Keep ME Healthy

From 1980 to 2008, the rate of obesity tripled for children in the United States, and by 2011, 17% of American children were considered obese, according to the Centers for Disease Control and Prevention (CDC). Obesity increases the risk of many chronic health conditions in adulthood, including coronary heart disease, stroke, high blood pressure, type 2 diabetes, high total cholesterol, certain cancers, liver and gallbladder disease, and sleep apnea. In a 2011 report, the Institute of Medicine highlighted the opportunity afforded to pediatricians and other health care professionals to make parents aware of their child's excess body weight early on, at routine pediatric visits. The Institute of Medicine recommends that health care professionals measure weight and height/length in a standardized way and encourages parents to (1) keep children active throughout the day; (2) provide them with diets rich in fruits, vegetables, and whole grains; (3) limit energy dense nutrient poor foods and screen time; and (4) ensure that children sleep an adequate amount daily.

Keep ME Healthy, an initiative of the Maine Youth Overweight Collaborative (MYOC), is an 18-month intervention for pediatric primary care practices that aims to improve care and outcomes for overweight and obese youth. The intervention trains providers to:

- Implement improvements in clinical decision support that optimize the management of obesity in youth aged 5-18 years

- Provide counseling to children and parents about the "5-2-1-0" daily behavioral goals for obesity risk reduction: 5 or more servings of fruits and vegetables; 2 hours or less of TV or computer screen viewing time; 1 or more hours of moderate to vigorous physical activity or exercise; and 0 sugar-sweetened drinks

- Develop overall practice and provider improvements for obesity management following the chronic care model

The Keep ME Healthy intervention was developed primarily from research conducted by the Harvard Prevention Research Center, the National Initiative for Children's Healthcare Quality (NICHQ), and the CDC. The intervention provides a toolkit that addresses both clinical decision support and counseling for providers and self-management support for patients and their parents. The toolkit includes:

- Pediatric Obesity Clinical Decision Support Chart, a 24-page flip chart for providers that includes guidelines for medical evaluation of overweight patients; reference values for laboratory tests and blood pressure; body mass index (BMI) percentile charts; guidelines for hypertension management; and guidelines for effective communication with families around the 5-2-1-0 goals using elements of brief motivational interviewing during routine health care delivery

- 5-2-1-0 Healthy Habits Survey, a 1-page behavior screening survey completed by parents or children, depending on the age of child

- Keep ME Healthy poster featuring the 5-2-1-0 goals for display in waiting and exam rooms

- Goal-setting worksheets, goal trackers, and parent/child flip charts with healthy lifestyle tips for families 

Over a series of three 1.5-day training sessions, primary care practice teams are trained to deliver the 5-2-1-0 healthy lifestyle message to all pediatric patients during annual preventive care visits; assess patient readiness to make behavior changes; and promote self-management skills and set goals with patients and their families.  Practice teams are encouraged to conduct routine assessments of BMI on all youth between the ages of 5 and 18 years. In addition, they are encouraged to follow the Keep ME Healthy expert panel recommendations, which include checking fasting lipid profiles, a liver function panel (alanine aminotransferase/aspartate aminotransferase) if the youth is obese and 10 years or older, and ordering a fasting blood glucose if more than one risk factor for diabetes is identified.

Keep ME Healthy trainings are attended by three staff members from each practice, including a provider leader/champion, another medical staff, and an administrator. Training sessions focus on how to implement the chronic care model by (1) making joint decisions about patient tracking, assessment, education, and follow-up, with decisions tailored to the needs, context, and skills of each team, (2) putting a quality improvement protocol in place at a systems/practice level to identify performance gaps in obesity management, and (3) forming alliances with State and community agencies (e.g., schools, faith organizations, and local businesses) to support the healthy lifestyle treatment plans recommended to their pediatric patients and families. In the first two sessions, providers receive training on brief, motivational interviewing counseling techniques for negotiation and patient goal setting, evidence-based guidelines for managing pediatric obesity, and quantifying practice improvements. The third training session provides information on shared medical appointments and group visits for overweight patients. After training, coaching and ongoing support are provided through bimonthly conference calls and site visits. Periodic newsletter emails provide the latest information and literature on relevant topics, and performance feedback is provided by an expert faculty review of bimonthly team reports.

- Three 1.5-day formal training sessions for three-member practice team

- 4-6 minutes during each well-child visit for the health care provider to deliver the 5-2-1-0 healthy habits message, promote self-management skills, and set goals

- 5 minutes during each well-child visit for another practice team member (e.g., medical assistant or nurse) to measure height and weight for BMI

- Two 30-minute meetings per month to assess team progress and discuss partnerships with community and State organizations (can be combined with the practice's regular staff meetings)

- 10-20 minutes per month to generate reports from the team meetings

- Two 1-hour conference calls per month, usually taking place before the work day starts

- A 1-hour site visit every few months, typically occurring over the lunch hour

The intervention targets pediatric primary care practices and patients (aged 5-18 years) and their families. 

The intervention is designed for pediatric primary care practices and clinics.

Materials required for implementation include:

- Toolkit available from the Harvard School of Public Health Research Center/MYOC Website

For costs associated with the program, please contact the developer: Michele Polacsek.  (See products page on the EBCCP website for developer contact information.)

A quasi-experimental, multisite study evaluated the effects of the Keep ME Healthy intervention on parent recall of provider counseling on the 5-2-1-0 risk behaviors for childhood obesity at the well-child or acute visit of their child (aged 5-18 years) in 9 intervention and 10 control sites.

Study sites (pediatric primary care practices) were self-selected and located throughout the State of Maine. Intervention and control sites were similar in demographic characteristics; intervention sites had an average of 4,600 children/youth as regular patients of the practice, and control sites had an average of 4,400; the average percentage of patients with MaineCare Medicaid was 45% in the intervention sites and 34% in the control sites. Of the 539 youth who participated, 51.6% of the intervention group and 57.1% of the control group were aged 5-11, and 48.4% of the intervention group and 42.9% of the control group were aged 12-18.
 
To measure the intervention's effect on parent recall of 5-2-1-0 risk behaviors, a brief paper-and-pencil survey was administered to parents in waiting rooms at the study and control sites. The survey was administered at baseline (before implementation of the intervention) and after 2 years of implementation. It included four yes/no questions, each beginning "Has a doctor, nurse, or anyone else in this office ever talked to you about" and ending with one of the following: (1) nutrition, (2) physical activity or exercise, (3) TV viewing or other screen time, and (4) sugar-sweetened drinks. In the post-implementation survey, four additional questions asked "Did a doctor, nurse, or anyone talk with you about [nutrition, physical activity, TV viewing/screen time, and sugar-sweetened drinks] at your child's last visit?"

At the time of the study, the intervention sites had been implementing Keep ME Healthy for about 2 years. Up to 100 surveys were distributed to parents at each site (73 per site on average) over a 7-week period; return rates were estimated at 96% for intervention sites and 98% for control sites. Surveys were dropped from the analyses if they (1) did not indicate a clear age of the child or children, (2) indicated children with no previous visit to the practice or outside the ages of 5-18 during the study, and/or (3) were missing information on the 5-2-1-0 risk behaviors. The final sample consisted of 539 surveyed parents. 

• Parents of youth seen at pediatric primary care practices that had been implementing Keep ME Healthy for 2 years more frequently recalled their health provider discussing obesity risk behaviors with them at the last well-child visit, compared with parents at control sites. Specifically:
  • 74.0% of parents at the intervention sites recalled their provider talking to them  about fruits and vegetables, compared with 58.5% of parents at control sites (p=.0001).
  
  
  • 71.5% of parents at the intervention sites recalled their provider talking to them about TV viewing or screen time, compared with 48.7% of parents at control sites (p=.001).
  
  
  • 81.3% of parents at the intervention sites recalled their provider talking to them about physical activity or exercise, compared with 69.4% of parents at control sites (p=.005).
  
  
  • 63.8% of parents at the intervention sites recalled their provider talking to them about sugar-sweetened drinks, compared with 41.1% of parents at control sites (p=.0001).