“Make Health, Not War” in Rochester, New York: Promoting healthy weight and avoiding stigma
By Julie Eisen
Before joining NICHQ’s Healthy Weight Collaborative, the clinicians, policy experts, and public health professionals from the Rochester, New York, team were already emerging leaders in the field of obesity prevention. Led by Dr. Steve Cook, a pediatrician and associate professor at the University of Rochester Medical Center, the members of this team have been involved in a variety of initiatives with local and national partners aimed at preventing and reducing obesity since 2008. Focus areas have included changing local school lunch and worksite wellness policies, organizing running clubs for area youth, and developing a campaign, Be A Healthy Hero, that engaged both the general public and clinicians of Monroe County to promote physical activity and nutritious meal plans.
Given this baseline, the team’s participation in the Collaborate for Healthy Weight initiative was an opportunity for something more. The chance to learn from and engage with other teams from different communities is what drew Rochester to this project. Through in-person meetings and an online forum, the teams have been able to share best practices and exchange ideas and materials that have worked in their communities. “While we’re doing great work in Rochester,” says team member Rachel Pickering, “there is so much to know about different challenges and successes that other communities are facing.”
Planning for Healthy Weight
The Rochester team entered the Collaborate for Healthy Weight project with a desire to systematize a way for providers to work with parents and kids with overweight or obesity to develop a healthy weight plan. “We had a lot of practices that had perfected the basic parts around the well-child visit,” says Cook, “such as screening for BMI and counseling around nutrition and physical activity.” But providers needed tools for the next steps – so they could send patients and their families home with a plan and motivate them to return for follow-up visits.
The team focused on two clinical sites in Monroe County: Strong Pediatrics, which serves an urban population of about 13,000 kids, and Panorama Pediatrics, which serves a suburban population of approximately the same size. Reaching out to clinicians at these practices, Cook and his team collected and developed ideas on different healthy weight plan options and began tracking rates of use and follow-up. “We asked questions like, how were clinicians following up with patients? Were they giving a healthy weight plan? How did they feel they were following up with those patients? How were patients doing with their plan?” says Cook.
Cook says that this work has inspired providers to communicate more appropriately with patients and families to gauge motivation. “If a patient is motivated,” he says, “we tell clinicians not to wait. Schedule them to come back in three or four weeks.” But the goal is not to force patients to come back; it’s to meet them where they are, balancing urgency, motivation, and reality. “If a child is obese, but there aren’t any imminent medical issues,” explains Cook, “and if that family tells you it’s important, but they don’t have the time to come back – or they’re going through a tough time or they’re working three jobs, then don’t schedule them for an appointment and make them come back.” Instead, Cook suggests to clinicians that they think about how their system can get back in touch with those families at a better time, which might involve a solution like setting up a reminder prompt in the patient’s electronic medical record to call the family in two months.
Communication and Stigma
The team has also come to realize that another part of motivating children and families to engage in healthy behavior change is to be mindful of language. “As pediatricians, as nice as we think we are, we still have a lot of weight bias towards families in terms of how we approach and address weight with overweight and obese children and/or their overweight or obese parents,” says Cook. As the team worked with the test sites, they found that communication and stigma were recurring issues. In response to this concern, Cook partnered with Dr Richard Kreipe, a national expert in adolescent medicine and eating disorders, to hold a community grand rounds in March 2012 at the University of Rochester Medical Center about communication strategies for talking with patients and their families about obesity. Cook says he has heard from the test sites’ clinicians that focusing conversations with parents on the health risks associated with obesity has been more effective than focusing on the child being obese. “You can show parents that their child is in the high risk zone on the BMI chart and tell them they are obese,” Cook says, “or you can show them their child is in the high-risk zone and tell them that they are at risk for diabetes.”
To demonstrate the importance of slight language shifts, he says that teaching clinicians that a nuance as simple as saying “Your child has obesity” rather than “Your child is obese,” can have a big impact, because it avoids labeling the child. “When you say your child is obese, we immediately throw lots of blame at a parent, whether we intend to or not. When you say your child has obesity, it appropriately labels obesity as a disease.” To test the effect of changing the language “is obese” to “has obesity,” Cook and his team have begun piloting exit interviews with parents asking for their feedback, and early results show that the language change may have some benefit. “When we held the grand rounds, we had infectious disease doctors saying that this is how it was with AIDS and HIV twenty years ago. We stigmatized and labeled these people, which didn’t help.”
As Cook’s grand rounds title put it, which aptly depicts the work of the Rochester Healthy Weight Collaborative team, “Make Health, Not War…On Obesity.”