophy? Do they have a goiter? Is their abdomen tender? Do they have a big liver? Do they have bowing of the legs? You could think of blast disease. Limited hip range of motion. You think of maybe a slipped capitol epiphysis. Are their optic discs a little fuzzy thinking it's pseudotumor? Do they have things like acne, skin inflammation? This is another graph, a little busy, I know, but it's in table 6. It's table 6 and the 2007 expert committee recommendations. And again, on the far left hand side, you have the symptoms, the symptoms. The findings on physical exam and the possible explanation as a primary care provider, you don't have to memorize this table, but we are going to be through the institute, we will be making um some quick reference cards for this table and the table that I mentioned earlier in the review of systems. And lastly, so these are again for kids greater than the 85th percentile, you've done a little more in-depth review of systems. You've done a little more in-depth physical exam. Now the family history, is there anything there in 1st degree, 1st, and 2nd degree relatives that are popping out that are making you think that these kids may be at more risk for comorbidities? And some of the obvious ones that are very important to think about are obesity. Now, in pediatrics, we don't often measure the moms and dads, and it's difficult to really tell whether they, a mom or dad may have obesity, but we often can tell whether they may be struggling with their weight and carrying extra weight. Um, so that's you may have a parent or a grandparent in the room that helps give you some of those clues. Also, type 2 diabetes, hypertension, lipid level abnormalities, and heart disease. The parents and the grandparents will all be happy to talk to you about type 2 diabetes and hypertension, tell you how many family members have heart problems. It may be difficult to really get a good history of obesity, but you might be able to get a history if you ask about people struggling with weight issues. Here's another busy slide, um, but it is table 7 from the 2007 expert committee recommendations, and it tracks through everything I just talked about. Again, it's another reference that you may want to, uh, refer to. OK, so now what we did is we now have a patient who's, as I talked about in this middle section, they're in the overweight category. The BMI has placed them there. The BMI is between 85th and 94th percentile. You've done a little more in depth, um, look at them, and maybe you found out that their family history, they don't have anybody who has anything, uh, for obesity or diabetes. The review of systems, And the physical exam didn't put them at increased risk, and then you go to the left-hand side of the algorithm and they, they don't need anything else other than routine care that I just described. However, if you have a patient in this category who has a strong family history or positive review systems or positive PE, they may be at risk and they should go to the right-hand side of the cat this, um, algorithm and get more further screenings for, uh, comorbidities. So let's talk a little bit about that. So, if you go to the right hand side of this, this algorithm, now we have who are greater than the 85th percentile, equal to or greater than the 85th percentile. So, the BMI put them in the obesity category. You still should do that augmented family history, because you symptoms and PE. However, based upon their BMI, they are at increased risk for comorbidities. And I'm going to pause here because my take home message, if I haven't already said it, I'm going to say it a couple more times. This algorithm, the take home message of all of this is patients who are in the overweight category, the BMI has placed them in the overweight category. They have a risk factor defined by positive family history, you systems, or PE. And patients in the obese category, obesity category, those patients should have additional screening and additional and potentially additional workup for underlying comorbidities. That's what this algorithm is all about, and we hope that this provides the guidance the primary care provider would need to know the next steps. So let's talk about the next step. So lab screening. This is a fascinating conversation with the experts that we had between primary care and the sub-specialist. And where we landed on it are 6 bullets, and I want to walk you through them. The, the first bullet is most. The 2007 expert committee recommendations state that a fasting glucose and a fasting lipid profile, along with an ALT and an AST should be obtained in those patients that I just mentioned who are in the overweight category with risk factors in the obese category. Again, all those patients should have fasting glucose, fasting lipid, ALT and AST. Additionally, guidelines from the ADA and the Endocrine Society recommending a hemoglobin A1c, fasting glucose, or an oral glucose tolerance test to screen for diabetes or pre-diabetes. So based upon what you're getting and a family history of review of systems, you may want to add those tests on, or some of those tests on to the panel that you're going to be getting for your patients. The third bullet, and we do know this, that for some for patient convenience, some providers are obtaining non-fasting labs. Not ideal, but if you have your patients and family there in your office and they're coming from an hour away in a rural state like Maine, this happens a lot, the likelihood that they're going to come back at another time to get a fasting lab is unlikely. So some providers are doing non-fasting. The fourth bullet, clinical judgment, local preferences, and availability of testing should help determine how you follow up abnormal labs. It's not quite, uh, very clear and cut and dry that you should follow up on a routine schedule because sometimes there's local preferences for that. Sometimes the availability of the testing will come in and also, and also how abnormal were those labs. The 5th bullet is really interesting of note, some subspecialty clinics, we'll talk about these are probably stage 3, stage 4 kinds of clinics are screening for vitamin D and insulin resistance by obtaining vitamin D and fasting insulin levels. The clinical utility and the cost effectiveness of such tests is yet to be determined. The costs of both of those tests are very high. And lastly, there are no current guidelines on when to start laboratory testing for patients with obesity. Based upon the patient's health risks, some experts may start screening patients as early as 2 years of age. So now we want to get into the comorbidities, and this is, um, there's another fascinating conversation because as I said, the, the, the understanding and the research is telling us that many of these patients are ill and we need to help figure out which ones are ill, what comorbidities do they have, which ones have prediabetes or sleep apnea, very significant. Morbidities or a non-alcoholic fatty liver. So this is a a table here of obesity related conditions. These conditions are associated with obesity and should be considered for further workup. Additional lab tests other than the ones that I mentioned, and additional other workup tests should be maybe indicated by the patient's clinical condition. In 2004, the consensus statement by the Children's Hospital Association, actually two consensus statements, described the management of a number of these conditions, and it's very critical. I'll go over those references in a minute. So here, I won't go through the list of them, but you can see we, we, uh, bulk them up by system, cardiovascular, and we have there dyslipidemia and hypertension and endocrine. PTOS, type 2 diabetes, uh, prediabetes. We also look at gastro, uh, intestinal, GERD, constipation. Again, constipation is a very common comorbidity, um, that we should really always ask about because it's very easily to treat and the patients will feel tremendously better, be able to eat more, be able to be more physically active. There's neurological, uh, comorbidities, orthopedic, psychosocial, pulmonary, skin. You can see them all listed here. These are important references that uh, I put here, uh, Ken Coopelman, uh, management of the newly diagnosed type 2 diabetes, the Child Children's Hospital Association consensus statement for comorbidities, um, and assessing pre-diabetes and, and, uh, BC treatment programs. These three references are really critical to review and to look at when thinking about, uh, your approach to dealing with comorbidities. This is a great statement from the consensus, um, uh, from the Children's Hospital consensus statement. The consensus statements presented in this article may help keep the management of these children in their medical home and provide guidance to those sites that may not have such specialists available. We think this is critical. We all know we want our patients and families in our medical home, especially in rural states like Maine where they cannot always travel to see the subspecialist. I'm going to pause here. I didn't know if we wanted to take any questions about the first part of the algorithm, and then I can go into the second part, or I can hold the questions till the end. Stephanie, whatever you'd like to do? Well yeah, well, there were some questions, one in particular about getting an electronic version of the algorithm. And, and the availability of it, I guess, to, to folks. Absolutely. So it's, uh, I think one of my last slides you say where the link is and the link will be on the institute's, uh, website. Excellent. Has, has anyone, uh, put this in a format that's compatible with any of our, with any of the common electronic medical records and such as setting up a smart set or anything like that? Great question, Mark. So we here, um, at Let's go, we're gonna be doing a couple of things with the algorithm. We're gonna be working with about 10 to 15 clinicians who have already been doing a lot of work with us over the years to really try out this algorithm, uh, and part of that, we're gonna be, um, looking at putting it in in the coming year into Epic. We use Epic, so we're very excited about that. So are we. That's great. Yeah, I'm, I'm glad you mentioned all the, the issues around sort of the labs and the ones that you're ordering. I know, especially the, the insulin and the vitamin D levels because insulin levels, it's very, very, um. Particular, I, I know around where we are, half the folks want you to get insulin levels. If you ask the endocrinologist, they half say yes and half say no. So you're sort of in the middle. And so just really knowing where to stand at, you're right, I think just time will tell really if those are going to be of use and of value. Yeah, that's a great point. There's, um, I don't know, uh, Stephanie, are you guys involved with the power registry? Yes, the Kelly? Yeah, so the power registry is going to be this amazing resource, um, over the next 2 or 3 years. I think there are last I looked, 27 different, uh, clinics that are going to be inputting data into. This registry and I think that will help tell us whether things like getting insulin levels are a great idea, an OK idea, or not a good idea. No, I agree. I was, I, I ordered them for a while and then I stopped and now back with the power we're ordering them again, so I'll be interested to see as well. Mhm. Uh, any other questions, or should I go, keep on going on? Um, I think you can keep going. OK, great, thanks. So that was the first, uh, the front page of the algorithm, and the algorithm is all around assessment, and that's really our key point. We did know that we're really trying to make the point here is that patients need to be screened, and I do know from talking to many primary care providers in the state of Maine and across the country that many aren't doing it. They felt they needed a little more guidance, so we helped the first page of the algorithm to help provide that guidance. So now the second page of the algorithm is on the management and treatment, but before we get there, I think there are a couple of key points. Not every patient is ready for treatment. And, you know, it's hard here because who are we to, to force that every patient needs treatment? I, I, you know, I hear this a lot in Maine, you know, Corey, my kid's fine. They're just really big boned. I don't, we don't need to do anything about it. And, and when they're, if the patient's not ready and the parent's not ready, I love to say that's OK. When you're ready, I'm ready. In the meantime, I might want to do some screening labs just because they may fall into that category, but I don't use fear tactics for that. That doesn't work. It's not the approach that we think works. There are no quick fixes. There really aren't any quick fixes. People think there are because they've been watching The Biggest Loser for, I personally feel, a little too long. So people think that there are going to be some quick fixes, some quick pill, some quick surgery, sorry surgeons. There may be, there may be, but there really aren't quick fixes, as you know. Anybody who goes into a surgical treatment are older kids who may be eligible, there's many, many months of behavior mod and treatment that goes. Into that before surgery, I think that's a great point because you can't, right, I mean when people aren't ready, I think we try to, you know, we can still express our concern or say, hey, when you're ready I'm here so they know, you know, you're keeping that door open, but I think we sometimes feel compelled to say things or to prompt or try to persuade them to, to be more motivated, and that's really not the way to get things going in a long lasting way anyway. It, it really isn't, and the really great work that has happened um with Ken Ruakau and his team at the University of Michigan and all the studies around, uh, motivational interviewing, we do know that motivational interviewing works for behavior change. We do now know that motivational interviewing actually works for, uh, obesity management and treatment, so that's fantastic. Um, a couple of other things, and it was alluded to that Lisa and Kathleen brought up. Small behavior changes can have a profound effect on health and they're usually much more sustainable. And I bring this up. I wanna tell you a story. I was working with, um, Mike Sadekian, who's our pediatric endocrinologist, and he runs our countdown, uh, program, and he always tells his patients, it's really not about the number on the scale that I care about. It's about the behaviors that you've. to change, and I'm here to help you with those. And he was seeing a patient the other day and I got an opportunity to be with him, and it was a wonderful 12 year old boy and he's very quiet in the, in the exam room. And um Mike was gussing over him saying, Hey, Joe, you did an amazing job. You've gotten more physically active. You joined a rec team to play um spring soccer, and this is great. And Joe's like, well, that's all I did. And Mike's like, but that's a lot. And then Joe said, but I didn't, I didn't lose any weight, Dr. Mike. And Mike said, but you didn't gain any. And look, and then Mike was able to show him the growth curve, which showed a tremendous decrease in the velocity of the BMI, the BMI velocity that had been going up. And quickly then Mike said, but I don't care about those numbers, Joe. What I really care about is these behavior changes. And so these people just are so, we're so sort of in this culture of, of big things, right? So when we work with patients and families, it's a small thing. It's from going, I know people aren't gonna like this, but it's from going from 6 sodas a day to 5 sodas a day, that's pretty big, right? It is, or for going from soda to or going from juice to hot juice and water to then gradually water. So I think it's really important as primary care providers that we understand that we should be focusing on small behavior change and on the healthy habits. The great thing about pediatrics, by and large, up until their growth plates fused, the kids are going to get taller, so that's on our side. OK, the last thing I'll say before we get into the stages, the stages are a guide, and not every patient fits neatly into one stage, and this is again where we use our clinical judgment. So this is the back page of the algorithm. Again, we're sorry there's a lot of text in the algorithm, but we have a lot of stuff that we wanted to get on there. So here's the, I'm gonna take you through each of the stages. Also, at the bottom, you'll see each of the references. So in the talk, um, I also wanted to talk a little bit about, uh, a little disclaimer. So, the patient should start at the least intensive stage and advance through the stages based upon the response to treatment, the age of the patient, their BMI. The health risks and most importantly, the motivation of the patient and family. The last thing you want to do is take a patient through stage 1 through 4, even if they're really ill, but if they're not ready for it, you're just, you're just, that's not fair to them. You're not really listening to them. You also, we do know an empathetic, empowering counseling style such as motivated salinity should be employed to empower patients and their families, empower the patient and family in behavior change, no fear tactics. OK, let's go through the four stages. So stage one is called Prevention Plus. These all come from the 2007 Expert Committee recommendations. The stages come through there. The titles of the stages come through there. However, with this algorithm, we updated a couple of the specifics in each of the stages based upon new evidence. So for stage one, it happens in the primary care provider office by a primary care provider. What is it? It's planned follow-up, uh, themed visits, 15 to 20 minutes focusing on behaviors that resonate with the patient, the family, and the provider. Patient was first. What's really important about this is if you're seeing a patient and family and you think that they really need to work on decreasing the sugar, sugar sweetened beverage consumption, however, they want to work on physical activity, you obviously go wherever the patient and family is, and that's sometimes hard for us sort of controlled pre kind of pushy primary care docs. You also want to consider partnering with dietitian, social worker, athletic trainer, or physical therapist for added support and counseling. Here in Maine, we have an amazing, um, partnership with a physical therapy group. They have 4 major, uh, centers across southern and, uh, sort of coastal Maine. It's called Fit For Me. And the primary care provider sees them in the office. And then for these kids who are between the ages of 8 and 12, 8 and 16 probably, they'll go to the physical therapist for about 6 visits. It's reimbursed and it's amazing to see the kids light up and working with the physical therapy, I mean, sorry, a physical trainer. Um, and physical therapists, but oftentimes these physical therapists and trainers are closer in age to the kids than I might be, and the kids really relate with them. It's also amazing they'll put them on a treadmill and they'll be talking to them when they're on the treadmill. They really work on core strength and strengthening overall. So that's another thing to be thinking about in, in this category at any of the stages. The goals for this, as I mentioned, are positive behavior change irregardless of the change in BMI. Weight maintenance or a decrease in the BMI velocity is the next goal, and we put this next statement in each of the stages. It's a, it's a sort of disclaimer that we want, want to make sure that our patients are not losing too much weight too quickly. So children between the ages of 2 and 5 who have obesity should not lose more than 1 pound per month. And older children and adolescents with obesity do not lose more than an average of 2 pounds a week. The follow-ups should be tailored to the patient and family motivation, and many experts recommend monthly follow-up visits. I will say in follow up, there's lots of ways to do follow up these days, depending upon your practice. You can text your patients, you can e-mail your patients, you can Facebook your patients. There's lots of different ways to do it. We do know with any behavior change, um, quick follow up, um, from the primary care provider to the patient and family is, is recommended. I will also say that there are many providers who let the patient and family say, when would you like to follow up? And that's what Dr. Mike does in Countdown. Mike says, When do you want to follow up? And sometimes the patient's like, You're asking me? Well, I'm thinking maybe 2 weeks. And that's really important again for some of our patients that come from very far away, and a weekly follow-up visit would be very difficult for them. Lastly, after 3 to 6 months, if the BMI and the weight status does not improved, consider advancing to stage 2. So stage two is called structured weight management, and here are the specifics of that. Again, this happens by the primary care provider in the primary care office. The primary care provider oftentimes probably should have some appropriate training. More training could be around, not necessarily around obesity, to be perfectly honest, the training is probably more around motivational interviewing. That's the same intervention as stage one, but includes more intensive support and structure to achieve healthy behaviors. I should have mentioned this in stage one, and I, and Chris may be talking about this later, but we have this amazing tool that the AAP now sells called Next Steps. It's themed follow-up visits. A group of us, uh, developed it about 2 years ago. There's 17 different themes, and within those themes, there's talking. That that providers can use for the patients and families. And so that is a tool that could be used for these kinds of visits. The goal here, the first bullet doesn't say, but the goal is still around behavior change as well measure of behavior change and then weight maintenance or a decrease in BMI velocity. And we have the same closure about monitoring to make sure the patient, um, doesn't lose too much weight too quickly. Follow-up is a little more frequent if the patient and family are ready for that, and we think every 2 to 4 weeks as determined again by patient, family, and physician. Again, after 3 to 6 months, if the BMI and weight status is not approved, consider advancing to stage 3. And stage 3, it's called a multi, a comprehensive multidisciplinary intervention, a little bit of a mouthful there. And here, again, with each of the stages, it's basically the same thing. The intensity of the counseling increases and the intensity and frequency of the follows and increases. So here, this is often done by a pediatric weight management clinic with a multidisciplinary team, because these patients often will need a social worker, may need a dietitian involved. So what in here is increased, uh, intensity of behavior change, frequency of visits and specialists involved. Many of these, um, uh, patients may need to see an endocrinologist. They may need to see a pulmonologist for sleep apnea. They may need to see a gastroenterologist. And this, again, it's a structured behavior modification program including food and activity monitoring, development of short-term diet and physical activity goals. The goal here is really weight maintenance or decrease in BMI. I will say the first goal would all be about behavior change because that behavior change will lead to the weight maintenance or decrease in BMI. The same caveat we have here too around, uh, making sure the patient doesn't lose weight too quickly. Follow-up again, very similar to stage 2, every 2 to 4 weeks based upon the case and family. After 3 to 6 months, if the BMI and weight status has not improved, consider advancing to stage 4. And stage 4 is called tertiary care intervention. This is really for, um, patients who are greater than the 95th percentile with significant comorbidities, and it happens in a pediatric weight management center with providers with expertise in treating childhood obesity. Again, the WD is for the patients who are sicker, and the, the WD is also a very intensive diet and activity counsel with consideration of use of medications and surgery, uh, surgery obviously for age, um, uh, age appropriate. The goal here is a decrease in BMI. Like, these kids are sick, so they need to, uh, they need, the goal can be to have some clearly behavior change initially, but you really need to get that BMI down. In the same caveat, we want to make sure the patients aren't losing weight too quickly. The follow-up is determined upon the patient's motivation and their medical status. For some of these kids, we follow, Mike and his team followed very closely because they are pretty ill. Here's the reference, um, this is hard to read here, but the references are, um, on the bottom of the, uh, uh, algorithm. So now the fun begins. Um, I'd like all of you to try implementing some or all of the algorithm in the office and keep the conversation going. Let me know how it's working or isn't working. Sometimes, as you know, the best thing is to tell me like, hey, this doesn't work at all. I had a really hard time implementing this. Feel free to just email me, email me directly. My email's right there. You can find the algorithm online, and here is the uh link down below. We will be doing a number of, um, at the institute, a number of, uh, educational pieces. Around the algorithm we will be having an MOC that will debut probably in late fall early winter, and we'll be using the algorithm a lot for that. Here at Let's go we're gonna be trialing it. I will also put a plug into Letsos having a national conference in the fall, and we're going to be taking this algorithm and dissecting it apart piece by piece and having national presenters do many aspects of this, talking about comorbidity and lab screening and working with patients and families. If you want to know more about that, you can go to let's go.org, and the conference material is there September 10th and 11th. Uh, thank you very much. I also want to do a shout out to my team at the Institute. We're amazing helping me put this together. Jeanie Lindros, Janna Liebert, and Corey Pierce, who was amazing to put some of the graphics together. Uh, thank you very much, and I'm happy to answer any questions. Well, that's great. Thank you, and I have been on the outskirts of everything you all were doing out there and I know the amount of time and effort that has gone into putting this algorithm together and talking with all the different folks and making sure that we really had the best evidence in, in putting this together. We did have several questions. Um, I don't know if you want to hit the reimbursement area first, but certainly. There are questions about um reimbursement for the trainer as well as physical therapy and what diagnosis codes have gone along with those. So, so, um, uh, there's, there's a couple of things about reimbursement, as you know, it's an ever moving, um, sort of target. So we do know that there are a couple of things that are happening at the institute. There's something called the Coffy Project, and that is being done, um, where there are, I believe, 10 different, uh, places across the country that are using parts of this algorithm, um, and having planned follow-up visits with primary care providers for 4 visits and dietitians for 4 visits, and that's being reimbursed by a number of, uh, plans right now. And if that goes very well, we're thinking there's an opportunity to I want to be careful when I say bundle, and I'm not quite sure I mean bundle, but there's an opportunity to look at these kinds of services and make sure that insurers are reimbursing for them. Uh, so that's happening at the through the institute something called the Copy Project. That information should be out later this fall or early December. I would ask um individuals in their own state in their own communities to um be advocates to their insurers to make sure that they do pay for planned follow-up visits without um sharing that cost with the provider. Copays can be very expensive. Many people also have health, healthy savings accounts. They may be paying for some of this out front and knowing that, um. In the beginning is critically important. We do know that patients and families will pay for service if they see a value to it. So one of the things that we work a lot, we work on a lot at Let's go and through next steps is making sure there is a value to those visits. Patients see value mostly when they feel like they got a chance to talk more than we did, so that's. are you thinking about? Last thing we talked about codes. There are encrypt, um, has done a lot of work on this, Chris Bowen. There are, um, the AAP has some coding documents. Those coding documents are in something called the 5210 flip chart that is sold, um, at the AAP. Uh, we probably can find that and, and, and send that to you, Stephanie, if you, uh, get that one piece also. OK, great. Um, the other thing, could you talk a little bit more about the education pieces around the, um, the algorithm that you plan to see and the MOC? Absolutely. So I think there's gonna be, there's a couple of educational pieces that we're gonna put together. One is, um, there will be a series of 6, CMEs that will be free for anybody to view on the institute's website, and they will be up by mid-October. And those 6 CMEs, um, will be an hour of Sandy King talking about the obesity epidemic, uh, and the role of the primary care provider. Chris Bowling will be talking about the algorithm and walking people through the algorithm, many of the same slides you've all just seen. There'll be, uh, Bob Schwarts talking about the uh MI use of MI. Jeannie Wong, Doctor Wong from uh California will be talking about treatments. And then lastly, we will have the 6th, um, will be about using quality improvement methodology in your practice. So beginning in, um, mid-October, there will be those 6 CMEs that can be used, um. Uh, 6 PowerPoints that you will get CME for. You can use them to teach off of, uh, you can use them to get your own CMEs. We will be using them as part of the maintenance of certification, uh, that we will be doing at the institute. The recruitment for the MOC will start in early October, and that MOC will run from January through June. It's a pilot. We're going to do something a little different. It's uh it's 6 months. There's going to be some pre-work. The folks to do the MOC will have to view at least 2 of those TMEs. And then um we're gonna be doing a, a virtual learning collaborative and having 3 webinars and pulling in some local experts to, to walk uh practices through the algorithm and, and then it concludes in 6 months. So we're gonna try it. We'll probably keep the first MOC to about 20 practices just so we can learn a little bit about it. The last thing that I'll talk is that we're, we're going to be developing um some tools, some of those. Those charts that I showed you that were very busy, um, we're going to be taking them and making them into sort of usable. I don't know if it's, it may be a flip chart. I hate to say flip chart, but it may be something like that. So in your practice you may be able to just have something that you can use as a more usable format than having to go to a journal article. And those will be ready by mid-October also. Tory, great, great talk. Um, so from a subspecialist standpoint, uh, you know, one of the things that you talked about was readiness to change, and you can't, you know, you can't just tell somebody, oh gosh, you got to do X, Y, and Z right now. As a, as a, as a sub-specialist and as a surgeon, you'll see plenty of kids come in through the ED, whether it's with appendicitis or in the office with hernias, reflux, other comorbidities. Uh, that drives some of the procedures that we do on these kids and you know it's interesting in the beginning I was all excited and I, you know, I'd tell them all about our Strong for Life program and try to get them all in Stephanie's program and what we found is that none of them ever showed up. So what is my role as a subspecialist when I have, you know, when I see these patients, one in the non-acute setting in the office, and 2. When they present in the acute setting in the hospital, is that the time to bring this up, or you just let it go? So, that's a great question. And, and I'll say that we do know that when, when patients, um, have an acute episode, sometimes they're ready to make a change. So, for some patients, let's talk about the acute episode first. How I might address it is first, deal with the acute episodes. The, the thing that patients and families can't stand, if, if they're in there in the ER and it's an a or a hernia, they want you to take care of that, right? So, so dealing with acute issue and then maybe in a follow up after that, just say like, hey, you know, you came in and you had, you had an appendectomy or a hernia, and, I think that maybe the excess weight that you're carrying may have made some, made it made difficult, uh, for, or may have complications for this, or the hernia may have been a, a complicating factor in this. Would you like to spend some time talking about the excess weight? And I use excess weight. You could use the words that you want. We do know obesity is a pretty loaded word. I also don't, I don't say that people are obese. I say that people have obesity, and that makes it a little easier for them to realize like, oh, obesity isn't me. It's something that I have and something that I can work with. So, in the acute setting, I would deal with the acute setting and then in follow up, let the patient know that you think that the excess weight they have may have some complicating factors to their acute, uh, episode. And if, You're Ready to talk about it. You're ready. And then you open the door and they might say, Yeah, I guess, I guess I hadn't really thought that that extra weight was that might have, might have made it more difficult or might have caused the hernia or made more complications with the appendix appendectomy. Yeah, I think I'm ready to listen. And if they're ready, then you can do a little more MI and then do the nice soft handoff to Stephanie's program. In the non-acute setting, I would handle it pretty much the same way, except you don't have the acute issue to handle, to deal with, and it's all really MI. I learned MI about 10 years ago, motivational interviewing, and once I learned it, it clearly changed my um interaction with patients. Families, I learned to roll with resistance. I learned to do the reflective listening, so I would use some MI techniques in a non-acute setting to say like to let them know that you think that the excess weight may be putting them at risk. Would they like to talk more about it? And when they, if they say yes, then you can talk about it. You might think there's some things that I feel that we might need to screen for, and would you like to start working on this. And what this is, is behaviors that out weight and you quickly make that switch. We have found that many patients and families are very ready to work on sugar sweetened beverage consumption. It's probably the easiest thing that people can, can work on. Screen time is the hardest. Physical activity right there in the middle, but some of the tips that Kathleen was bringing up were incredible. So, again, using MI to let you know when the patient or patient and family, depending upon the age you're ready to make a change, and then realize the change is not about weight, it's about the behaviors. Great. No, those are, those are all fantastic tips. Are there, is there any role, like, do I, as a sub-specialist, do I need to know what's in the algorithm, or is it something that I should be aware of? Is it something, is there anything I need to do in there? Yeah, it's a great question. I would like you to be aware of it, um, for a couple of reasons, because you may be getting some referrals as a subspecialist. So as a primary care doc, if I have to start doing a lot of screening for pre-diabetes, I should make sure my endocrinologist knows this, and he's sort of in step, or he or she is in step with me on it. So, as primary care providers, uh, if you're a children's hospital, it may be something you want to talk. About a department meeting, hey, do you guys, do you want to try this? And that may mean that you're going to, the gastroenterologist may be getting more calls on what to do with some of these lab results. Some are easy to do, deal with, and some aren't. So, as a community of clinicians, it would be great if the community were all together on this. That helps the patient and family, um, navigate the system too, because as a primary care provider, if I, To get some unusual labs and I send them to Mike, our endocrinologist. Mike's like, Oh yeah, I know Corey was doing that screening, so great, glad to see you here, kind of thing. So that's what I'd like the subspecialist to be aware of it. Also, I will tell you, my guess is that in 6 months to a year, we may make some tweaks to this, and the subspecialist may help us to figure out some of the areas that we, we may want to tweak. Yeah, that's great. 11 last thing, do you have any, uh, MI programs that you suggest people go to, maybe your top two that you would recommend people look at, and then we'll have to transition to our next speaker. Sure, any MI is great. Any MI is fantastic. Um, there are a number of, of, of motivational Interviewing.org is an amazing site to go to, and there are amazing resources there. Um, we just had Ken Resncaro, um, come from University of Michigan. He did an amazing program for 2 days for primary, about 30 primary care providers, um, and Ken is top of the line in my book because he takes MI and it's related to obesity, but everybody can't always get Ken. So I think going to motivational Anything.org and doing some on that site, there's some resources and some great books. MI for the primary care clinician is one of my favorites. Great. We also, I will say we do have some resources on our website. Uh, apply for our website, let's go.org under the healthcare feed. We have a whole section of our healthcare toolkit on MI. Yeah