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 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 Increases the specialists involved to Intervention 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
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
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 Increases the specialists involved to Intervention 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
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: Limitations : • Community Based • Limited connection to • Easily Accessible resources and ongoing • Established relationship with support families • Lack of standardization • Ability to initiate prevention • Lack of expertise measures
Community Team Members • Primary Care Provider • Practice Manager/Office Coordinator • Lifestyle Coach • Medical Assistant • Office Staff • Receptionist • Scheduler
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 R esist 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. U nderstand your patient’s motivation C: Making changes can be overwhelming, but when you think about how it could benefit your family, you feel encouraged. L isten to your patient C: I hear what you’re saying. You have some concerns about how to make these changes work for your family. E mpower your patient C: You are ready to commit to a healthier lifestyle. When you have made commitments in the past, you have been successful.
O A R S Open-ended questions Affirmation Reflection Summary
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?
Giving Information and Advice How NOT TO do it How TO do it • Without first asking • Get permission permission • Honor autonomy • “Wagging your finger” • Ask – Provide – Ask • In a moralistic or • For suggestions, offer warning voice several instead of one
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
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