Previous research has indicated that medical schools don't spend enough time teaching students about nutrition and weight. Now, a recent study suggests a similar shortfall in childhood obesity training exists among primary care residency programs. But thanks to innovative programs springing up around the country, that deficit may be about to change.
The study(www.biomedcentral.com), "Training in Childhood Obesity Management in the United States: A Survey of Pediatric, Internal Medicine-Pediatrics and Family Medicine Residency Program Directors," surveyed residency directors from September 2007 to January 2008.
Slightly more than half of respondents said childhood obesity training in residency is "extremely important," and the majority of programs said they offer training in various aspects of childhood obesity management, such as prevention, diagnosis and treatment. However, less than one in five residencies overall reported having a formal childhood obesity curriculum, and only about 14 percent of family medicine programs surveyed have such a curriculum.
"Given the high prevalence of childhood obesity, a greater emphasis should be placed on development and use of effective training strategies suitable for all specialties training physicians to care for children," the study concluded.
Such deficits in training may well change in the future. Five California residencies, including three in family medicine, are participating in Fit for Residents, a collaborative pilot program of the AAFP and the American Academy of Pediatrics, or AAP. Sponsored by the WellPoint Foundation, the program aims to train primary care physicians to prevent and manage childhood obesity. When the pilot is completed in June, the model resident curriculum is expected to be promoted nationally.
According to Wendy Slusser, M.D., an associate clinical professor of pediatrics at the Mattel Children's Hospital, University of California-Los Angeles, and principal investigator for Fit for Residents, the curriculum incorporates elements of the AAFP's Americans In Motion-Healthy Interventions program with those of the AAP's breastfeeding curriculum. The three family medicine programs participating in the pilot are Scripps Family Medicine Residency in Chula Vista, the Family Medicine Residency Program at White Memorial Medical Center in Los Angeles and the Contra Costa Family Practice Residency Program in Martinez.
Family physician Shaila Serpas, M.D., assistant program director of the Scripps residency, outlined some of the key features of the program, including
- training in motivational interviewing;
- incorporation of the AAP breastfeeding curriculum;
- chart reviews that focus on childhood obesity;
- improved documentation of obesity services;
- the addition of lifestyle key words to electronic medical records; and
- the integration of community resources and patient handouts.
"We try to focus on the lifestyle and the behavior and not the weight," Serpas told AAFP News Now. "What behavior have you identified that could be changed? Are they successful in the behavior change? Have they shut the TV off?"
As a result of the enhanced training, more children are getting follow-up visits to monitor their progress and more children are having their physical activity levels assessed -- both of which are important to support lifestyle changes in their families, Serpas said.
Other family medicine residencies also are striving to bolster residents' knowledge about healthy patient lifestyles.
Located in an unusually health-conscious community, the Loma Linda University Medical Center Family and Preventive Medicine Residency(lomalindahealth.org) in Loma Linda, Calif., has the only lifestyle medicine track in the country. As part of its four-year, longitudinally integrated, combined residency program, resident physicians in the track earn a master's of public health degree in lifestyle medicine.
According to Wayne Dysinger, M.D., M.P.H., director of the combined residency, the program is based on the belief that a "significant proportion of physicians are better off if they have strong population-based skills, as well as skills to take care of patients one-on-one.
"We make people really good at systems and work with community groups and populations," he explained.
Gregory Steinke, M.D., M.P.H, the first graduate of the lifestyle medicine track of the Loma Linda University Medical Center Family and Preventive Medicine Residency in Loma Linda, Calif., hopes to conduct group visits and participate in nutrition seminars when he starts work at Bayshore Family Medicine in Lincoln City, Ore., in several weeks.
His training, especially in motivational interviewing, has given him confidence to counsel patients about such issues as nutrition, obesity, exercise and smoking cessation -- either one-on-one or in groups.
"This is a skill that many family physicians did not develop in residency. With the dawn of group medical visits as a core part of the patient-centered medical home, understanding how to facilitate a group is vital," said Steinke.
Residents in the lifestyle track receive additional training in prevention and focus heavily on three big lifestyle issues: nutrition, physical activity, and rest and stress management, Dysinger said. They learn behavioral science techniques and strive to become experts in lifestyle change.
In the hospital, lifestyle residents do smoking cessation consultations with patients who are admitted for pulmonary problems or cardiac surgery. In the community, they participate in group visits with patients with diabetes and talk about healthy food choices.
In the clinic, they identify and address obesity issues and set specific goals with patients.
"Our lifestyle medicine residents have a search-and-destroy mission for fat cells. At a time when none of us gets paid (specifically) for obesity counseling, our residents document obesity and give recommendations for lifestyle changes better than the faculty," said Jamie Osborn, M.D., family medicine program director and associate director of the combined program.
The University of Missouri-Kansas City, or UMKC, Family Medicine Residency based at Truman Medical Center-Lakewood in Kansas City, Mo., emphasizes the use of community resources, according to program director Todd Shaffer, M.D., M.B.A.
Faculty and resident physicians frequently refer patients to community resources, especially the free or low-cost nutrition education classes and dietary consultations conducted by an in-store registered dietitian at the local Hy-Vee grocery. (See audio interview sidebar below).
"If patients sit in the doctor's office and there's a dietitian with (that physician), that's great. But people make decisions about food in the store when they're buying things," Shaffer explained.
Residents in the program also regularly tackle weight issues with patients, a "touchy subject" for both patients and resident physicians, said Shaffer. They learn tactful approaches to talking with families about weight and lifestyle issues and an awareness of cultural and ethnic differences in people's views of obesity, he said.
In particular, residents focus on counseling pregnant women in the federally funded Women, Infants and Children, or WIC, program to avoid excessive, unhealthy weight gain during their pregnancies.
"If they gain 15 extra pounds during pregnancy, then after several babies, they end up being 45 pounds overweight," Shaffer said. "So it's important for the residents to advise them that if they don't gain that weight during pregnancy, they might not develop an overweight or obesity problem."