What’s Rx: Motion?
Fifty seven children with BMI scores of 85th percentile or higher were referred to existing physical activity programs in the community. Seven children participated for 6 months, and 50 children participated for 3 months. The participating children had a high rate of enjoyment in post-activity polling. Recruitment from the medical community was problematic, as was post-activity data collection. There was little objective change in BMI or self- image noted at the end of the activity period(s).
Childhood obesity has been a “silent” problem for the last decade. The causes and effects are as much social, political and economic as nutritional. Some involved with the issue feel the problem is better understood as epidemics of inappropriate nutrition and inactivity1. Fortunately, while the problem is serious, it has now become recognized as an issue that must be confronted. It is now public knowledge that this generation of children has a lower life expectancy then that of their parents2. It is known that if current trends continue, one of three children born in 2011 will become diabetic at some point in life. It is clear that neither the U.S. health care delivery system, nor the economy can support a population that some experts predict will have a 75% rate of overweight and obese citizens by 2020.3
Among attempts to reverse this trend, bringing fresh foods to inner city areas, improving school meals, and increasing physical activity for youth are being promoted. The First Lady’s Let’s Move campaign is the most visible of such efforts.
New Zealand’s Green Prescription program has shown that actual prescriptions for physical activity are effective in increasing adult overweight and obese patients’ exercise, and the increase has been shown to continue long term. 4 In 2010, the Portland Prescription Play Pilot Program suggested that the logistics of a physician based prescription program could be integrated with a public park and recreational program, though the participation of the medical community and the follow-up of participants were both less than optimal. 5
KidZone Community Foundation (KZCF)
KZCF is a young (founded in 2006) not-for -profit 501(c)(3) organization, whose original mission was to “challenge and support our community to positively impact children through physical activity and healthy lifestyles”. In April. 2011, the mission was refocused to “ promote physical activity for children“.
The ultimate goal of the foundation is to get children moving in ways that they enjoy; therefore developing lifelong habits of movement and exercise. We are striving to make our community the healthiest in the nation.
In its short lifetime, KZCF has organized a set of 4 quarterly educational forums, organized a pedometer-based activity program coordinated with National TV Turn off Week, aided in establishing an outdoor year round public cardio exercise mini-park, and was a catalyst in bringing a combined physical education and nutrition training program into the local schools curriculum (Be a Fit Kid6).
Energized by the initial description of the Portland Rx: Play program7, KZCF was successful in acquiring grant funds from Asante Community Connections, Mid Rogue Health Plan and Pacific Source Healthy Communities to create a community- centric pilot project in which local physicians (family physicians, pediatricians and physician assistants) could write prescriptions for physical activities, choosing from a menu of options provided by the local YMCA, Boys & Girls Club, and two local fitness facilities, Club Northwest and Unlimited Sports Academy.
The goals of the pilot program were to:
1. Assess the process of formal physician patient recruitment and referral to pre-existing and ongoing community based physical activity programs, some of which included nutritional and self-image counseling (see the file “Full Menu” in both the “RxMotionProviderPacket and ProviderPacketJanFebMar2011 folders for activities available in the program, which is included in the accompanying CD.)
2. Evaluate the logistics of acquiring data sets of pre and post activity BMI and self-image.
3. Inquire at the completion of the activities whether the children enjoyed the program, would like to continue, and ask if they thought they would alter their own activities as a result of participation in the Rx: Motion program.
4. Ideally, identify if and which specific activities were correlated with decreased BMI and improved self-image.
5. Most importantly, offer “at-risk” 6 to 12 year olds an opportunity to participate in supervised activity programs.
Preparation and Execution
Initially, we created a budget and timeline. With a budget of $6000 in grant funds, we met with local fitness providers and were able to create a “menu” of 12 activities which emphasized physical activity without “winners and losers”. We sought activities which met at least twice a week. Additionally, the Boys & Girls Club Triple Play program was appealing because bus service was provided from virtually all of the schools which had participating children. Their program and the Y’s Operation Fit Kids also offered nutrition counseling, but no children enrolled in the latter menu option. We assumed a mean cost of $40/month/participant, which gave us a target of 50 children in a program lasting 3 months. Our eligibility requirements were age 6 through 12, with a BMI percentile score of 85th percentile (overweight) or higher.
Primary care physicians and mid-level practitioners were approached and voiced willingness to participate in the program. We requested approximate numbers of children in their practices who would be eligible for the program and the practitioners’ responses suggested there would be no problem acquiring 50 participants for the study.
Instruction packets including criteria, menu, contact information, HIPAA consent, check list and descriptions of available activities were distributed to all local allopathic medical practices. (The complete contents of the material presented to medical practitioners is included in the folders on the CD noted above.)
Our expectation was that medical practices would pro-actively review their patient populations and invite them to join the Rx: Motion program. Pre-activity data sets would be acquired by the staff of the offices and Faxed to KZCF at the conclusion of the program. Each practice was to phone the City of Grants Pass Park and Recreation office to register a child in the program. Each participant was given a number which allowed for collection of data sets in an HIPAA-compliant process. This designated a “neutral site” as the registration center, which was chosen to avoid potential concerns among the activity providers, which for all practical purposes, are economic competitors
We allotted two months after presenting the program information to the medical community for registration of children for the activities. The target registration window was July and August, 2010 with the activity portion to run from the beginning of September through the end of November 2011.
The initial registration period produced 18 enrollees, of whom only 13 children participated. The logistics were reevaluated, and a second session of the program was offered, , which allowed referral of children by the medical community as well as the activity providers, if the children met the original eligibility requirements and the parents were offered any of the menu options in the Rx: Motion program. The second session ran from the beginning of January through the end of March, 2011. Sixty nine children were enrolled; of that number, fifty children participated in the second session, along with 7 who continued from the first session. Three children were expelled from the program for disruptive behavior or inadequate attendance. We were able to collect 32 complete pre and post activity data sets. We received complete data sets of 11 of 30 medical referrals (37%) and 22 of 28 complete data sets from activity provider referrals (79%).
The biggest data collection shortcoming was failure of parents to schedule or keep follow-up appointments after the completion of activities in the medically referred group. There were also some incorrectly completed self-image surveys, primarily from the medical referrers. We received no data on 6 of the children, all of whom were medically referred. We received 21 incomplete or incorrectly completed data sets, 7 from activity referrals and 14 from medical referrals.
43 BMI pre and post activity data sets were returned. 22 children had lower BMI scores, 17 had higher BMIs and 4 had no change in BMI.
33 Harter self- image profiles were correctly completed and returned. “global self-worth” scores improved in 12 children, were decreased in 13, and 9 scores were unchanged.
Youth Aquatic PE offered by the YMCA, for which 5 complete data sets were returned, was the only activity that had clearly improved BMI results, with 4 children showing lower BMI percentile scores, with one child’s score unchanged.
We also asked if children had enjoyed the program, would like to do it again, and if they thought they would change their daily activities as a result of being in the program. Of the 30 who responded, 27 stated they had enjoyed the program, 23 said they would like to do it again, and 22 said they would become more active on their own as a result of their participation.
The initial grant budget was $6000. The final activity cost of the program was $6155. Organizational costs (printing and CD production) were supported by smaller additional grants and volunteer time.
1. Motivating the parents is crucial. Physicians reported this was a significant obstacle to patient registration for Rx:Motion. New data suggests that obese parents see their obese children as normal, which need to be addressed in planning similar programs in the future.8
2. Physicians have been reticent to formally “code” or diagnose children as obese, for fear of compromising future insurability. Hopefully, implementation of the Patient Protection and Affordable Care Act will make this problem moot.
3. Several of the electronic health record systems in use in the community were not “searchable” for BMI or BMI percentile, which made proactively finding children eligible for the program problematic.
4. The program was designed to fax all data sets at the conclusion of the activities. In future programs, it would be more effective for the referring physicians to immediately send the program director entry data and for activity providers to collect the post-activity data set. (It should be noted that the Portland Rx: Play Pilot Study had negligible post-activity data collection.5)
5. While there were no clear cut changes in self-perception or BMI. It is unlikely the a 3 month program would provide significant changes.
6. Rx: Motion used BMI percentile for eligibility, but raw BMI for data reporting. In retrospect, we should have used percentile throughout because so many of our participants had very high BMIs and the percentile curves rise very sharply in the age range we were dealing with. In many instances a slight rise in raw BMI would actually be a decrease in percentile BMI. It should be noted, however, that validity of BMI percentile changes above the 95th are a subject of considerable debate in the literature. 10
7. While it is possible that a successful program descendent of Grants Pass Rx:Motion would have a higher chance of physician buy-in if it were designed by and operated by a physician group or medical association, the poor participation by physicians in the Portland Rx:Play study may indicate that external forces, such as pay-for-performance insurance programs might have a higher chance of success.4,5
8. The Boys & Girls Club Triple Play program holds significant promise because the club has an essentially “captive” population of children in the “at risk” sedentary population. While a published study indicates subjective improvement in multiple variables compared to Boys & Girls Club members who did not participate in Triple Play, the variables followed in the study were not directly comparable to those followed in Rx: Motion.9
Comparison of Goals to Reality
Goal 1) Assessment of recruitment: Physician recruitment was disappointing. Some practitioners reported that less than 25% of parents with children eligible for the program were interested in participation. It appeared that many medical providers did not actively recruit their at-risk pediatric patients for the program. Electronic health records were not as beneficial as we had expected in identifying potential participants.
Goal 2) Data acquisition: Data acquisition and transfer to the project coordinator was poor from the medical community. Part of this weakness was the foundation’s original logistical plan, which included faxing all vital sign and self- image data at the conclusion of the activities. Inability to acquire post-activity data from the medical community was disappointing. The data collection by the activity providers themselves was of higher quality and quantity. The fact that they were enjoying the benefit of additional income from the participants no doubt played a significant role in their success. Additionally, they acquired the post- activity data set the last week of the activities, when attendance was strong.
Goal 3: Did the kids have fun? Clearly, the questionnaire results indicated this goal was met.
Goal 4) Search for specific activities which were correlated with improved self-image and/or BMI improvements: While the small volume of data makes statistical analysis difficult, the one activity which stood out on a subjective basis was the YMCA’s swimming activity, for which there was strong indication of lowered BMI scores. There were no obvious self image changes during the program.
Goal 5: Get kids moving in ways they enjoy: KidZone Community Foundation has as one of its primary objective to “get kids moving in ways they enjoy”. Rx: Motion provided 3 months of organized physical activity for 52 children and 6 months of activity for 7 children who would likely have been sedentary. That alone marks the program as successful. Additionally, the fact that 87% of responders stated that they had had fun also qualifies Rx: Motion as a success.
Several of the physicians (and activity providers) expressed their desire for an ongoing referral path for physical activity programs for their obese pediatric patients. A long-term program, perhaps organized through insurance carriers, should be considered. Concepts such as “medical homes” would benefit from having programs similar to Rx: Motion. It is likely that at least a year of activities would be necessary to evaluate the benefits of a program such as Rx: Motion. Swimming appeared in our small sample to be a viable option for a limited option physical referral program. Gymnastics and yoga should be considered as well.
The similarities and differences of the Portland Rx: Play4 and our Grants Pass Rx: Motion are instructive and should be reviewed for further understanding of the approaches and limitations of physician-based physical activity referral programs. (The final report on the Portland Rx: Play program is included in the supplemental CD)
KZCF would be pleased to be a partner in designing a long-term version of Rx: Motion. The data sets can be made available for analysis and are HIPAA compliant.
The KidZone Community Foundation is thankful to Asante Community Connections, Mid Rogue Health Plans and PacificSource Healthy Communities for funding Rx: Motion. We also thank the activity providers who discounted their usual and customary fees which allowed KZCF to offer their programs. Finally, we thank those members of the medical community who referred and followed up on the participants in Rx:Motion.
1) Mark Fenton, www.ncbi.nlm.nih.gov/pubmed/16246279
3) Organization for Economic Cooperation and Development) At current rates of increase, half of the U.S. population will be diabetic or pre-diabetic by 2020, (The Center for Health Reform & Modernization of UnitedHealth Group 23 Nov 2010) In this scenario, The current annual health care bill of $194 billion will rise to nearly $500 billion. by 2020.
10) Characterizing extreme values of body mass index for age by using the 2000 CDC and Prevention growth charts, Flegal et al. Am. J Clin Nutr 2009;90:1314-20