Transcript Know How - Yale University

OWCH
Online Weight management Counseling
program for Healthcare providers
Module 4:
The Pressure System Model of Lifestyle
Counseling in Primary Care
Yale-Griffin Prevention Research Center
www.yalegriffinprc.org
1
Module 4
• Module 1 described the obesity epidemic and stressed the
importance of lifestyle counseling.
• Module 2 provided a basic understanding of healthpromoting diet and physical activity recommendations in
clinical practice.
• Module 3 introduced key behavioral theories and
motivational techniques to support patient change.
• This module provides simple and practical steps to integrate
lifestyle counseling into the primary care setting using the
Pressure System Model (PSM).
•
Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001 Jan;32(1):66-72
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WHY?
Primary Care Lifestyle Intervention
National advisory groups and major medical organizations consistently
recommend therapeutic lifestyle changes as the initial and preferred
means of modifying chronic disease risk factors such as hypertension,
hyperlipidemia, low HDL and obesity.
Reduction of risk factors through lifestyle intervention may reduce the
incidence of premature mortality and of the leading chronic diseases.
Aronne L, Havas S, et al. The Obesity Epidemic: Strategies in Reducing Cardiometabolic Risk. Am J Med. 2009:122:4A•
www.nhlbi.nih.gov/guidelines•
ADA 67th Scientific Sessions, June 2007•
Alberti et al. Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the Association for the Study of Obesity Heart •
Federation; International Atherosclerosis Society; and International National Heart, Lung, and Blood Institute; American Heart
Association; World International Diabetes Federation Task Force on Epidemiology and Prevention;. Circulation. 2009:120 (16): 1640.
NCEP - http://www.nhlbi.nih.gov/about/ncep/index.htm•
JNC 7 Guidelines - http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm•
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AAFP Recommendation
Family physicians should counsel all patients on nutrition,
physical activity, and behavioral strategies to prevent
inappropriate weight gain and obesity. Family physicians
should screen all adult patients for obesity and offer intensive
counseling and behavioral interventions to promote sustained
weight loss for obese adults. (Intense counseling involves
more than one session per month for at least 3 months).
Am Fam Physician. Metabolic Syndrome: Time for Action; 2005
www.aafp.org/online/en/home/policy/policies/o/obesityandoverweight.html
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Purpose of PSM
The Pressure System Model (PSM) was developed to distill
leading behavioral theories and make them work in the primary
care setting for lifestyle counseling.
The 3 objectives of this program are to:
• Make lifestyle counseling fit comfortably into the context
of primary care.
• Make lifestyle counseling and behavior change incremental, and
thus manageable for patient and provider alike.
• Direct counseling toward the domain where it is most likely
to make a positive difference.
Each of these will now be addressed in greater detail.
•
•
Katz DL, Shuval K, Comerford BP, Faridi Z, Njike VY. Impact of an educational intervention on internal medicine residents'
physical activity counselling: the Pressure System Model. J Eval Clin Pract. 2008 Apr;14(2):294-9
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Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001 Jan;32(1):66-72.
Making Lifestyle Counseling Fit
Comfortably into Primary Care
The PSM offers a counseling system that respects the time
constraints of the primary care setting.
A simple two-question algorithm identifies the focus for a
brief, targeted counseling session which may be conducted
in less than two minutes per encounter.
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Making Lifestyle Counseling and
Behavior Change Incremental
Behavior change is approached incrementally. An ongoing
dialogue between you and your patient during brief multicontact counseling interventions allows for adjustments
with modifications over time.
Acceptance of the incremental nature of change by you and
your patient is essential to avoid frustration and resultant
failure.
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Directing Counseling Where It Will
Make a Positive Difference
Nutrition and exercise counseling is performed with
consideration for the motivational and/or resistance forces that
govern behavioral patterns. Your approach to counseling is
individualized based on your patient’s stage or readiness for
change.
The two-question algorithm determines your patient’s current
lifestyle practice and their willingness to change. It places your
patient in one of five categories which identify the counseling
focus: raising motivation, lowering resistance, or some of both.
8
PSM Validation Research
The PSM research model was tested in a randomized
controlled trial to evaluate the promotion of physical activity.
Seven Yale University-affiliated internal medicine programs
were randomly assigned to a PSM-based behavioral
counseling program (intervention) or standard curriculum
(control).
PSM training consisted of skill building in behavioral
counseling, didactic sessions augmented by role-play, use of
the algorithm to identify counseling needs of patients and a list
of commonly encountered barriers to physical activities with
strategies to address them.
Katz DL, et al. Impact of an educational intervention on internal medicine residents' physical activity counseling: the Pressure
System Model. J Eval Clin Prac. 2008 Apr;14(2):294-9.
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PSM Research Results demonstrated
efficacy in the primary care setting
• 65 internal medicine residents trained in PSM; 35 controls
received standard residency training.
• 195 patients were in the PSM group; 121 in control group
• Results: Patients improved physical activity (PA) from
baseline after 6 and 12 months of intervention (p = 0.0376 and
p = 0.046). No improvement was observed in the control
group (p = 0.7224 and p = 0.5160).
•
Medical residents in the intervention group increased PA
counseling 1.5 times more than at baseline.
Katz DL, et al. Impact of an educational intervention on internal medicine residents' physical activity counseling: the Pressure
System Model. J Eval Clin Prac. 2008 Apr;14(2):294-9.
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Origins of the PSM
The Pressure System Model derives its name from
meteorology, where differences in barometric pressure
determine the direction in which the wind blows. Just as
wind blows from a high pressure area to a low pressure
area, so does behavior move in accord with the greater
force: motivation vs. resistance.
This is displayed schematically in the next slide.
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Motivation vs. Resistance
Change is attempted when motivation exceeds
perceived resistance.
Motivation
Maintenance of status quo
Obstacles/
Resistance
Change
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Here are the steps to implement
the PSM with your patients:
Your patient’s weight, waist circumference, waist-hip ratio and BMI, as
well as lab results, will provide the introduction and rationale for
addressing lifestyle change.
You then Apply the Algorithm: 2 questions are posed to place your
patient into one of the five categories, each of which determines the
appropriate emphasis of counseling: raising motivation or overcoming
resistance or some of both.
The next 3 slides will review the 2 questions and the algorithm to
identify the category.
1st Step: Two Questions
• Question 1: Are you currently (eating a healthful
diet / getting regular physical activity, etc.)?
If no:
• Question 2: Are you ready and willing to begin
(eating a healthful diet / getting regular physical
activity)?
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ALGORITHM to determine PSM CATEGORY
Are you currently (eating a healthful diet / getting
regular physical activity, etc.)?
QUESTION 1:
YES
NO
QUESTION 2:
Are you ready and willing to begin (eating a
healthful diet / getting regular physical activity)?
CATEGORY
1
CONDITIONAL YES
Recent
Attempt /
Relapse
Prior
Attempts /
Given Up
CATEGORY
CATEGORY
2
3
YES
NO
CATEGORY
4
CATEGORY
5
PSM Algorithm- Patient Questions
• Question 1: Are you currently (eating a healthful diet /
getting regular physical activity, etc.)?
– YES:
– NO:
Category 1: Maintenance
Go to Question 2
• Question 2: Are you ready and willing to begin (eating a
healthful diet / getting regular physical activity)?
– MAYBE: Category 2/3: Tried: relapsed or burned-out
– YES:
Category 4:
Ready to change
– NO:
Category 5:
Unprepared for change
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Category Counseling Focus:
the ‘M/O’
•
•
•
•
Category 1
Category 2/3
Category 4
Category 5
=
=
=
=
Maintenance
Relapse / Burn-out
Motivated, but anticipates barriers
Low Motivation
Focus on “M” motivation
Focus on “O” obstacles
Counseling Focus
Motivation vs. Resistance
• The conventional approach to behavior change counseling has
focused primarily on raising motivation, i.e., pointing out risks of
a behavior and stressing benefits of changing the behavior.
– This ‘advice-giving’ is a relatively ineffective means of raising motivation.
And, even if the desire for change, or motivation, is high, change cannot
occur if resistance or obstacles are higher still.
• Failure to change diet or improve physical activity is often a
consequence of excessive resistance rather than inadequate
motivation. Thus, impediments to sustainable lifestyle change
must be identified and strategies to overcome them must be
explored and implemented.
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Counseling Focus
Motivation vs. Resistance
• The PSM separates two fundamental goals of behavioral
counseling: raising motivation and overcoming resistance. Each
of the 5 categories determined by the PSM algorithm has specific
implications for counseling.
• Patients for whom motivation is relevant should receive motivational
interviewing. The objective here is to assist your patient to work
through ambivalence about changing behavior. A simple tool to
expedite a patient’s progress through his/her ambivalence is a decision
balance.
• When resistance is greater than motivation, it is necessary to work
collaboratively with your patient to identify the impediments to change
and identify solutions.
• The following slides address counseling approaches to raise
motivation and overcome resistance.
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Motivation
• Motivation is fundamental to change.
• Motivation must exceed resistance for behavior change to occur.
• Eliciting patient’s own positive reasons and arguments for change
will maximize motivation.
• Belief in the importance of the condition to be avoided, in
personal risk, and in the utility of change, are components of
motivation.
• An accepting, empowering climate helps to increase motivation.
• Motivational Interviewing is a patient-practitioner communication
that is designed to resolve ambivalence and promote motivation
for behavior change.
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Principles of Motivational
Interviewing (MI)
• Express empathy: Respectful listening; attitude of acceptance; nonjudgmental: acknowledging patient’s ambivalence as a normal part of
change; legitimizes patient’s feelings.
• Develop discrepancy: Highlighting discrepancy between behavior and
their important goals. The patient should state the arguments for making
a change. Decisional Balance can help.
• Avoid Argumentation: Conveys that the patient is in charge and builds
the therapeutic alliance. Argumentation leads to defensiveness.
• Roll with resistance: Resistance is a signal to respond differently.
Acknowledge that change may take time.
• Support self-efficacy: Offer encouragement and support in the patient’s
belief to be able to change. Build on past success. The patient is
responsible for choosing and making the changes.
Miller W, Rollnick S. Motivational Interviewing: Preparing people for change. New York: Guilford. Press, 2002 21
MI uses the OARS method of
communication. Here are some examples:
• Open-ended questions:
 How do you see exercise fitting into your daily schedule?
 Why is a change important to you?
 Tell me about the physical activity you enjoy.
• Affirmations:
 Beginning something new is difficult.
 That is great that you were able to exercise most days.
• Reflective listening:
 Making this change sounds important to you.
 You are worried about your weight.
• Summaries:
 You expressed several activities you would like to do more
but have difficulty fitting them into your schedule. Is this
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how you feel?
Decision Balance
• This is a simple tool to help your patient assess his/her sources
of ambivalence. These may change over time, so it is helpful to
use this tool intermittently, especially when progress has slowed.
• The decision balance table may be completed during an office
visit or between visits.
• The apparent gaps in the balance provide opportunities for you
to give advice or information that may swing the balance in
favor of making positive behavior changes.
• This tool also helps you to identify when change efforts are
likely to be premature and potentially unsuccessful.
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Decision Balance
Weighing the pros and cons (costs & benefits) of change
• Patients “talk” themselves into making changes. Helps identify true
issues and find motivation.
• Clinicians can explore and support in a collaborative effort.
 Pros: Benefits of changing
 Cons : Costs of changing
Costs of change
Benefits of change
•
•
Miller W, Rollnick S. Motivational Interviewing: Preparing people for change. New York: Guilford. Press, 2002
Glanz, K., Lewis, F.M., & Rimer, B.K. , 2000. (3rd Eds.) Health Behavior and Health Education:Theory Research
and Practice. San Francisco, CA: Jossey-Bass Publishers.
Decision Balance Table
CHANGE
DON’T CHANGE
Advantages/
Pros
Advantages/
Pros
Disadvantages/
Cons
Disadvantages/
Cons
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An Example of a Physical Activity
Decision Balance
Increase Physical Activity
Maintain Current Activity Level
Weight loss
Advantages
Disadvantages
Improved health
Easy
Advantages
Comfortable
More energy
Avoid sweating
Hard work
No weight loss
Limited time
Unsure how
Disadvantages
No health benefits
Possible weight gain
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Resistance
• Obstacles or resistance must be acknowledged in order to change a
behavior.
• You can assist patients to convert obstacles into challenges or
opportunities by
– Identifying universal barriers
– Identifying patient-specific barriers
– Collaboratively addressing solutions/alternatives
• Impediment Profiling: Research with smokers to identify patient
specific barriers and solutions concluded that individualizing
interventions based on personal barriers can enhance success with
behavior change.
O'Connell M, Yanchou-Njike Vkatz D, et al. Far Impediment profiling for smoking cessation: application in the worksite. Am J Health
Promot. 2006 Nov-Dec;21(2):97
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Impediment Profiling
Identifying the impediments to changing a diet or implementing a
physical activity program can help to shift the balance between
motivation and difficulty. Once you and your patient recognize
the obstacles to the behavior change, you can collaborate to find
strategies to overcome them.
Examples of impediments to behavior change: a schedule that
does not accommodate exercise, lack of cooking or food shopping
knowledge, household smoker, etc.
•
•
•
•
O'Connell M, Comerford BP, Wall HK, Yanchou-Njike V, Faridi Z, Katz DL. Impediment profiling for smoking cessation:
application in the worksite. Am J Health Promot. 2006 Nov-Dec;21(2):97-100.
Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC. Impediment profiling for smoking cessation. Preliminary experience.
Behav Modif. 2003 Sep;27(4):524-37.
O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan W, Katz DL. Impediment profiling for smoking cessation: results of
a pilot study. Am J Health Promot. 2003 May-Jun;17(5):300-3.
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Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001 Jan;32(1):66-72.
Category-Specific Counseling
You have identified the need for lifestyle counseling
and you have asked the 2 questions to determine
your patient’s category which directs your
counseling focus: maximizing motivation or
overcoming obstacles, or some of both.
The following slides provide category specific
information and examples of counseling.
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Patient Category 1
Patients in this category are currently in the action phase.
Behavior change is in the process of being modified or
maintained. Motivation may wane as new and unexpected
obstacles are encountered. The patient needs
encouragement to sustain motivation.
Identified difficulties should be discussed to develop
tailored strategies. Counseling is focused on how and why
to maintain positive changes.
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Patient Category 1
Goal: Maintain Motivation
Anticipate potential obstacles
Counseling Emphasis: Motivation
Emphasize success; praise, encouragement
Anticipate real or potential obstacles
Reinforce self-efficacy
Offer opportunity for follow-up
Key Questions:




List reasons for your success
Which strategies were successful for you?
Do you anticipate difficulties in maintaining these behaviors?
Do you wish to change any part of your action plan?
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Patient Category 2
– Patients in this category were motivated in the past to attempt
change but had a relapse and are not currently practicing the
healthy lifestyle change.
• A relapse generally suggests that an obstacle was encountered. The
obstacle (s) resulted in a temporary lapse as the difficulty in sustaining
change exceeded motivation.
– Troubleshooting the obstacle of the previous effort, as well as
identifying and planning for other potential obstacles, should be
a focus of the counseling effort. Counseling must also reestablish self-esteem and motivation.
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Patient Category 2
Goals: Overcome Resistance / Obstacles
• Re-establish self-efficacy (belief in one’s ability to achieve a particular
goal) and re-establish and motivation.
Counseling Emphasis: Resistance
• Foster forgiveness; Alleviate feelings of failure
• Lapses and fall-backs must be accepted as a normal element of behavior
change.
• Identify Obstacles & strategies to overcome them
• Restore confidence and encourage a new attempt.
Key Questions:




Tell me about what helped to motivate you when you tried previously?
How might we revise your action plan to help move forward again?
What difficulties occurred when you previously tried?
Do you anticipate the same obstacles now?
33
Patient Category 3
Patients in this category often have a history of repeated,
unsuccessful efforts. Multiple failed attempts at behavior
change may result in a feeling of ‘burn-out’ producing feelings
of remorse and low self-esteem. This patient needs help to
overcome the sequelae of prior failed attempts.
Counseling efforts should help patients in this group to
understand that failure is not their fault, but a result of
encountering barriers. Assistance to identify the barriers and
collaborate on solutions should be a focus. Assisting to regain
self-esteem and motivation are also important to this patient
category.
34
Patient Category 3
Goals: Overcome Resistance / Obstacles
– Re-establish self-efficacy (belief in one’s ability to achieve
a particular goal) and re-establish motivation
Counseling Emphasis: Resistance/Obstacle
• Foster forgiveness; Alleviate feelings of failure.
• Lapses and fall-backs must be accepted as a normal element of behavior
change.
• Identify Obstacles & strategies to overcome them.
• Help to establish a new set of goals.
• Restore confidence and encourage a new attempt.
Key Questions:




Tell me about what helped to motivate you when you tried previously?
How might we revise your action plan to help move forward again?
What difficulties occurred when you previously tried?
Do you anticipate the same obstacles now?
35
Patient Category 4
Patients in this category are considering or contemplating
behavior change. They are not currently practicing the
beneficial behavior, but are interested in making the change.
Motivation & opposing resistance are of similar strength. This
balance can be tipped by raising motivation and/or addressing
perceived impediments with strategies to reduce the difficulties.
Thus, counseling efforts should focus on increasing motivation
to induce change, with attention to potential barriers and their
solutions. Emphasis is both on why change should occur and
how change can be achieved.
36
Patient Category 4
Goals: Overcome Resistance / Obstacles:
• Increase self-efficacy & motivation
• Establish action plan collaboratively
Counseling Emphasis: Motivation and Resistance:
∙ Decision Balance to clarify rationale for change
∙ Emphasize personal benefits of healthy behaviors
∙ Identify potential obstacles & strategies to overcome
∙ Increase motivation/self-efficacy
Key Questions:
• What are your biggest obstacles for change?
• How do you see exercise / improved nutrition fitting into your daily
schedule?
• Why is a change important to you?
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Patient Category 5
Patients in this category are pre-contemplative and have not
yet thought about making the behavior change. Initial
counseling goals are directed at raising awareness, interest,
and motivation.
The counseling effort should attempt to encourage
contemplation for change and preparation for action. The
focus of counseling is on what behavior changes are
indicated and why. Difficulties in achieving behavior
changes should be discussed in anticipation of potential
obstacles.
Keep in mind that behavior change is incremental and done
over time. Small steps should be recognized and counseling
focus may be adjusted according to need at each visit.
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Patient Category 5
 Work with patient to complete a decision balance; revise it over
time as indicated.
 Motivation must increase for change to occur.
Goal: Establish motivation
Counseling:
Motivational Interviewing.
Assist to develop decision balance chart.
Explore ambivalence.
Relate to patient’s personal health status.
Key Questions:
 What does having elevated cholesterol / high B/P mean to you?
 What would help you to make a change?
 What are the pros / cons of making a change?
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Revisiting the algorithm and
category specific counseling focus:
•
•
•
•
Category 1 =
Category 2/3 =
Category 4 =
Category 5 =
Maintenance
Relapse / Burn-out
Motivated, but anticipates barriers
Low Motivation
Focus on “M” motivation
Focus on “O” obstacles
QUESTION ALGORITHM to determine PSM CATEGORY
Is patient engaged in a healthful lifestyle practice
(regular physical activity / healthy diet)?
QUESTION 1:
YES
NO
QUESTION 2:
Is patient willing to adopt a healthful
lifestyle practice?
CATEGORY
1
CONDITIONAL YES
Recent
Attempt /
Relapse
Prior
Attempts /
Given Up
CATEGORY
CATEGORY
2
3
YES
NO
CATEGORY
4
CATEGORY
5
Summary of PSM Steps
1. Identify Category: Ask the two questions to identify patient
category.
2. Identify counseling priority based on category: should counseling
be focused primarily on raising motivation, lowering resistance,
or both?
3. Provide relevant homework: dietary advice & instructions;
physical activity prescription; decision balance.
4. Schedule follow-up visit as with other clinical interventions:
track behavior; assess response; tailor counseling to help your
patient move forward at each visit.
Remember that behavior modification is a process and change
is incremental.
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In summary…
• Healthcare providers have an important role in motivating and
assisting patients’ healthy behavior changes; patients expect
advice and assistance from providers.
• Interventions must evaluate readiness, motivation and potential
obstacles to increase the likelihood of maintaining a plan of
action.
• Adopting a healthy, balanced diet and a physically active
lifestyle requires a series of behavioral changes.
• Reinforcement and continuity of care in the primary care
setting can help with long-term adherence to a healthy
lifestyle.
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Summary, cont.
• Nutrition and physical activity should be addressed as a routine
part of primary care.
• Incorporating lifestyle counseling into primary care practice can
be done in brief exchanges of approximately 2 minutes.
• The PSM model provides a 2-question algorithm to determine
patient’s readiness to change.
• Counseling is category specific, directed to either
maintain/maximize motivation or identify/problem-solve
obstacles toward the goal of healthy behavior change.
• Behavior changes are facilitated by empowering patients to gain
increasing control.
• A therapeutic alliance between clinician & patient is essential.
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Patient Vignette
Assess:
56 y/o male presents for annual PE; BMI(32); waist
circumference 108 cm (42.5 inches); taking no medications;
diet high in refined carbs and low in fruit/vegs; “weekend
warrior”; history of joining gym for regular exercise but
dropped out.
Question 1:
For the past 6 months (or more) have you performed moderate
physical activity for 30 minutes or more on most days of the
week?
Answer: NO
Question 2:
Are you ready to begin a regular program of physical activity?
Answer: YES
You identify this patient as a Category 3.
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Patient Vignette Visit 1:
1. You have already related the need for a lifestyle change to
physical findings (labs, waist circ, weight).
2. Your counseling focus is to work with the patient to identify the
obstacles from previous attempts that resulted in dropping out.
3. Strategize to find solutions that may bypass the obstacles and
enhance success; collaborate to create a new action plan:
1.
2.
What other physical activity options are available? (30-45 minutes
walking/biking/hiking 5 times weekly; resistance training 2 times weekly).
Write FITT exercise prescription.
If timing is an issue, would several shorter physical activity sessions per
day be an option?
4. Foster forgiveness for previous failed attempts; do not allow
blame; help your patient re-establish the belief that success is
possible.
5. Schedule follow-up visit.
46
Patient Vignette Visit 2
1. Assess response; track progress
- How is exercise fitting within your life now? Tell me about
it (when, where, type, intensity).
- Check weight, waist circumference.
- Record current physical activity type, duration, intensity.
2. Counseling focus:
- Continue to support motivation and self-efficacy.
- Acknowledge all success.
- Explore new or potential obstacles.
- Collaborate to find solutions (alternative physical
activities; several shorter physical activity intervals, etc).
3. Arrange follow-up visits; telephone call and mail/internet
47
support; consider community opportunities.
Patient Vignette – ongoing visits
1. Continue to assess physical activity lifestyle change.
2. Track progress
- Measurements (weight, waist circ, BMI).
- Physical Activity type, duration, frequency.
- Add resistance exercise or increase duration if indicated.
3. Counseling focus:
- Continue to explore new/potential obstacles and solutions.
- Continue to acknowledge & support successes.
- Use decision balance as appropriate.
4. Revise counseling focus as indicated
- Address nutrition as physical activity becomes integrated.
48
Patient Vignette
Agree: collaboratively develop action plan: example:
30-45 minutes walking/biking/hiking 5 times weekly;
resistance training 2 times weekly.
Assist: decisional balance chart: benefits and
obstacles of increasing physical activity; strategies to
overcome barriers; exercise Rx using ‘FITT’,
community opportunities for support.
Arrange: follow-up visits, telephone calls,
mail/internet support.
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-Resource Materials-
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Websites for Healthcare Providers
• http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/profmats.htm
• http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/
• http://www.health.gov/paguidelines/default.aspx
• http://www.acsm.org/AM/Template.cfm?Section=Home_Page&CONTENTI
D=11398&TEMPLATE=/CM/HTMLDisplay.cfm
• http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/nutrition_350_ENU_HTML.
htm
• http://www.cdc.gov/nutrition/professionals/tools/index.html
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Websites for Patients
• www.walkingabout.com
• http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/patmats.htm
• http://www.thewaytoeat.net/content?page=274&cat=0
• http://win.niddk.nih.gov/publications/walking.htm
• http://www.cdc.gov/physicalactivity/growingstronger/index.html
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Websites for Kids
• http://www.bam.gov/sub_physicalactivity/index.html
• http://www.cspinet.org/smartmouth/
• http://www.nutritionexplorations.org/kids/
• www.kidnetic.com/
• http://www.fruitsandveggiesmorematters.org/
• http://library.thinkquest.org/10991/
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CME Credits
Click here for information about obtaining CME credits for completion of the
O.W.C.H. training program.
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