Childrens Hospital of Pittsburgh Weight Management Center Ellen - - PowerPoint PPT Presentation

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

Historical Perspective of Childhood Obesity

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 2012.

• Similarly, the percentage of adolescents aged 12–

19 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.

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

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

WHO most recent map of adult obesity, 2015

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

A.A.P. Stages of Obesity Prevention and Treatment

Barlow SE and the Expert Committee. Pediatrics 2007;120;S164-S192

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

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.

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.

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

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

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%.

Treatment Options – Who, What, Where and When

– Who, What, Where and When

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

AAP Stages of Obesity Prevention and Treatment

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

Hospital Team Members

• Medical Provider: Endocrinologist, PA, NP
• Nurse: Cholestech, A1C
• Wellness Advisor: LDN
• Behavior Psychologist

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

• Primary Care Provider
• Practice Manager/Office Coordinator
• Lifestyle Coach
• Medical Assistant
• Office Staff
• Receptionist
• Scheduler

Community Team Members

Motivational Interviewing in the Clinical Setting

Collecting Information While Empowering the Family to Succeed

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

Motivational Interviewing is…

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

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

Four MI Principles

Resist the righting reflex

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.

Open-ended questions Affirmation Reflection Summary

O A R S

Communication Skills Ask 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?

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?

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

Giving Information and Advice

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?

A tool for collecting topics of concern for the family

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

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
• https://ihcw.aap.org/resources/Pages/default.

aspx

• Practice for motivational interviewing

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

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.

Lifestyle Modules

Family Education:

• 1. Teaching tools used
• 2. Age group specifics
• 3. Role Playing

Teaching Tools

Lifestyle Lessons

Patient Self- Assessment

Tools

• Elicit ideas from the

patient for healthier drink

• ptions:

“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?”

Education

Goals

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.

Limit “occasional” foods to 1 serving/day

Tip Sheets

• 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
• 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

Additional Tip sheets for, Healthy Eating Habits

• Lifestyle Log
• Eat the Colors of the

Rainbow

• Feeding Guide Log for

Children

• Get Moving! Action Chart

Tracking Tools

56

Shop for the Colors of the Rainbow!

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

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

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

Age Group Specifics

Elementary:

• Picky eating can be a learned behavior
• Make only one meal
• Takes at least 15-20 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?

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

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

Age Group Specifics

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

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

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.

Role Play

Scenario # 1: Jake

• 12 yr old, male
• Height: 64 inches
• Weight: 183.5 lbs
• BMI: 31.5 (98th percentile)
• 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

Scenario # 2: Claire

• 14 year old, female
• BMI percentile: 99th
• 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

Case Study 3: Betty

• 13 year old, female
• Prior success in a structured pediatric weight

management program

• BMI percentile: 85th
• 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

Prevention

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 lower- income families

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.

There may be a correlation between education and poverty

Environmental factors fueling this epidemic

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.

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 community-

scale 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

• f obesity.

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.

Increasing portion sizes

• Research shows that children eat more

without realizing it if they are served larger portions.

School Lunch Programs

School Breakfast Programs

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 85th%tile may be

referred up to 18 years of age.

• Family may call 412-692-5200 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.

Thank you for your interest.