CHEO s Centre for Healthy Active Living

Transcription

1 CHEO s Centre for Healthy Active Living Dr. Stasia Hadjiyannakis Pediatric Endocrinologist Medical Director Dr. Annick Buchholz Psychologist- Lead, Program Evaluation Northern Ontario Pediatric Conference October 2, 2015

2 Mission To improve the health and quality of life of children and youth with severe complex obesity and support them and their families in achieving a healthy active lifestyle. Direct Clinical Contact Capacity Building Program Evaluation Knowledge Translation

3 Severe Complex Obesity Children and youth (5-18 years) with obesity and: Weight related health complications requiring subspecialty care Medical, Mental Health, Developmental and/or Psychosocial factors that complicate weight management

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5 Key Principles

6 Key Principles A Child s Best BMI May Never Be His or Her Ideal BMI

7 Key Principles Obesity Management is About Improving Health and Well-being, and not Simply Reducing Numbers on the Scale

8 Key Principles Weight bias can be a barrier to weight management

9 Key Principles Interventions should include addressing root causes of obesity and removing roadblocks for families to make healthy changes

10 Key Principles Success is different for every child and family

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12 Weight is a sensitive issue. Many children and parents may be embarrassed or fear blame and stigma, so asking is an important first step.

13 When ASKing ASK Do you have any concerns about your/your child s health? Do you have any concerns about your/your child s weight? What are your concerns about your/your child s weight? How does your/your child s weight impact you/them?

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15 Create a Weight-Friendly Practice ASSES Facilities: wide doors, large restrooms, floormounted toilets Scales: over 350lb/160kg, wheel-on accessible, located in private area and used with sensitive weighing procedures Waiting room: sturdy, armless chairs, appropriate reading material no glossy fashion magazines Exam room: appropriate-sized gowns, wide and sturdy exam tables, extra-large blood pressure cuffs, longer needles and turniquets, long-handled shoe horns

16 ASSES ASSESS Assess Obesity Status and Stage Assess for Obesity Drivers, Complications, and Barriers (4Ms) Assess for Root Causes of Weight Gain

17 The 4 M s of Pediatric Obesity Mental Mechanical Metabolic Milieu Anxiety Depression Body image ADHD Learning disorder Sleep disorder Eating disorder Trauma Sleep apnea MSK pain Reflux disease Enuresis Encopresis Intertrigo IGT/T2DM Dyslipidemia Hypertension Fatty liver Gallstones PCOS Medication Genetics Parent health/disability Family stressors Family income Bullying/Stigma School attendance School support Neighbourhood safety Medical insurance Accessible facilities Food Environment Opportunities for physical activity

18 Oscar 15 yo, male, BMI 44 kg/m 2 Mental Mechanical Metabolic Milieu ADHD (untreated) Nonverbal Learning Disability Sleep apnea nonadherent with BiPAP 70% have 2 or more co-morbidities 55% have psychiatric disorders Type 2 Diabetes (A1C 12.2) Dyslipidemia Combined family income (< $25000) maternal type 2 diabetescomplications maternal eating disorder Bullied at school School refusal Frequent suspensions

19 Clinical Staging Tools Edmonton Obesity Staging System- Pediatrics Risk stratification system that classifies obese children and youth into 4 graded categories based on weight related health complications and factors that complicate weight management (4Ms)

20 EOSS BMI Class Survival Curves diverge when stratified by EOSS score but not BMI Class Padwal R S et al. CMAJ (2011)

21 STAGE METABOLIC MECHANICAL MENTAL 0 No metabolic complications 1 Mild metabolic abnormalitiesnot requiring medication 2 Moderate metabolic complications requiring pharmacotherap y 3 Inadequately managed metabolic complications No biomechanical Complications Mild biomechanical complicationsnot interfering with ADL Moderate biomechanical complications requiring intervention Severe mechanical complications interfering with ADL HEALTH No mental health difficulties Mild difficulties not interfering with functioning Moderate mental health difficultiesrequiring therapy Uncontrolled mental health difficulties MILIEU No social stressors - home, school, community Mild social stressors Moderate social stressors Severe social stressors E O S S - P

22 Advise on Family-Based Management Options ADVISE Sleep Sedentary Behaviour Eating Behaviour s Mental Health Physical Activity Bariatric Surgery

23 Advise on Family-Based Management Options ADVISE Sleep management interventions can significantly improve eating and activity behaviours as well as mood and school performance. Eating Behaviour s Physical Activity should focus on eating & drinking hygiene. Extreme and fad diets are not sustainable in the long-term. interventions should aim at reducing sedentariness and increasing daily physical activity levels to promote fitness, overall health, and general wellbeing, rather than focusing on burning calories.

24 Advise on Family-Based Management Options ADVISE Sedentary Behaviour Mental Health Bariatric Surgery should be limited through minimizing recreational screen time to less than 2 hours per day, choosing active transportation over motorized, and increasing active play and active family time. treatment referrals to help manage underlying /co-morbid psychological issues interventions can improve body-esteem, selfesteem, reduce emotional eating, and promote coping strategies. may be considered for adolescents who ve reached their final adult height, with BMI>40, and with obesity related health complications. Candidates & their families are required to have completed a multidisciplinary 6-month presurgical intervention.

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26 Management Options Parent Group Children 10 years old Care Coordination Community Resources Motivational Interviewing Readiness to Change Intermediate Family Group Youth years old Family Group Youth 14 years old

27 CHAL Program Parent Group Children 10 years old 10 weeks, evenings Assessment Intermediate Group Youth weeks, evenings Family Group Teens 14 years 28 weeks, 3 phases, evenings

28 The Team Dr. Stasia Hadjiyannakis Pediatric Endocrinologist Dr. Katie Baldwin- Pediatrician Dr. Annick Buchholz Psychologist, Lead Program Evaluation (0.6 FTE) Dr. Laurie Clark Psychologist (0.6 FTE) Lori Anne Marks Nurse, Case Manager (0.8 FTE) Jane Rutherford Exercise Specialist (1.0 FTE) Anna Aylett Dietitian (1.0 FTE) Shaun Reid Child & Youth Counselor (0.3 FTE) Maura Manuel Social Worker (0.3 FTE) Charmaine Mohipp- Clinical Research Associate (0.3 FTE) Melanie Gervais Administrative Assistant (1.0 FTE)

29 Conclusion Complex care patients Interdisciplinary team approach Intensive care with frequent follow up Focus on health and well being Significant improvement in Quality of Life approaching population norms

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31 Quality of Life Outcomes Scores across time:

32 High Parent Satisfaction with CHAL

33 Low Attrition at 3 years Total 330 Current 210 Discharged 7 2% Transitioned 57 17% Attrition 56 17%

34 Medical Outcomes Stabilization of BMI Z-Score, TG/HDL, Non-HDL-C

35 Building Capacity Invited Lectures & Workshops: Healthcare Sector Educators Community Trainees: Medical students/residents/fellows Undergraduate/Graduate students Visiting clinicians Number Attendees Satellite Clinic 1

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37 BMI of girls (upper) and boys (lower) who where normal weight ( ) or overweight ( ) at the age of 13. Lagström H et al. Pediatrics 2008;122:e876-e by American Academy of Pediatrics