Childhood Obesity & Motivational Interviewing Causes, Consequences and Current Management Strategies of Childhood Obesity Dana Rofey, PhD University of Pittsburgh School of Medicine Division of Weight Management and Wellness Children's Hospital of Pittsburgh Goals Overview of the problem Epidemiology Pathogenesis Discuss Co-morbidities Outline current strategies for screening Outline Current Management Strategies Emphasis on Motivation Interviewing (MI) CDC Definitions Advantages of BMI Weight Category Underweight Healthy Weight At Risk of Overweight BMI Percentile Range < 5 th 5 th to 85 th Between 85 th and 95 th Overweight 95 th CDC Website 1. Age and gender cutoffs readily available on standard growth charts. 2. Index that allows us to plot a measure of weight & height, for age, on same chart. 3. BMI in children is consistent with adult index, so tracks body size throughout life. 4. Correlates well with laboratory measures of body fat. 5. Correlates well with clinical risk factors for the development of cardiovascular disease. Freedman et al., Pediatrics 1999;103:1175-1182. BMI Tracks into Adulthood Probability of Obesity at age 25 in Relation to Childhood BMI For Children, BMI Changes with Age BMI BMI % obese as ad dults 100 80 60 40 20 0 BMI < 85th BMI >=85th BMI >=95th 83 75 77 69 67 26 16 17 19 15 52 36 55 12 11 10 9 Birth 1 to 3 3 to 6 6 to 10 10 to 15 15 to 18 N = 854 Whitaker et al. NEJM: 1997;337:869-873 Adiposity Rebound BMI BMI 1
What is the Pathogenesis of Overweight in Children? Pathogenesis of Overweight When to Suspect Otherwise Energy Intake Energy Excess Genetic Predisposition Energy Expenditure Sedentary Lifestyle Hypogonadism Short Stature Dysmorphic Features Developmental Delay / Mental Retardation Syndromes Prader Willi Laurence-Moon-Biedl Presence of Hypothalamic Lesions Endocrine Disease Associated with Abnormal Weight Gain Thyroid hormone deficiency Glucocorticoid excess Endocrine causes of overweight are associated with Decreased Linear Growth What are the Metabolic Consequences of Childhood Obesity? High blood pressure High blood cholesterol Coronary heart disease Congestive heart failure Stroke Diabetes Gallstones Osteoarthritis Obstructive sleep apnea Cancers PCOS Fertility problems and complications of pregnancy Psychological disorders Early mortality / Sudden Death Promotes Risk for Cardiovascular Disease Metabolic Syndrome Abdominal adiposity Elevated blood pressure Elevated triglycerides Low HDL cholesterol Insulin resistance No agreed upon criteria for diagnosis Abdominal Adiposity Associated with cardiovascular disease risk PT Katzmarzyk et al. Diabetes Care 2006;29:404-409 Strong association with insulin resistance and increases risk of T2DM in youth Bacha, F. et al. JCEM 2003;88:2534-2540 2
Waist Circumference is Correlated with Abdominal Fat Content Correlation of Insulin Sensitivity with Waist Circumference 100 R 2 = 0.304, P = 0.005 Insulin Sen nsitivity (mg kg FFM 1 min 1 per μu/ml) 10 1 80 90 100 110 120 130 Waist Circumference (cm) Data from TS Hannon, F Bacha, SA Arslanian. Pediatric Diabetes In Press Elevated Blood Pressure BP at ages 30 and 50 are predicted by BP measured at early school age and early puberty. MJ Nelson et al. Am J Epidemiol 1992 Sep 15;136(6):633-45. SBP measured in childhood is a consistent and independent predictor of arterial stiffness in adults. Shengxu Li et al. Hypertension 2004;43:541 The Bogalusa Heart Study Arterial Stiffness in Adolescents with Type 2 Diabetes vs Obese and Normal Weight Adolescents Pulse Wav ve Velocity (cm/ /sec) 1000 800 600 400 200 0 * NW OB T2DM Data from N Gungor, S Arslanian et al. In TS Hannon and SA Arslanian. Current Opinion in Endocrinology and Diabetes 2006; 96(4): 111-118. Dyslipidemia Insulin Sensitivity in TG/HDL Groups triglycerides HDL Correlate with measures of insulin resistance tivity Insulin Sensi er µu/ml mg/kg FFM/min p 10.0 7.5 5.0 2.5 P = 0.003 003 0.0 TG/HDL < 3 TG/HDL 3 Hannon TS et al. Pediatric Diabetes 3
Insulin Resistance Development of Type 2 Diabetes Assessment of the Overweight Child Thrifty Genotype Past Medical and Developmental History IR Normal GT Environmental Influence IGT st phase insulin 1 st IFG DM Family History: Obesity, type 2 diabetes, CVD, cancer, bariatric surgery, etc. Diet History Caretakers Eating patterns Beverages / Snacks Activity History Barriers Time spent in play/ organized or vigorous activity Time spent sedentary Identify Co-Morbidities Blood Pressure Age and height specific BP norms for boys and girls Pediatrics.. 2004;1142(2 suppl):s15-s35. S35. Pre-hypertension: SBP or DBP 90 th to 95 th %ile Stage 1 hypertension: SBP or DBP 95 th %ile Stage 2 hypertension: SBP or DBP > 99 th %ile + 5 mmhg Guidelines for Children 2-19 years (Available on AHA Website) Total cholesterol (mg/dl) Acceptable less than 170 Borderline 170 199 High 200 or greater LDL cholesterol (mg/dl) Acceptable less than 110 Borderline 110 129 High 130 or greater Identify Co-Morbidities Liver Function Tests Pediatric Gastroenterology Menstrual History / Gynecologic Family Hx PCOS Clinic Sleep History Pediatric Sleep Medicine Risk Factors for T2DM At-risk for overweight / Overweight Family History of T2DM Minority Race / Ethnic Background Native Americans, African-Americans, Americans, Hispanic Americans, Asians/South Pacific Islanders Signs of Insulin Resistance puberty, acanthosis nigricans, high blood pressure, dyslipidemia, PCOS Exposure to Hyperglycemia In Utero Diabetes Care 2000, 23:381-389. 4
Who to Screen for Diabetes BMI 85 th percentile + 2 of the following: Have a family history first- and second-degreedegree relatives Belong to a minority race/ethnic group Native Americans, African-Americans, Americans, Hispanic Americans, Asians/South Pacific Islanders Have signs of insulin resistance acanthosis nigricans, hypertension, dyslipidemia, PCOS Diabetes Care 2000, 23:381-389. sitivity per μu / ml) Longitudinal Study of Insulin Sensitivity Pre-pubertal vs Insulin Sens (mg / kg FFM / min p 25 20 15 10 5 0 P < 0.001 Pubertal Time-Points (N=9) Insulin ml) 1 st Phase (μu / m 200 150 100 50 0 P < 0.05 Hannon, Arslanian et al. Ped Res What Test? Criteria for the Diagnosis of Diabetes Fasting Plasma Glucose (FPG) is the ADA recommended screening test faster easier to perform acceptable to patients less expensive NOT the most sensitive makes it controversial OGTT may be necessary for the diagnosis of diabetes when the fasting glucose tolerance is normal Diabetes Care 2000, 23:381-389. Normoglycemia FPG <100 mg/dl OGTT 2 h PG <140 mg/dl IFG or IGT FPG 100-125125 mg/dl (IFG) OGTT 2 h PG 140-199199 mg/dl (IGT) Diabetes FPG 126 mg/dl OGTT 2 h PG 200 mg/dl Symptoms + random PG 200 mg/dl What are the Treatment Options for the Overweight Child? Maintain normal growth and development; emphasize health For most, the first goal is weight maintenance Long-term weight goal BMI below the 85 th %ile If weight loss desired, should be slow Starting goal may be as little as 1 lb per month Improvement in lipid profile, blood pressure Steps toward Success Increased Consumption of Fruits and Vegetables 77% of Adults Consume <5 Servings of fruits and vegetables per day (from the CDC) Turn off the television Be active together from MyPyramid.gov Eat meals together 5
Reduce Added Sugars Food Categories % of Total Added Sugars Consumed Regular pop 33.0 Sugars and candy 16.1 1 Cakes, cookies, pies 12.9 Fruit drinks 9.7 Dairy desserts and milk products 8.6 Other grains 5.8 Guthrie and Morton, Journal of the American Dietetic Association, 2000. Predictors of Treatment Response Family motivation Parental support not Food Police Patient motivation Magnitude of changes in the lifestyle of the family and individual Treatment: Family-Based, Behavioral Oriented Lifestyle Modification Medical Nutritional Therapy Registered dietician / Wellness Advisor Physical Activity Exercise physiologist / Wellness Advisor Behavior Modification Behavioral psychologist Set Family-Oriented Goals Set Patient-Oriented Goals if Appropriate Treatment: Motivational Interviewing What is MI? A clinical method used when a person needs to make a behavior or lifestyle change and is reluctant or ambivalent about doing so A collaborative, person-centered form of guiding to elicit and strengthen motivation for change (Miller WR, Rollnick S. Behavioural and Cognitive Psychotherapy 37:129-140, 2009) Direct vs. Guide vs. Follow MI Research Evidence Significant support for efficacy of MI across studies Average effect size of 0.77 following treatment Average effect size of 0.30 at follow-up of one year MI at the beginning of treatment led to sustained outcome improvements Outcomes better when no manual used (effect size = 0.65 vs. 0.37; NOTE: both are significant effect sizes) Enlighten, shepherd, encourage, motivate, support, lay before, look after, support, take along, accompany, awaken, promote autonomy, elicit solutions Manualized treatment combining MI with empiricallyvalidated theoretical orientations is efficacious 6
10 Things that Are MI 1. Conversation about change, generally about behavior change 2. Toward the purpose of eliciting and strengthening motivation 3. Collaborative 4. Centered on the person and honoring autonomy 5. Evocative: asks for the person s own motivation for change 6. Uses particular skills in particular ways 7. Goal oriented: moving toward a particular change goal 8. Keyed to patient language: elicits and strengthens change talk 9. Responds to change talk 10. Responds to sustain talk in a specific, non- confrontational way Miller and Rollnick, ICMI 2010; What Makes it MI? What MI Is NOT The Ineffective Physician i The Righting Reflex We may think... 41 What is it? The natural inclination we have to make it better for another person What s the danger? We tell the other person what to do, how to do it, and why they should do it without talking to them and learning what they think It often creates resistance on the part of the patient. What to do when you find yourself doing this? Stop and Reset Ms. Smith, I realize I have been just lecturing you on how you should make better food choices without learning what you are thinking OR I understand this isn t a priority for you right now. 42 They don t see (denial, lack insight, etc.) They don t want to see They don t know They don t know how They don t care 7
We may try to Give them Insight - if you can just make people see, then they will change Give them Knowledge - if people just know enough, then they will change Give them Skills - if you can just teach people how to change, then they will do it Give them Hell - if you can just make people feel bad or afraid enough, they will change What Happens? 43 44 Core MI Principles The Effective Physician i Resist the righting reflex ( roll with resistance ) I just don t think I have time for all these changes right now. You feel overwhelmed by all of this, and you re wondering what changes can fit into your life. Understand your Patient s motivation While the thought of making all these changes is overwhelming, when you think about how good you could feel, it s energizing. Listen to your Patient I hear what you re saying. Losing weight is really hard and you are concerned about not being successful. Empower your Patient More than ever, you are ready to make a commitment to yourself. When you have made similar commitments in the past, you have succeeded. Learning MI 1) Spirit of MI 2) Patient centered counseling skills (OARS) 3) Recognizing and reinforcing change talk 4) Eliciting and strengthening change talk 5) Rolling with resistance 6) Negotiating change plans 7) Solidifying Patient commitment 8) Shifting flexibly between MI and other intervention styles 4 Processes of Motivational Interviewing 1. Engaging: listening to understand the dilemma, use of OARS 2. Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, use of information and advice 3. Evoking: selective eliciting, selective responding, selective summaries toward change talk 4. Planning: moving to a change plan and obtaining commitment 47 Miller & Moyers: 8 stages of learning MI 8
Communication Skills Open-ended Questions to Promote Change Ask - Open-ended questions What would you like to do for you and your baby s health? Listen - Reflectively and with purpose Changing lifestyle habits takes time and commitment. You are prepared to make the effort for the benefit of yourself and your children. Inform - With permission and choices I have some suggestions that might be helpful, would you like to hear them? Disadvantages of the Status Quo How do you feel about smoking? Advantages of Change What would the benefits be for you, if you were to quit smoking? Optimism for Change What makes you feel that now is a good time to try something different? Intention to Change What would you like to see happen? How might things be different for you, if you did make a change? Reflections Why Reflections? State hypothesis about the patient s experience Patient: I ve tried to lose weight many times before. I don t see what good trying again will do. Provider: Making the attempt seems like a waste of time. There are things that made past attempts unsuccessful and you re wondering how it s going to be different this time. Openings: You re feeling like It sounds like you You re wondering if Reflections clarify that you are understanding Reflections serve as an invitation for the participant to respond and set the direction for the conversation In conversations, reflections are shown to generate more patient talk about change Focusing on reflections keeps you from getting caught in asking a series of questions and shifting the balance from collaboration to being in charge Reflections are a great tool for addressing resistance Desire: Ability: Reasons: Need: Talk about Change I want to go back to school and work my way toward a good job. I can do this if I get some more support on my side. Hanging out with him and his friends gets me in trouble. I know that using drugs is not good for my baby. I need to get my blood sugar under control! My family worries about me so much; it is not fair to them. Commitment: I plan to make a schedule for my blood sugar checks and my meals. Brief MI Intervention Myths in the Medical Setting MI is viewed as time intensive MI is viewed as allowing the patient to talk and take over the session MI is viewed as counter to the role of the medical professional to be in charge and give advice MI is viewed as a therapy 9
Brief MI Intervention FRAMES Personalized Feedback Responsibility Advice Menu of Options Empathy Self Efficacy Brief MI Intervention Goals of the intervention Change the way we see, understand, or feel about a particular risk factor or behavior Should empower individuals to take action Support the natural process of change Cannot adequately meet the needs of all individuals who need help in initiating or stopping health behaviors Pharmacologic Therapy Pharmacologic Therapy Few trials have evaluated drugs for obesity in children Orlistat Lipase inhibitor that inhibits dietary fat absorption For use in adolescents 12 years Poor compliance rates Sibutramine Norepinephrine, serotonin, and dopamine re-uptake inhibitor For use in adolescents 16 years Behavioral Therapy + Sibutramine vs Behavioral Therapy +Placebo Limitations of the Sibutramine Study MI, kg/m 2 Mean Change in B N = 498 N = 368 Berkowitz RI et al. Annals of Internal Medicine.2006 Only 12 months No long-term safety or efficacy data Cardiovascular side-effects effects Tachycardia Higher blood pressures 30% drop-out out rate 10
Surgical Therapy Bariatric Surgery Not routinely indicated for growing children May be indicated for children with extreme and morbid obesity that is life-threatening Complications of Treatment More Study is Needed Psychiatric disorders Depression Disordered Eating Substance Abuse Gallstones Conclusions Obesity continues to increase in children. Obesity is centrally related to younger age of onset of T2DM and CVD. Complications of obesity have profound societal implications. Conference Evaluation Online evaluations at: www.pacnp.org/conference Screening and treatment modalities need further study. 11