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Health Care and Work Environments

Health Care and Work Environments: Goal, Recommendation, Strategies, and Actions for Implementation

Goal: Expand the role of health care providers, insurers, and employers in obesity prevention.

Recommendation 4: Health care and health service providers, employers, and insurers should increase the support structure for achieving better population health and obesity prevention.

Strategy 4-1: Provide standardized care and advocate for healthy community environments. All health care providers should adopt standards of practice (evidence-based or consensus guidelines) for prevention, screening, diagnosis, and treatment of overweight and obesity to help children, adolescents, and adults achieve and maintain a healthy weight, avoid obesity-related complications, and reduce the psychosocial consequences of obesity. Health care providers also should advocate, on behalf of their patients, for improved physical activity and diet opportunities in their patients’ communities.



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8 Health Care and Work Environments Health Care and Work Environments: Goal, Recommendation, Strategies, and Actions for Implementation Goal: Expand the role of health care providers, insurers, and employers in obesity prevention. Recommendation 4: Health care and health service pro­ viders, employers, and insurers should increase the sup­ port structure for achieving better population health and obesity prevention. Strategy 4-1: Provide standardized care and advocate for healthy com- munity environments. All health care providers should adopt standards of practice (evidence-based or consensus guidelines) for prevention, screening, diagnosis, and treatment of overweight and obesity to help children, adoles- cents, and adults achieve and maintain a healthy weight, avoid obesity-related complications, and reduce the psychosocial consequences of obesity. Health care providers also should advocate, on behalf of their patients, for improved physical activity and diet opportunities in their patients’ communities. 285

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Potential actions include • health care providers’ standards of practice including routine screening of body mass index (BMI), counseling, and behavioral interventions for chil- dren, adolescents, and adults to improve physical activity behaviors and dietary choices; • medical schools, nursing schools, physician assistant schools, and other relevant health professional training programs (including continuing educa- tion programs), including instruction in prevention, screening, diagnosis, and treatment of overweight and obesity in children, adolescents, and adults; and • health care providers serving as role models for their patients and providing leadership for obesity prevention efforts in their communities by advocat- ing for institutional (e.g., child care, school, and worksite), community, and state-level strategies that can improve physical activity and nutrition resources for their patients and their communities. Strategy 4-2: Ensure coverage of, access to, and incentives for routine obesity prevention, screening, diagnosis, and treatment. Insurers (both public and private) should ensure that health insurance coverage and access provisions address obesity prevention, screening, diagnosis, and treatment. Potential actions include • insurers, including self-insured organizations and employers, considering the inclusion of incentives in individual and family health plans for maintaining healthy lifestyles; • insurers considering (1) benefit designs and programs that promote obesity screening and prevention and (2) innovative approaches to reimbursing for routine screening and obesity prevention services (including preconception counseling) in clinical practice and for monitoring the performance of these services in relation to obesity prevention; and • insurers taking full advantage of obesity-related provisions in health care reform legislation. Accelerating Progress in Obesity Prevention 286

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Strategy 4-3: Encourage active living and healthy eating at work. Worksites should create, or expand, healthy environments by establishing, implementing, and monitoring policy initiatives that support wellness. Potential actions include • public and private employers promoting healthy eating and active living in the worksite in their own institutional policies and practices by, for example, increasing opportunities for physical activity as part of a wellness/health promotion program, providing access to and promotion of healthful foods and beverages, and offering health benefits that provide employees and their dependents coverage for obesity-related services and programs; and • health care organizations and providers serving as models for the incorpora- tion of healthy eating and active living into worksite practices and programs. Strategy 4-4: Encourage healthy weight gain during pregnancy and breastfeeding, and promote breastfeeding-friendly environments. Health service providers and employers should adopt, implement, and monitor policies that support healthy weight gain during pregnancy and the initiation and con- tinuation of breastfeeding. Population disparities in breastfeeding should be specifically addressed at the federal, state, and local levels to remove barriers and promote targeted increases in breastfeeding initiation and continuation. Potential actions include • all those who provide health care or related services to women of child- bearing age offering preconception counseling on the importance of con- ceiving at a healthy BMI; • medical facilities, prenatal services, and community clinics adopting policies consistent with the Baby-Friendly Hospital Initiative; • local health departments and community-based organizations, working with other segments of the health sector, providing information on breastfeeding 287 Health Care and Work Environments

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and the availability of related classes to pregnant women and new mothers, connecting pregnant women and new mothers with breastfeeding support programs to help them make informed infant feeding decisions, and devel- oping peer support programs that empower pregnant women and mothers to obtain the help and support they need from other mothers who have breastfed; • workplaces instituting policies to support breastfeeding mothers, including ensuring both private space and adequate break time; and • the federal government using Prevention Fund dollars to support imple- mentation of the Baby-Friendly Hospital Initiative nationwide, and providing funding to support community-level collaborative efforts and peer counsel- ing with the aim of increasing the duration of breastfeeding. M illions of individuals have the opportunity to be influenced by health care and work environments daily: • More than 140 million American civilians were employed as of November 2011 (Bureau of Labor Statistics, 2011). • In 2008, it was estimated that there were more than 6.2 million profes- sionals in health care occupations (including physicians, registered dietitians, nurses, and counselors) in the United States. The field is projected to increase by 22 percent by 2018 (Bureau of Labor Statistics, 2010). • As of June 2011, among Americans under age 65, nearly 23 percent were covered by a public health insurance plan, and 61 percent had private health insurance coverage (Martinez and Cohen, 2011). • For 2011, the total number of Medicare beneficiaries in the United States was 48 million (KFF, 2011). It is clear that health systems, health care providers, employers, and insurers are in a position to influence the health of the population. By engaging in obesity prevention and treatment strategies, such as providing community-level resources (education, support, and opportunities) for individuals and their families, health care and work environments can help catalyze individual and, ultimately, popu- Accelerating Progress in Obesity Prevention 288

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lation health improvement. For example, as seen with smoking, another public health concern, cessation initiatives by insurance and health care providers that supported and encouraged policy holders and patients to quit, as well as work- place interventions that included counseling or support, had a noticeable effect on quitting rates (Cahill et al., 2008; CDC, 2011c). As health care continues to evolve and as new forms of health systems emerge (such as patient-centered medical homes, accountable care organizations, and other new systems of care), attention to obesity prevention, screening, diagnosis, and treatment must be considered.1 RECOMMENDATION 4 Health care and health service providers, employers, and insurers should increase the support structure for achieving better population health and obesity prevention. As depicted in Figure 8-1, health care and work environments are intercon- nected with the other four areas of focus addressed in this report and are a neces- sary component of the committee’s comprehensive approach to accelerating prog- ress in obesity prevention. The committee’s recommendations for strategies and actions to expand the role of health care and health service providers, employers, and insurers in obesity prevention are detailed in the remainder of this chapter. Indicators for measuring progress toward the implementation of each strategy, organized according to the scheme presented in Chapter 3 (primary, process, foundational) are presented in a box following the discussion of that strategy. STRATEGIES AND ACTIONS FOR IMPLEMENTATION Strategy 4-1: Provide Standardized Care and Advocate for Healthy Community Environments All health care providers should adopt standards of practice (evidence-based or consensus guidelines) for prevention, screening, diagnosis, and treatment of overweight and obesity to help children, adolescents, and adults achieve and maintain a healthy weight, avoid obesity-related complications, and reduce the Attention to overweight prevention, screening, diagnosis, and treatment is implicit within 1 obesity prevention and treatment efforts. 289 Health Care and Work Environments

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Message Environments School Environments Physical Food and Activity Beverage Environments Environments Health Care and Work Environments FIGURE 8-1 Five areas of focus of the Committee on Accelerating Progress in Obesity Prevention. NOTE: The area addressed in this chapter is highlighted. psychosocial consequences of obesity. Health care providers also should advocate, on behalf of their patients, for improved physical activity and diet opportunities in their patients’ communities. Potential actions include • health care providers’ standards of practice including routine screening of body mass index (BMI), counseling, and behavioral interventions for chil- 8-1 dren, adolescents, and adults to improve physical activity behaviors and dietary choices; Accelerating Progress in Obesity Prevention 290

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• medical schools, nursing schools, physician assistant schools, and other rel- evant health professional training programs (including continuing education programs), including instruction in prevention, screening, diagnosis, and treatment of overweight and obesity in children, adolescents, and adults; and • health care providers serving as role models for their patients and providing leadership for obesity prevention efforts in their communities by advocat- ing for institutional (e.g., child care, school, and worksite), community, and state-level strategies that can improve physical activity and nutrition resources for their patients and their communities. Context Health care and health service providers have frequent opportunities to engage in screening for disease risk factors and to encourage their patients to engage in healthful lifestyles. The current health care system has an opportunity to incorpo- rate obesity and lifestyle screening and prevention into routine practice as it has done with colon cancer, breast cancer, cervical cancer, and cardiovascular disease, for example. Health care professionals, both individually and through their profes- sional organizations, can work to make obesity prevention part of routine preven- tive care. To maximize the value of patient visits and help children, adolescents, and adults achieve and maintain a healthful lifestyle, health care providers should adopt standards of practice for the prevention, screening, diagnosis, and treat- ment of obesity that include screening of BMI, counseling, and behavioral inter- ventions aimed at improving the physical activity and dietary behaviors of their patients. Standards of practice, or clinical practice guidelines, are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options (IOM, 2011a). Such guidelines offer an evaluation of the quality of the relevant scientific literature and an assessment of the likely benefits and harms of particular interventions or treatments (IOM, 2011a). This informa- tion enables health care providers to proceed accordingly, selecting the best care for an individual patient based on his or her preferences. Health care providers have the opportunity to see children and adolescents, in particular, at regular and frequent intervals for well and acute care, and they are in a unique position to promote childhood obesity prevention in several ways. 291 Health Care and Work Environments

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Evidence In 2000, the Centers for Disease Control and Prevention (CDC) recom- mended the use of age- and sex-adjusted BMI to screen for overweight children 2-19 years of age and developed revised standardized growth charts (Kuczmarski et al., 2002). In 2003, the American Academy of Pediatrics (AAP) recommended that health care providers calculate and plot BMI percentiles on a yearly basis for children and adolescents (Krebs and Jacobson, 2003). More recently, the Institute of Medicine (IOM) committee that produced the report Early Childhood Obesity Prevention Policies recommended that health care professionals consider a child’s BMI, rate of weight gain, and parental weight as risk factors for obesity (IOM, 2011b). If health care providers monitor the rate of weight gain using BMI, they are more likely to identify children who are at risk for overweight or obesity earlier than if they use traditional methods for plotting weight for age (Sesselberg et al., 2010; Wethington et al., 2011). Yet even though most health care providers report being familiar with BMI screening guidelines and have the tools to cal- culate patient BMIs, few providers report actually using BMI to assess over- weight or obesity (Barlow et al., 2002; Hillman et al., 2009; Larsen et al., 2006; Wethington et al., 2011). Indeed, many health care providers are not properly diagnosing obesity (Dennison et al., 2009; Hamilton et al., 2003; Perrin et al., 2010). Some providers report not having enough time during patient visits for overweight screening (Boyle et al., 2009; Hopkins et al., 2011), and others report lack of reimbursement and inadequate resources (i.e., staff and/or access to nutri- tion specialists) as barriers to BMI screening, obesity diagnosis, and counseling on weight/health status (Barlow et al., 2002; Hopkins et al., 2011; Tsai et al., 2006). Clinicians who document overweight in the patient medical record are more likely to screen for BMI, provide counseling, and make referrals to specialists (Sesselberg et al., 2010; Wethington et al., 2011). The United States is currently undergoing a transition to more universal and higher utilization of electronic health records (EHRs). This transition is the result of a recent government effort (through the Health Information Technology for Economic and Clinical Health [HITECH] Act) to support the adoption and “meaningful use” (meaning use intended to improve health and health care) of EHRs and health information technology (Blumenthal, 2011). Accelerated adop- tion of EHRs might facilitate the adoption of standards of practice that include BMI screening, assessment, and tracking, and would allow for the capture of quality improvement efforts and measures. Use of EHRs has been shown to signif- Accelerating Progress in Obesity Prevention 292

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icantly increase BMI assessment and documentation and treatment of obese adults among family physicians (Sesselberg et al., 2010). Use of EHRs would allow BMI and BMI percentiles (which are important measures, particularly for children and pregnant women, because ideal weights vary by age) to be calculated automatically when patient vital signs are obtained. In addition, EHRs can incorporate decision-support tools that could provide prompts for brief motivational interviews, links to food and activity resources, or facilitated referrals to specialists. If EHR vendors included data fields to capture pediatric and adult BMI, document nutrition and activity counseling, and identify resources on healthy lifestyles for physicians and patients, they would facilitate the delivery of individual care, as well as allow for better population health manage- ment at the practice level and surveillance and monitoring of public health data at the community, local government, and state levels. Practice-level data could be fed into health information exchanges (HIEs), a system of aggregated health care information available electronically across organizations within a community, region, or hospital system. HIEs would allow for community-based, as well as clinically based, interventions by allowing public health and medical care pro- viders to fully utilize decision support and resources. Including BMI screening as part of routine visits would give health care pro- viders a platform through which they could engage patients (and their families) on the health benefits of a healthy weight and lifestyle and the health consequences of overweight and obesity (including elevating parental concern about child- hood obesity if a patient was at risk) (IOM, 2005). In addition to monitoring and tracking of BMI, other predictors of risk for obesity should be added to risk assessment, including birth weight and parental BMI (for pediatric patients) and maternal gestational weight gain, gestational diabetes, and smoking status (for adult patients) (Flegal et al., 1995; IOM, 2009b; Whitaker et al., 1997). If health care providers addressed risks for overweight and obesity, families would receive the full benefit of counseling and early intervention. Although it is recommended that clinicians offer counseling and behavioral support to obese patients, however, studies have found that many health care pro- viders do not feel prepared, competent, or comfortable in discussing weight with their patients and lack reliable models of treatment to guide their efforts (Appel et al., 2011; Hopkins et al., 2011). Few report offering specific guidance on physical activity, diet, or weight control, even though clinical preventive visits that include obesity-related discussions have been shown to increase levels of physical activity among sedentary patients (Calfas et al., 1996; Sesselberg et al., 2010; Smith et al., 293 Health Care and Work Environments

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2011). Moreover, disparities are seen in which patients actually receive screen- ing and counseling. A recent study of more than 9,000 adolescents, for example, found that overweight teens are receiving less screening and fewer preventive measures than normal-weight and obese patients during routine checkups (Jasik et al., 2011). This finding calls for accelerating educational and quality improvement efforts aimed at incorporating obesity care into practice. In addition to BMI screening, the use of physical activity as a vital sign is considered a promising way to increase the frequency with which health care providers counsel patients about physical activity. It has been found to be a valid clinical screening tool (Greenwood et al., 2010), although more evidence is needed to determine whether it correlates with improved BMI and/or health status. To measure physical activity as a vital sign, health care providers could ask adult patients simple questions about days per week of physical activity and the inten- sity of that activity. Parents and their children also could be asked questions about how much time they spend in physical activity or physical education in school and how much time they spend outdoors. Because responses to such questions about typical behavior have been found to be highly correlated with BMI (Greenwood et al., 2010), they would provide an opportunity for health care providers to discuss physical activity with their patients. Many health care providers are already focused on helping patients adopt healthy lifestyle behaviors, but a significant gap remains between current practice and universal and consistent lifestyle counseling (Huang et al., 2011). Increased education for health care providers, both during initial schooling/training and as part of continuing education, on how to incorporate BMI screening (measur- ing and assessment) and effective counseling and behavioral interventions into patient visits could lead to broader use of these practices (Klein et al., 2010). For example, training focused on human nutrition would allow a health care provider to counsel effectively on nutrition, while training in behavior change counseling could help a health care provider motivate a patient to make lifestyle changes. In fact, a recent study found that physician participation in a learning collaborative increased the number of primary care practices that provided anticipatory guid- ance on obesity prevention and that identified and treated overweight or obese children (Young et al., 2010). By maintaining a healthy weight and lifestyle of their own, health care pro- viders also have an opportunity to influence their patients. Studies suggest that providers’ own weight, eating habits, and physical activity levels may influence how they approach these subjects with their patients (Hopkins et al., 2011). Accelerating Progress in Obesity Prevention 294

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Studies also have shown that physicians who engage in physical activity are more likely to counsel patients on the benefits of exercise (Abramson et al., 2000). Confidence scores from patients receiving health counseling from obese physicians are consistently lower than those from patients seeing normal-weight physicians (Hash et al., 2003). Outside of their offices, health care providers can use their influence and authority to inform policy at the local, state, and national levels by advocating for health improvement and obesity prevention. Health care providers can be power- ful advocates for obesity-preventing environmental and policy change in their communities. More than 90 percent of U.S. physicians surveyed supported physi- cian participation in public roles defined as “community participation and indi- vidual and collective health advocacy” (Gruen et al., 2006, p. 2,473). Involvement in issues closely related to individual patients’ health was rated as very important (Gruen et al., 2006). By engaging in advocacy, health care providers can play a pivotal role in incorporating knowledge of individual factors that promote or inhibit healthy lifestyle change into a wider community perspective. Implementation Recent surveys have found that approximately 44 percent of U.S. hospitals and nearly half of outpatient practices are employing EHRs (Classen and Bates, 2011). The challenge now is how to ensure meaningful use of EHRs for patient care, as data have suggested that simply using EHRs does not necessarily result in improved quality of care provided, even over time (Classen and Bates, 2011). The U.S. Preventive Services Task Force recommends that children and adoles- cents be screened for obesity and that clinicians offer or make referrals for “com- prehensive, intensive behavioral interventions to promote improvement in weight status” (USPSTF, 2010a, p. 362). These recommendations for children, adolescents, and adults also have been included in a list of preventive services to be provided with no copay under the federal health care reform legislation signed into law in March 2010 (USPSTF, 2010b). The American Academy of Family Physicians (AAFP) has stated that family physicians should offer assistance to patients who are obese or overweight or who request assistance in preventing obesity (Lyznicki et al., 2001). Health care professional organizations and provider groups support the adoption of practices that will contribute to obesity prevention. Recommendations, toolkits, resources, and guides currently are available to encourage and assist health care providers in adopting approaches to care that promote the prevention, screen- ing, diagnosis, and treatment of overweight and obesity. 295 Health Care and Work Environments

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INTEGRATION OF STRATEGIES FOR ACCELERATING PROGRESS IN OBESITY PREVENTION The creation of systems to support healthy decision making at the community level is a necessary step linking individual health behavior change and choice to improvements in the physical and nutritional environments. Health care providers, employers, and insurers are all components of a system of support and service that enables individuals to access obesity prevention and treatment. However, these three components have tended to work independently. For example, individuals may hear messages in the workplace about healthy lifestyle change but have no access to additional visits with their health care provider or community resources because of a lack of health insurance coverage; conversely, individuals may see their health care provider for obesity treatment but lack healthy physical activity and nutrition choices at the worksite. Insurers may cover nutrition services but not physical activity. Integration of these interdependent entities can provide a system of community-level care with synergistic effects. Moreover, pregnant women and infants need to be surrounded by a system of broad-based support, with insurance coverage for all the services necessary to provide for a healthy pregnancy and early infancy. Health care providers and employers need to pay special attention to the support mothers and infants require to maintain healthy early infancy nutrition. REFERENCES AAP (American Academy of Pediatrics). 2011. Community pediatrics training initiative. http://www.aap.org/commpeds/cpti/about.htm (accessed December 2, 2011). Abramson, S., J. Stein, M. Schaufele, E. Frates, and S. Rogan. 2000. Personal exercise habits and counseling practices of primary care physicians: A national survey. Clinical Journal of Sport Medicine 10(1):40-48. Academy of Nutrition and Dietetics. 2011. Energy balance 4 kids (EB4K) with play. http:// www.eatright.org/Media/content.aspx?id=6442465058 (accessed November 22, 2011). ACOG (American Congress of Obstetricians and Gynecologists). 2007. ACOG com- mittee opinion no. 361: Breastfeeding: Maternal and infant aspects. Obstetrics and Gynecology 109(2 Pt. 1):479-480. Aldana, S. G. 2001. Financial impact of health promotion programs: A comprehensive review of the literature. American Journal of Health Promotion 15(5):296-320. AMA (American Medical Association). 2010. AMA healthier life steps: A physician’s guide to personal health program. http://www.ama-assn.org/ama/pub/physician- resources/public-health/promoting-healthy-lifestyles/healthier-life-steps-program/ physicians-personal-health.page? (accessed August 15, 2011). Accelerating Progress in Obesity Prevention 318

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