Identifying, Treating and Preventing the Disease of Pediatric Obesity

Transcription

1 Identifying, Treating and Preventing the Disease of Pediatric Obesity Children s Hospital of Pittsburgh Weight Management Center Ellen Cernich MS, LDN, CDE Ann Condon Meyers MS, LDN

2 Historical Perspective of Childhood Obesity

3 In the United States Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years. The percentage of children aged 6 11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in Similarly, the percentage of adolescents aged years who were obese increased from 5% to nearly 21% over the same period. In 2012, more than one third of children and adolescents were overweight or obese.

4 Percentage of high school students who were obese* selected U.S. states, Youth Risk Behavior Survey, 2013

5 Prevalence of Self-Reported Obesity Among U.S. Adults, CDC, 2014

6

7 WHO most recent map of adult obesity, 2015

8 Definition of Overweight / Obesity Underweight Less than the 5th percentile Normal or Healthy Weight 5th percentile to less than the 85th percentile Overweight 85th to less than the 95th percentile Obese 95th percentile or greater

9 A.A.P. Stages of Obesity Prevention and Treatment Stages Description 1. Prevention Plus First step to focus on basic healthy lifestyle habits 2. Structured Weight Management Specific nutrition and exercise goals are established Behaviors are monitored on a monthly basis 3. Comprehensive Multidisciplinary Intervention Increases the specialists involved to maximize support for behavior changes 4. Tertiary Care Intervention Offered to severely obese children May include medication, low-calorie diets, surgery Barlow SE and the Expert Committee. Pediatrics 2007;120;S164-S192

10

11 Risk Factors of Childhood Obesity High blood pressure and high cholesterol, which are risk factors for cardiovascular disease (CVD). In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more. Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes. Breathing problems, such as sleep apnea, and asthma as well as joint problems and musculoskeletal discomfort. GI diseases such as liver disease, gallstones, and gastro-esophageal reflux (i.e., heartburn). Psychological stress such as depression, behavioral problems, and issues in school. Low self-esteem and low self-reported quality of life. Impaired social, physical, and emotional functioning.

12 Lead to Consequences Later Children who are obese are more likely to become obese adults. Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, metabolic syndrome, and cancer. If children are obese, obesity and disease risk factors in adulthood are likely to be more severe.

13 Besides the health care community, who cares about overweight children?

14 Weight Management Center Children s Hospital of Pittsburgh Strengths: Experts in obesity treatment Multidisciplinary approach Comprehensive care Limitations: Limited reach Not easily accessible High levels of attrition Resource intensive

15 Does the CHP program work? Results published in 2010 found: 52% decrease in BMI percentile (Adult programs report an average of 2-20% decrease in weight after 1 year.) Quality of life improves as measured by the patient and family in the families with weight loss (6.83 fold improvement) after 12 months. Program satisfaction after 3 months 93%, and after 12 months 86%.

16 Treatment Options Who, What, Where and When Who, What, Where and When

17 AAP Stages of Obesity Prevention and Treatment Stages Description 1. Prevention Plus First step to focus on basic healthy lifestyle habits 2. Structured Weight Management Specific nutrition and exercise goals are established Behaviors are monitored on a monthly basis 3. Comprehensive Multidisciplinary Intervention Increases the specialists involved to maximize support for behavior changes 4. Tertiary Care Intervention Offered to severely obese children May include medication, low-calorie diets, surgery Barlow SE and the Expert Committee. Pediatrics 2007;120;S164-S192

18

19 Weight Management Center Children s Hospital of Pittsburgh Strengths: Experts in obesity treatment Multidisciplinary approach Comprehensive care Limitations: Limited reach Not easily accessible High levels of attrition Resource intensive

20 Hospital Team Members Medical Provider: Endocrinologist, PA, NP Nurse: Cholestech, A1C Wellness Advisor: LDN Behavior Psychologist

21 Community PCP s: family centered to develop and maintain healthy lifestyle habits. Strengths: Community Based Easily Accessible Established relationship with families Ability to initiate prevention measures Limitations: Limited connection to resources and ongoing support Lack of standardization Lack of expertise

22 Community Team Members Primary Care Provider Practice Manager/Office Coordinator Lifestyle Coach Medical Assistant Office Staff Receptionist Scheduler

23

24 Motivational Interviewing in the Clinical Setting Collecting Information While Empowering the Family to Succeed

25 This is not motivational interviewing: What fits your busy schedule better? Exercising one hour a day or being dead 24 hours per day?

26 Motivational Interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.

27 The way in which you talk with your patients about their health can substantially influence their personal motivation for behavior change. - Rollnick, Miller & Butler, 2008

28 Resist the righting reflex Four MI Principles P: I just don t think our family has time for all these changes right now. C: You feel overwhelmed by all of this, and you re wondering what changes can fit into your life. Understand your patient s motivation C: Making changes can be overwhelming, but when you think about how it could benefit your family, you feel encouraged. Listen to your patient C: I hear what you re saying. You have some concerns about how to make these changes work for your family. Empower your patient C: You are ready to commit to a healthier lifestyle. When you have made commitments in the past, you have been successful.

29 Open-ended questions O A R S Affirmation Reflection Summary

30 Ask Communication Skills Open-ended questions What would you like to do for your child s health? Listen Reflectively and with purpose You are prepared to make changes for the benefit of your child and your family. Inform With permission and choices I have some suggestions that might be helpful, would you like to hear them?

31 Open-ended Coaching Questions What do you think about the amount of time you spend watching TV? What could the benefits be for you, if you were a little bit more active? What makes you feel that now is a good time to try something different? What would you like to change first? How might things be different for you, if you did make a change?

32 Giving Information and Advice How NOT TO do it Without first asking permission Wagging your finger In a moralistic or warning voice How TO do it Get permission Honor autonomy Ask Provide Ask For suggestions, offer several instead of one

33 Ask, Provide, Ask ASK about existing knowledge/interest What do you already know about? ASK permission! There are some things others have found helpful. Are you interested in hearing about them? PROVIDE small chunks of information or feedback A few things I have seen help other young children have been. ASK for interpretation or reaction What do you think about these suggestions? What are your thoughts about trying one or two of them?

34 A tool for collecting topics of concern for the family

35 How will you know how you re doing? Patient / family is doing most of the talking Patient / family is working harder than you Patient / family is making statements about change Patient / family resistance is minimized

36 Institute for Healthy Weight in Childhood Interactive web site or app that allows you to role play and get feedback using MI when talking about weight with families. Affiliated with AAP and sponsored by Nestle aspx Practice for motivational interviewing

37 Or think of it this way Doing motivational interviewing with someone else is like entering their home. One should enter with respect, interest and kindness, affirm what is good and refrain from providing unsolicited advice about how to arrange the furniture. Kamilla Venner

38 Forms to organize your visit Long form for an hour interview and motivational session is included in your packet along with references. If you develop a patient questionnaire to be filled out before your visit, it can lead you to the issues the family sees as important. A detailed food intake record can also help you identify areas of concern BUT it often makes the family defensive if you dwell on it.

39 Lifestyle Modules

40 Family Education: 1. Teaching tools used 2. Age group specifics 3. Role Playing

41

42 Teaching Tools

43 Lifestyle Lessons

44 Patient Self- Assessment

45 Tools

46 Elicit ideas from the patient for healthier drink options: There are a lot of ideas here for drinks that are lower in sugar. What do you think about these ideas? What is one change you think you could make?

47 Education

48 Goals

49 Goal-setting: Collaborate with patient/family to establish personal and family goals Invite patient to establish his/her own goals. So where do you want to start? Try one new vegetable each week. Limit sweet drinks to 6 ounces per day. Eat a piece of fruit for lunch each day. Eat dinner without the television on. Take a family walk for 30 minutes on Saturdays. Buy more fruit to have at home.

50 Limit occasional foods to 1 serving/day

51 Add More Vegetables Build a Healthy Meal Changing Habits Choose Beverages Wisely Choose My Plate Cut Back on Treats Dairy Dining Out: Pick or Pass Facts About BMI Focus on Fruits Get Active Indoors Getting Started with Pedometer Healthy Body Image Tip Sheets Healthy Plate Breakfast Healthy Plate Dinner Healthy Plate Lunch Healthy Plate Snacks Helpful and Harmful Phrases Helpful Resources Healthy Role Model Kid-friendly Veggies & Fruits Picky Eaters Reduce Screen Time Serving Size in Hand Smart Shopping Veggies & Fruits Vegetarians Whole Grains

52 Additional Tip sheets for, Healthy Eating Habits

53

54 Tracking Tools Lifestyle Log Eat the Colors of the Rainbow Feeding Guide Log for Children Get Moving! Action Chart

55

56 Shop for the Colors of the Rainbow! 56

57 Age Group Specifics Toddler/Preschool: Drinks: Water and low fat, white milk only Eat your fruit, don t drink it All meals/snacks at the table, no screens Routine is necessary: meals, snacks Appetites fluctuate portions will be much smaller Child Development age appropriate expectations

58 Age Group Specifics Toddler/Preschool: Offer fruit/veggie at each meal Have daycare/caregivers keep food/drink log Relatives need to be on same page Parent must remain in control Don t use food as reward Encourage free play limit TV/screen time Make snacks quality fruits/veggies, dairy, whole grain Don t lock cabinets, special shelves, etc

59 Age Group Specifics Elementary: Drinks: Water and low fat, white milk Eat your fruit, don t drink it School meals: flavored milk, double lunches/breakfast, juice, allowed 2nds Communicate with the school Don t use food as reward fun fitness instead Meals/snacks at table no screens No exceptions for any family member

60 Age Group Specifics Elementary: Picky eating can be a learned behavior Make only one meal Takes at least times of trying new food Keep offering fruits/veggies at meals/snacks Daily fun fitness = 30 minutes Screen time has to be limited Boredom eating?

61

62 Age Group Specifics Adolescents/Teens: No good or bad food How much and how often Use fitness/food tracker app helps become aware of sleeping, water intake, food choices, steps Weighing depends on maturity, motivation level Not eating at school- embarrassed? Calorie counting? DRINKS, DRINKS, DRINKS. Low calorie flavored water, selzter water

63 Age Group Specifics Adolescents/Teens: Meals/snacks at table not in bedroom, NO SCREENS Slow down when eating Parents make only one meal keep offering fruits/veggies Picky eaters don t have to be forever Emotional/boredom eating? Hiding, sneaking, hoarding of food? Buying food on their own or with friends, etc

64 Parenting 101 Out of sight, out of mind = Don t buy it You are in control They aren t going to like everything you make Involve kids in meal planning, shopping Make meal time a priority sit at table, conversation, no screens

65 Parenting 101 Parents are the Role Model breakfast skipping, dislike of vegetables, etc Get all caregivers on the same page grandparents, aunts/uncles, siblings Picky eaters: Have one acceptable food and one new food per meal Stages of child development

66 Points to Remember Practices must be ready to implement the program, and have the infrastructure to support it. Physician referral and advocacy of the program is vital. Success of children and families is highly influenced by motivation to change. Not all children or families are ready to engage in a weight management program. Behavior change is a key indicator of success and tracking this can be difficult if families do not return for follow-up visits. Visible indicators of success, such as change in weight, can be difficult to attain in children.

67 Role Play

68 12 yr old, male Height: 64 inches Weight: lbs BMI: 31.5 (98th percentile) Scenario # 1: Jake Blood Pressure: XX/XX mm/hg Family History of hypertension Lifestyle Assessment: 5-6 sugary beverages/day; family dines out on fast food 3-4 times/week; 2-3 hrs of screen time on weeknights and 5-6 hrs of screen time on weekends; no structured physical activity Not concerned about weight

69 14 year old, female BMI percentile: 99th Scenario # 2: Claire Participant in Healthy Habits for 2 months Experiencing continued weight gain Engaging in emotional and sneak eating behaviors Numerous psychosocial challenges identified High motivation for weight loss yet low motivation for physical activity

70 13 year old, female Case Study 3: Betty Prior success in a structured pediatric weight management program BMI percentile: 85 th Mother concerned about recent increase in weight School lunch identified as potential barrier to sustained weight management efforts Patient motivated to maintain healthy weight and wants to learn more about improving her food choices

71 Prevention

72 Statistics for Childhood Obesity from the CDC Childhood obesity is associated with adult head of household s education level for some children Childhood obesity among preschoolers is more prevalent among those from lowerincome families

73 Poverty better predictor than race in childhood obesity A statistical model, based on information from more than 110,000 Massachusetts students, found that as children's family income dropped, rates of childhood obesity went up. Although the study found a link between poverty and childhood obesity, it didn't prove a cause-and-effect relationship. The study was published Jan. 7, 2016 in the journal Childhood Obesity.

74 There may be a correlation between education and poverty

75 Environmental factors fueling this epidemic

76 Advertising Nearly half of U.S. middle and high schools allow advertising of less healthy foods, which impacts students' ability to make healthy food choices. In addition, foods high in total calories, sugars, salt, and fat, and low in nutrients are highly advertised and marketed through media targeted to children and adolescents. Advertising for healthier foods is almost nonexistent in comparison.

77 Community Environment Half of the children in the United States do not have a park, community center, and sidewalk in their neighborhood. Only 27 states have policies directing communityscale design. One study showed that each additional hour spent in a car per day was associated with a 6% increase in the likelihood of obesity. Conversely, each additional kilometer walked per day was associated with a 4.8% reduction in the likelihood of obesity.

78 Energy Dense Foods and Beverages Sugar sweetened beverages are the largest source of added sugar and an important contributor of calories in the diets of children in the United States. High consumption of sugar sweetened beverages, which have few, if any, nutrients, has been associated with obesity. On a typical day, 80% of children and teens drink sugar sweetened beverages.

79 Increasing portion sizes Research shows that children eat more without realizing it if they are served larger portions.

80 School Lunch Programs

81 School Breakfast Programs

82 Referral to Children s Hospital WMC Pediatrician or PCP should screen patient first. Screen should include BMI, growth chart, family history and blood pressure. Labs such as lipid panel, glucose and HA1C% are helpful as well but not required. Any patient who has a BMI over the 85 th %tile may be referred up to 18 years of age. Family may call to schedule an appointment. Children s main campus is in Lawrenceville. We also have a satellite in Bridgeville, PA off of US interstate 79 known as Children s South.

83 Thank you for your interest.