Experts Develop Online CME Course on Childhood Obesity
In February 2003, staff from the University of Arkansas for Medical Sciences College of Public Health formed a 14-member panel of experts to identify and review innovative continuing medical education (CME) programs on overweight and obesity.
Subsequently, they developed an online CME course on pediatric overweight that reflected best practices recommended by the panel.
- Project staff offered the course online through August 2006 on the Web site of the Arkansas Foundation for Medical Care.
- By the end of the grant on January 31, 2005, three doctors and 40 other health professionals (mainly registered and practical nurses) had completed the CME program; 24 additional health professionals were taking the course at that time. Participants who completed evaluations gave the course high marks.
The Robert Wood Johnson Foundation (RWJF) provided a grant of $295,434 from February 2003 through January 2005 to fund the project.
Results from a 19992002 survey by the Centers for Disease Control and Prevention (CDC) indicate that an estimated 65 percent of American adults are either overweight or obese. The same survey showed that an estimated 16 percent of children ages 619 years are overweight, a 45 percent increase from the overweight estimates obtained in a 198894 survey.
While effective treatment of this problem must ultimately involve multifaceted approaches emphasizing both dietary changes and increased physical activity, primary care physicians' enhanced attention to obesity treatment and prevention may prove to be an important component. Most Americans see their primary care physician at least annually, and evidence shows that primary provider advice to change certain health behaviors produces statistically significant changes on a population-wide basis.
For example, a 2001 study conducted by Yuhua Bao, Ph.D., suggests that brief counseling interventions by primary care physicians may be more effective at getting people to quit smoking than most tobacco control policies, such as taxing tobacco products and clean indoor air laws. However, while many CME programs and courses exist to educate physicians in treating overweight and obesity, there is little research on their effectiveness, according to the project director, and what research exists indicates that the programs often do not result in altered provider behavior or patient behavior over the long term.
RWJF's work in addressing childhood obesity is focused on children and families in low-income and minority populations, concentrating on ages 3 to 12, an age range that represents a critical period for developing lifelong habits. Because there are few known, effective strategies for addressing the problem, RWJF is using multifaceted approaches, to be developed with partners at many levels.
RWJF is pursuing a four-pronged approach to halting the increase in childhood obesity:
- Building the evidence regarding what works to promote healthy eating and increase physical activity among kids.
- Testing innovative approaches so we can spread promising models.
- Educating leaders and investing in advocacy strategies.
- Working on ways to help health care providers screen and counsel to prevent and manage childhood obesity.
The project described here fits within the fourth approach.
RWJF funded the University of Arkansas for Medical Sciences College of Public Health to catalog innovative continuing medical education (CME) courses on treating and preventing overweight and obesity, to identify and evaluate innovative CME programs and to use the information gathered by the panel to develop an online CME course on pediatric overweight that reflected best practices an expansion of the focus from the original plan of evaluating a particular program run by Centers for Obesity Research and Education.
An added impetus to developing the course on pediatric overweight came from passage of Arkansas Legislative Act 1220 in April 2003, which requires the BMI (body mass index) of public school children in Arkansas to be measured and reported to parents. Data from the first statewide BMI assessment in 2004 showed that about 40 percent of children measured were at an increased health risk related to their weight. Schools advised parents of children with high BMIs to consult with their doctors.
To identify innovative CME programs on treating and preventing overweight and obesity, project staff polled leading researchers and clinicians nationwide in six fields: nutrition, physical activity, continuing education, behavioral intervention, program evaluation and family medical practice. The poll also identified 14 experts in obesity treatment, whom project staff invited to serve on a review panel (see Appendix 1 for panel members) to evaluate the identified CME programs and rate them on clarity and completeness of information in the following seven areas:
- physical activity
- behavior change
- educational value
- practicality of use in provider settings
- evidence of efficacy
- overall value.
The poll identified 13 CME programs for review. Project staff asked staff at the programs to submit their curricula for review, with the assurance that evaluation results would not be revealed to outsiders except as aggregated summaries. A primary reviewer and two secondary reviewers assessed each of the 12 programs that submitted materials. (See Appendix 2 for a list of the CME programs evaluated.) Project staff convened the expert panel on September 3, 2003, to present and discuss its reviews of the programs. Project staff subsequently used the findings and comments from the panel to develop a new online CME program on pediatric overweight.
The project generated the following results:
- Project staff the College of Public Health and faculty from other colleges developed a CME course for Arkansas pediatricians, family physicians, and nurses and nutritionists, entitled Management of Pediatric Overweight, that incorporates best practices recommended by the expert panel. Project staff posted the course on the Web site of the Arkansas Foundation for Medical Care (a nonprofit evaluation and educational resource for Arkansas health care professionals and consumers) in September 2004. By the end of the course, participants were supposed to be able to:
- Explain the purpose of BMI measurements, and calculate and interpret them in children and adolescents.
- Take a focused history with overweight children and adolescents.
- Identify diagnostic tests useful in the evaluation of overweight children.
- Provide basic recommendations for diet, physical activity and reducing sedentary activities.
- Apply behavioral change strategies for overweight children and adolescents, including the stages of change model (e.g., tailoring advice to a patient's readiness to change), motivational interviewing (i.e., client-centered counseling that elicits behavior change by helping clients to explore and resolve ambivalence) and family-based interventions.
- Consider practical tools to help clinical and office staff members manage overweight children, including guides for the office environment, clinical forms and billing codes.
- Understand the basics of community advocacy for instance, working with school administrators and parent-teacher associations to develop policies that promote physical activity and healthy diet.
- By the end of the grant on January 31, 2005, three doctors and 40 other health professionals (mainly registered and practical nurses) had completed the CME tests; 24 additional health professionals were taking the course at that time. Participants who completed evaluations gave the course high marks.
The expert panel generated the following findings:
- Of the 12 programs reviewed, eight received an "I" (insufficient) rating because they lacked evidence of evaluation or efficacy. None of the programs adequately evaluated changes in provider behavior, patient behavior or patient outcomes, according to the panel. Six of the programs had content directed toward children, but only two of those had enough information to be assessed completely.
- The panel agreed that the following issues and curricular features needed more attention among developers of CME programs on overweight and obesity:
- Cultural, economic and ethnic disparities.
- Societal bias and provider bias against obesity as a barrier to care.
- The metabolic health benefits of weight loss, including evidence that lowering weight changes risk factors and that even small behavior changes have beneficial effects.
- How to motivate people to lose weight and maintain the loss.
- Patient self-management.
- Outcomes-based evidence related to the time and effort of practitioner and staff.
- Community resources, social support systems and associated barriers.
- Family-based approaches and the role of the family in promoting and maintaining weight loss.
- Incorporating overweight and obesity treatment into the reality of primary care practice.
- The panel identified key features that an ideal CME program on overweight and obesity should include. The features address the following six areas:
- physical activity
- behavior change
- educational value
- practicality and use in provider settings
RWJF posted the CME program report of the expert panel on its Web site. The Arkansas Academies of Pediatrics and Family Practice and the Arkansas Foundation for Medical Care promoted the course in a Guide to Childhood Obesity. Notice of the course appeared in the Journal of the Arkansas Medical Society and other professional journals. The Arkansas Department of Health, the College of Public Health and the Northwest Area Health Education Center also promoted the course along with other CME courses offered by those entities. See the Bibliography for details.
- Educating doctors and other providers on childhood obesity may require supplemental efforts beyond online Web access to courses. Despite strong efforts to publicize the CME course developed in this project, only a small number of providers accessed and completed it. According to the project director, supplemental efforts in Arkansas could include:
- Urging appropriate professional organizations to promote the program through newsletters and at meetings.
- Disseminating information through all the state's Area Health Education Centers (the primary educational outreach effort of the University of Arkansas for Medical Sciences and the principal means of decentralizing medical and other health professions education throughout the state).
- Engaging the statewide Child Health Advisory Committee (which Arkansas Legislative Act 1220 of 2003 created to make policy recommendations to the State Board of Education and the State Board of Health to reduce childhood obesity) to disseminate information about the program. (Project Director)
AFTER THE GRANT
From February 2005 through August 2005, 168 participants passed the post-test for the Management of Pediatric Overweight course. The course will expire in August 2006.
GRANT DETAILS & CONTACT INFORMATION
Conducting an Assessment of the Centers for Obesity Research and Education Workshops
University of Arkansas for Medical Sciences College of Public Health (Little Rock, AR)
Dates: February 2003 to January 2005
James M. Raczynski, Ph.D.
Members of Expert Evaluation Panel
Director, Division of Nutrition and Physical Activity
Centers for Disease Control and Prevention
Patrick E. McBride, M.D., M.P.H.
Associate Dean for Students
University of Wisconsin
Nancy Copperman, M.S., R.D.
Schneider Children's Hospital
New Hyde Park, N.Y.
Andrea Dunn, Ph.D.
Van Hubbard, M.D.
National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
John Jakicic, Ph.D.
Assistant Professor, Brown Medical School
Staff Psychologist, The Miriam Hospital
Njeri Karanja, Ph.D.
Kaiser Permanente Center for Health Research
Connie Kohler, Ph.D.
Department of Health Behavior
University of Alabama
Karen Mann, Ph.D.
Director, Division of Medical Education
Dalhousie University Faculty of Medicine
Halifax, Nova Scotia, Canada
Sachiko St. Jeor, Ph.D.
Professor of Clinical Medicine
Director, The Nutrition Education and Research Program
University of Nevada
Mary Story, Ph.D.
Professor, Division of Epidemiology, School of Public Health
University of Minnesota
Elaine Prewitt, D.P.H., R.D.
Assistant Professor, Department of Preventive Medicine and Epidemiology
Loyola University Medical Center
Tom Wadden, M.D.
Director, Weight and Eating Disorders Program
School of Medicine
University of Pennsylvania
Delia West, Ph.D.
Associate Professor of Preventive Medicine
University of Arkansas for Medical Sciences
Little Rock, Ark.
CME Programs Evaluated
Children and Weight: What Health Pros Can Do
Department of Nutrition Sciences
University of California at Berkeley
Office Management of Obesity: Assessment and Evaluation: Practical Guide
North American Association for the Study of Obesity
Certificate of Training in Adult Weight Management
American Dietetic Association
Practical Approaches to Treatment of Obesity
Harvard University Medical School
Department of Nutrition
University of Tennessee
Marquette General Health System
New Orleans, La.
Center for Obesity Research and Education
Health Sciences Center
University of Colorado
Physician-Based Assessment and Counseling for Exercise (PACE)
Department of Psychology
San Diego State University
CVD Risk Assessment
Department of Medicine
University of Iowa
Lifecycle of Obesity
American Board of Family Practice
Obesity and Weight Management in Women
American Medical Women's Association
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Continuing Provider Education on Obesity: A Panel Review of Existing Programs. Little Rock, Ariz.: College of Public Health, University of Arkansas for Medical Sciences, June 2004. Also appears online.
World Wide Web Sites
www.afmc.org/html/professional/cme_ce/CoursesLive /overview.aspx?cid=Ped_Obesity_Phys (course no longer available). "Management of Pediatric Overweight for Physicians" on the Web site of the Arkansas Foundation for Medical Care. Little Rock, Ariz.: Arkansas Foundation for Medical Care, 2004.
Report prepared by: Nanci Healy
Reviewed by: Robert Crum
Reviewed by: Molly McKaughan
Program Officer: Laura Leviton