Concluding Report on AllCare Rx: Motion 2014-2019
Introduction
Childhood obesity was a somewhat "silent" problem until Michelle Obama took up the cause in her role as First Lady in 2008. 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 inactivity (1). 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 parents (2). It is known that if current trends continue, one of three children born in after 2000 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 in 2019 is approximately 40% and is predicted to continue to rise.
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.
Adult obesity has been the object of one well documented program. 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 (3). 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 (4,5).
In 2010 and 2011, KidZone Community Foundation offered the initial Rx; Motion program. 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), though swimming was noted to be correlated with decreased BMI.
Similar programs across the United States have faced the same hurdles and encountered less than optimal outcomes. Take the plunge in San Diego suffered from poor participation. New Mexico Prescription Trails was an informational program only and no data were collected. Rockville, Maryland offered financial assistance for children to attend summer camp activities, but no organized data collection was included in the program.
Rx: Motion 2014-2019
Utilizing grant funding from the AllCare CCO, KidZone Community Foundation organized and oversaw a program offering physical activity for children ages 6-18 between 2014 and 2019. Children were referred by their medical providers. The basic referral criterion was a BMI percentile of 85th or higher. Additionally, children who were thought to benefit from physical activity but did not fall into the guideline above could be referred after consultation with Richard Cohen MD, who oversaw the program. Height, weight, flexibility and shuttle run and self image data was collected at the entry to the program and (ideally) during the final (6th) month of the program.
There were one hundred twenty two children who entered the program for weight issues. Additionally, five children with other issues entered the program. Fifty four children finished the activity portion of the program and at least the pre and post activity data set height and weight collections. Eight were granted an additional 6 months of activities. There were 58 drop outs, Of the those who completed activities, 38 (70%) improved and 16 (30%) had increased BMI scores. The dropout rate was 48%. There were eight individuals whose pre or post activity sets were not collected properly whose data could not be salvaged from date-correlated medical records. Interestingly, all of the youngsters referred for non-obesity issues completed the activity portion as well as the data set collection. There were significant individual successes: Three youngsters decreased their BMI percentiles by 14, 25 and 30 points respectively.
A thorough statistical analysis was performed in February, 2019 by Ashley Wylie, a graduate student at Southern Oregon University. That study included youngsters covered by both AllCare and Primary Health. In early 2018, Primary Health discontinued their participation in the program. A review of all referrals after the program ended in November 2019 allowed minor corrections of the number of youngsters and results . It does not appear that the February 2019 statistical analysis in that report requires repetition/ revalidation. The subjective analysis included in that report remains unchanged. Data was also collected on two components of the Presidential Fitness program: Flexibility and shuttle run score - It did not appear that there was any significant relationship to BMI change. Self-image inventories were also collected. The results appeared to be random although those who participated at Motion Matrix in gymnastics did have higher self-image scores unrelated to BMI changes.
Included in the statistical analysis was a control group comprised of youngsters who began the program but dropped out was compiled by acquiring height and weight data from the referring medical providers at or shortly after the 6 month activity would have been completed. The control group consisted of 25 individuals. Twenty (20) had increased BMI scores and five (5) had decreased BMIs. The average control group BMI change was plus 2.2. The average BMI change of youngsters who completed AllCare Rx: Motion was minus 1.9. Three activity providers were involved in the program. Motion Matrix, Club Northwest and the YMCA. Pre and post activity results did not reach statistical significance for Motion Matrix, Both Club Northwest and the Y had BMI improvement in the 90% statistically significant range. Two specific activities of note were Martial arts at Club Northwest, with a 5.5 percentile BMI drop, and Teen X Fit at the Y had a 1.3 percentile improvement. Both results were significant at the 90% level. Boys overall had a 1.6 percentile improvement, significant at the 90% level, while girls improved 2.1 percentile, significant at the 95% level.
Completed pre and post activity Self image inventories were collected from 41 participants. It did not appear there was any significant change in self image correlated to BMI change.
In general, my opinion is that the 2014-2019 Rx: Motion program, while successful in terms of BMI change with activity showed success, it fell victim to several factors: 1: Social determinants of health (lack of family support and inadequate transportation being primary, 2: My inability to supervise multiple activities, billing, attendance and collection of post-activity sets by the activity providers. 3: Changes late in 2018 streamlining the program from grants as-needed to direct payment from AllCare to the activity providers dropped the medical director "out of the loop" which decreased scrutiny of attendance rate below that of the first 4 years, which was already less than desired. 4: The original logistics of Rx: Motion were structured to minimize physician time and "paperwork", however, registration and data collection became burdensome for activity provider staff members, which led to several failures to collect pre activity and post activity data sets. Additionally, personnel changes at the activity provider level were frequent, making pre and post activity set collection, especially the shuttle run and flexibility scores not reliably comparable. Protocols provided to the activity providers were seldom followed correctly, and "in service" wasn't helpful because of high turnover in staffing.
5: Nutritional guidance was not included in Rx: Motion. 6: The marginal utility of expenditure/BMI improvement overall problematic because of the high drop-out rate. 7: The fact that families participating in the program had no "skin in the game" may have made the perceived value low to them and increased the drop out rate. Additionally, 8: Many parents of obese children are in denial that there is anything wrong (6).
I am very thankful for AllCare's support of the program for almost 5 years. I feel our community should continue to seek ways to make healthier lifestyles for families available. I look forward to participating in programs and processes that make that possible.
Rx: Motion 2014-2019 Brief Summary
Activity Group Referred for BMI %8ile 85th or higher # 122
Completed activities and data collection 54
Referred for non BMI issues 5
Completed activities but data collection failure 8
Parent(s) refused post-activity data collection 2
Dropped out 58/122 48%
Improved BMI 38/54 70% Worse BMI 16/54 30% Average BMI %ile change 1.9 decrease
Control group 25
Improved BMI 5/25 20%
Worse BMI 20/25 80%
Average BMI %ile change 2.2 increase
#And started activities
Richard S. Cohen M.D. Rx: Motion medical director
12/6/2019
1) Mark Fenton, www.ncbi.nlm.nih.gov/pubmed/16246279
2) http://www.nih.gov/news/pr/mar2005/nia-16.htm
3) http://www.moh.govt.nz/moh.nsf/indexmh/greenprescription-research-councelling
4) http://www.oregon.gov/OPRD/PLANS/docs/scorp/RxPlay/Rx_PLAY_Pilot_Study_Report.pdf
5) http://www.oregonlive.com/health/index.ssf/2010/01/doctors_prescribe_play_to_get.html
6) https://www.nytimes.com/2015/06/16/health/parents-denial-fuels-childhood-obesity-epidemic.html