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Pediatric Weight Management

Susan Jacobsen, MPH, PT

University of Minnesota Masonic Children’s Hospital

sjacobs2@Fairview.org

Assistance from Nicole Hybben, PT, DPT; Sara Dooley, PT; Norrie McKnight, PT, DPT

Learning Objectives

1. Define childhood obesity and the differences between the overweight , obese and severely obese

2. Overview on prevalence of childhood obesity

3. Etiology of childhood obesity

4. Identify co-morbidities of childhood obesity and common lab values

5. Describe the important components in the Pediatric Weight Management Physical Therapy Evaluation for this population

6. Describe standardized tests useful in this population

7. Describe the literature support for this patient’s population for gross motor/functional performance impairments

8. Common PT diagnoses utilized and clinical impression comments to indicate need for service

9. Use of motivational interviewing to assist in goal setting

10. Physical therapy treatment and research support

11. Identify community resources

12. Identify clinics, their providers and roles within the University of Minnesota Health System

CHILDHOOD OBESITY DEFINED

Definitions16

• Overweight: refers to excess body weight

• Obese: refers to excess of fat

• Body Mass Index(BMI): provides a guideline for weight in relation to height – Body Weight (kilograms)/Height (meters)2

– Accepted standard to measure overweight and obese in children greater than or equal to 2 years of age

– Separate growth charts for boys and girls

BMI Categories16

• Underweight – BMI <5th percentile for age and sex

• Normal weight – BMI between the 5th and 84th percentile for age and sex

• Overweight – BMI between the 85th and 95th percentile for age and sex

• Obese – BMI ≥95th percentile for age and sex • Severe obesity – BMI ≥120 percent of the 95th

percentile values, or a BMI ≥35 kg/m2 (about the 99th percentile)

CHILDHOOD OBESITY PREVALENCE

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Prevalence5,16

• Nearly 1/3 of all children in the US are overweight or obese.

– Overweight or obese (BMI ≥85th percentile)

• 26.7 percent of preschool children (2 to 5 years) 32.6 percent of school-aged children (6 to 11 years) 33.6 percent of adolescents (12 to 19 years)

• According to the Center for Disease Control, 17% of all children aged 2 – 19 years are obese; this has almost tripled since the 1980s.

ETIOLOGY OF CHILDHOOD OBESITY

Environmental Factors16

• Sedentary lifestyle

• High sugar sweetened beverages

• Screen time – Television viewing at ≥5 years was

independently associated with increased BMI at age 26 to 30 years in 2 longitudinal cohort studies

• Large portions of food

• Decreased family presence at meal times

• Fast food frequency

• Availability of safe and structured places to do activity (playgrounds, sidewalks)

• Low income household

• Sleep patterns

Genetic Factors16, 22

• Race – more common in American Indian, non-

Hispanic blacks, and Mexican Americans than in non-Hispanic whites

• Obese parent – Increases child’s risk by 2-3 times

• Metabolic programming – Increasing evidence linking environmental

and nutritional influences during critical developmental periods

• Genetic or endocrine syndromes – Account for <1% of the obese population

– Prader-Willi Syndrome

– Cushing’s Syndrome

– Hypothyroidism

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COMORBIDITIES AND ASSOCIATED LAB VALUES

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Cardiovascular Related17

• Hypertension – Normal BP – Both systolic and diastolic BP <90th percentile.

– Prehypertension – Systolic and/or diastolic BP ≥90th percentile but <95th percentile, or if in adolescents the BP exceeds 120/80 mmHg even if <90th percentile.

– Hypertension –systolic and/or diastolic BP ≥95th percentile measured on three or more occasions. The degree of HTN is further delineated by the two following stages:

• Stage 1 hypertension – Systolic and/or diastolic BP between the 95th percentile and 5 mmHg above the 99th percentile or if in adolescents the BP exceeds 140/90 mmHg even <95th percentile.

• Stage 2 hypertension – Systolic and/or diastolic BP ≥99th percentile plus 5 mmHg.

Cardiovascular contd.17, 28

• Dyslipidemia – Occurs in those children and adolescents typically with central fat distribution

and increased adiposity (measured by triceps skin fold thickness >85%ile)

– Fasting Lipid Panel Abnormal Results for children and adolescents

• Low density lipoprotein cholesterol (LDL-C) ≥ 110

• High density lipoprotein cholesterol (HDL-C) < 45

• Triglycerides 0-9 years > 75

• Triglycerides 10-19 years > 90

• Cardiac Structure and Function – Obesity has been shown to be associated with increased left ventricular mass,

increased left atrial and left ventricular diameter, greater epicardial fat, and systolic and diastolic dysfunction.

– Growing evidence for link between childhood obesity and adult coronary artery disease.

Pulmonary Related15

• Obstructive sleep apnea

– Diagnosed via a sleep study

– “complete obstruction of the upper airway during sleep and cessation of air movement despite ongoing respiratory effort”

• Exercise intolerance

– In combination with cardiovascular related effects of childhood obesity

– Symptoms can include shortness of breath, dizziness, light headedness, nausea, chest pain or tightness, heart palpitations

Gastrointestinal Related3,16

• Non-alcoholic fatty liver disease

– Pathogenesis not fully understood, but support for strong association of obesity

and insulin resistance

– Highest rate in Hispanic male adolescents

– Laboratory diagnosis with elevated ALT and AST (liver transaminases)

– Common symptoms, though can be asymptomatic:

• right upper quadrant pain, hepatomegaly or nonspecific abdominal

discomfort, weakness, fatigue or malaise

– Weight loss through diet and aerobic exercise is currently the mainstay of

treatment with positive results published

• Cholelithiasis (gall stones)

– Increased risk with increasing BMI and girls>boys

– Common symptoms:

• Right upper quadrant pain, epigastric pain, jaundice, nausea, intolerance to

fatty foods, vomiting

– Early recognition is important for successful management

Endocrine Related27

• Impaired glucose tolerance and insulin resistance

– Approximately 40% of children and adolescents with Diabetes Mellitus Type 2 (T2DM) are asymptomatic. • Symptoms of hyperglycemia: polydipsia, polyuria, nocturia

• American Diabetes Association has guidelines on when to screen based on risk factors (see next slide)

– Pre-Diabetes: • Fasting plasma glucose 100-125mg/dL

• Hemoglobin A1C (HbA1C) 5.7-6.4 percent

– T2DM • Fasting plasma glucose ≥ 126mg/dL on 2 separate occasions

• Hemoglobin A1C (HbA1C) ≥ 6.5 percent on 2 separate occasions

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Musculoskeletal Co-Morbidities11,29,30

• Increased fracture risk

– Proposed mechanisms

• Inactivity leading to decreased proprioception and poor balance

• Childhood obesity has been linked with a lower relative bone mass and reduced area

when corrected for the effects of age and size during maturation

• Blount Disease or Tibia Varum

– Abnormal growth from the medial part of the proximal tibia thought to be due to

excessive compressive forces on the medial compartment of the knee causing

growth inhibition

• Infantile or adolescent onset

» Infantile onset between 2 and 4 years of age

» More common in African American race

• Associated with increased weight and severe obesity; though in a low percentage of the

population so proposed mechanism of cause likely is not the only present

• Bracing or surgery recommended once diagnosed; as deformity will continue to worsen

Musculoskeletal Co-Morbidities Contd11, 29, 30

• Slipped Capital Femoral Epiphysis (SCFE) – Proximal femoral metaphysis separates from the epiphysis of the femoral head

– Typically between 11 and 15 years of age during largest growth

– Diagnosed via x-ray after patient complains of chronic hip, knee or thigh pain

– Insidious onset of pain

– Childhood obesity creates a favorable environment for SCFE

• Decreased femoral anteversion in obese children compared to normal weight

children, which increases the shear component on the capital femoral growth plate

• Joint pain

• Lower extremity mal-alignment

– I.E. Genu valgum, genu varum, pes planus

PHYSICAL THERAPY EVALUATION

Subjective

• Medical History

– Note any above comorbidities

• Patient/Family Goals

• Exercise History

– Include if has gym memberships or if anyone else in the house gets regular exercise, past success or failures, gym at school, organized sports, frequent falls

• Barriers to Exercise

– Examples: Time, lack of access to safe areas, motivation (internal and external), knowledge of what to do, fatigue(overly tired during the day)

• Hours of screen time

• Other:

– Likes and dislikes of activity

Physiological Measurements

Vital Signs

• Listed under Cardiopulmonary section of evaluation

• Resting Heart Rate

• Resting Blood Pressure – A percentile will be listed for both systolic

and diastolic based on their age in their MD note from Pediatric Weight Management Clinic

• Resting Oxygen Saturations

• Rating of Perceived Exertion with activity – 0-10

– Borg’s Scale 6-20

Body Composition Measures

• BMI – Weight

(kilograms)/height(meters)2

• Waist Circumference20 – Measured at the level of the

iliac crest going from right to left, in standing, tape parallel to the floor • Not recommended BMI>35 as

it loses it’s predictive power to predict disease risk

• No identified norms for children/adolescents

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Normal Ranges for Vitals

Age Heart Rate

(beats/min)

Blood Pressure (mm

Hg)

Respiratory Rate

(breaths/min)

1-3 yr 70-110 90-105/55-70 20-30

3-6 yr 65-110 95-110/60-75 20-25

6-12 yr 60-95 100-120/60-75 14/22

12 * yr 55-85 110-135/65-85 12-18

2, 32

Physiological Measurements Cont.…

• Pain

– Joint(s)

– Onset

– Duration

– Exacerbating conditions

– Relieving conditions

• Pain in childhood obesity 11,29,30

• Back and knee pain are the most common reported in children overweight and

obese

• Pain is likely due to chronic poor musculoskeletal alignment and/or poor posture

combined with muscle weakness, hyper mobility and/or hypo mobility and

inactivity

• Since SCFE has insidious onset of hip, knee or thigh pain; may benefit from x-ray to

rule out as differential diagnosis

Postural Assessment11,29,30

• Note any postural impairments and joint misalignments

– Genu Valgum

• Increasing research connecting obesity and genu valgum

• Theory thought to be due to increased weight causing compression at the lateral distal femoral physis leading to diminished lateral growth and progressive deformity

– Pes planus or flat feet

• Limited research in this area

• Largely utilizing indirect measures of the medial longitudinal arch via footprints (electronic and ink) which can be distorted with increased adiposity vs a true collapse of the medial longitudinal arch

• Some research supporting increased dynamic peak pressures under the forefoot and mid-foot of obese children placing them at risk for foot pathology in the future

– Other postural impairments typically seen:

• Forward head

• Rounded shoulders

• Knee hyperextension

• Increased anterior pelvic tilt in static stance

Strength Assessment • Manual muscle testing

• Gross strength through functional movements

– Squat to stand

• Comment on knee control, range able to move through and any need for assistance

– 30 second sit-stand test

• Count the number of times the patient is able to move from a sitting to standing position

• Useful when patient is unable to do a sit-up or push-up

– 30 second push-up test

• Count the number of times able to perform a full or knee-push-up in 30 seconds

– Comment if unable to use correct posture indicated in Bruininks-Oseretsky

Test of Motor Proficiency – 2nd Edition

– 30 second sit-up test

• Count the number of times able to perform a sit-up in 30 seconds

– Comment if unable to use correct posture indicated in Bruininks-Oseretsky

Test of Motor Proficiency – 2nd Edition

– Standing long jump (2 foot take off and landing)

• Measure distance in inches

Balance Assessment

• Single limb stance

• Rhomberg test

• Lower extremity functional reach test:

– Useful when patient has a painful or injured limb

– Measure leg length from greater trochanter to lateral malleoli

– Reach one leg forward, lateral and back as far as possible without touching ground, repeat on other leg

• Divide farthest length by leg length and get a percentage of leg length – Anterior Reach: Normal: ≥ 80% leg length, Good: 70-79%, Fair: 65-69%, Poor: <65%

– Lateral Reach: Normal ≥ 100% leg length, Good: 90-99%, Fair: 80-89%, Poor <80%

– Posterior Reach: Normal ≥ 110%, Good: 95-109%, Fair: 94-85%, Poor: <85%

Cardiopulmonary Assessment

• 2 and 6 minute walk test

– Distance

– Monitor HR throughout

– No norms available, however Geiger et al10 has the largest group assessed using a “modified 6- minute walk test” where the individual will push the measuring wheel

• Modified Energy Expenditure Index (Modified EEI) (Haley et al)

– HR recorded at the end of walking 3 minutes in a 50 meter course, which is called “Working Heart Rate” (WHR)

– WHR/(Distance (meters)/3min)

– Ages 5-16 and >16 (N=150)

– This is nice for youth that cannot tolerate a full 6 minute walk test

– Adds additional information for youth that complete a full 6 minute walk test

Modified 6MWT Distance in Children

(Geiger et al)

Age Male (meters) Female (meters)

3-5 yrs 536.5 (95.6) 501.9 (90.2)

6-8 yrs 577.8 (56.1) 573.2 (69.2)

9-11 yrs 672.8 (61.6) 661.9 (56.7)

12-15 yrs 697.8 (74.7) 663.0 (50.8)

16-18 yrs 725.8 (61.2) 664.3 (49.5)

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Gross Motor and Functional Skill Assessment

• Transfers • Floor to/from standing through ½ kneel

– Comment on knee control and any need for assistance

• Gait • Running

– Comment on time from 50 meter shuttle run if completed during BOT-2 testing

– Alternative: 30 foot shuttle run (Haley et al) • Ages 5-21 • Run between start and finish x 2 to retrieve 2 blocks

• Stairs • Jumping/Hopping

Other Functional Outcome Measures

• Timed Up and Down Stairs (Zaino et al) – 14 steps

– Ages 8-14; Average 8.1 seconds or 0.58 seconds/step

• Timed Up and Go (Zaino et al) – 3 meters (9ft 10in)

– Ages 8-14, Average 5.2 seconds

• Timed Floor to Stand (Haley et al) – Start seated in tailor sit

on floor, then ask child to get up from the floor, walk 3 meters, turn around and walk back to sit down where started in tailor sit.

– Ages 5-22 (N=150)

Standardized Tests

• Peabody Developmental Motor Scales – 2 (PDMS-2) – Ages Birth – 5 years

• Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition (BOT-2) – Ages 4-21

• Pediatric Evaluation of Disability Inventory (PEDI) – Up to developmental age of 7 year old

When to Use What Measure • Peabody

– Children ≤ 5 years of age with suspected gross motor delay or weakness in trunk or legs

• BOT-2 – Children over 5 years of age with suspected gross motor delay or weakness in trunk or legs

– Strength and Agility Composite most often utilized

– Later in plan of care after an improvement in skills that allows actual performance of the measure

• 6-Minute Walk test

– Suspected exercise intolerance

– Inability to complete BOT-2 or Peabody due to low level of skill

– Later in plan of care after pain is addressed to work towards a healthy level of aerobic activity without pain

• Modified Energy Expenditure Index – Suspected exercise intolerance

– Short attention span or very poor endurance of patient

• Other functional outcome measures

– As clinically indicated

– I.E. difficulty with floor to stand, decreased walking pace

Recommendations on Re-Assessment

• Developmental tests

– When clinically indicated to show progress

– Minimum of every 6 months

• 6-Minute and Modified Energy Expenditure Index

– When clinically indicated to show progress

– Minimum of every 3 months to monitor progress

• Other functional outcome measures

– When clinically indicated to show progress

– Minimum of once a month; but could be every week

RESEARCH ON GROSS MOTOR AND FUNCTIONAL IMPAIRMENTS IN CHILDHOOD OBESITY

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Functional Mobility Related23

• In 2006 Riddiford-Harland et al reported on the effects of obesity on upper and lower limb functional strength and power in children

– 2 groups of 43 children each, average age of 8 y • Categorized as obese (BMI average 24) and non-obese (BMI average 16)

– Obese children displayed significantly greater upper body strength through push and pull compared to non-obese group (p<0.05)

– Obese children had significantly impaired vertical jump, and standing long jump compared to non-obese group (p<0.05)

– Obese children spend significantly more time during all transfer phases of the chair rising task • Many had to perform a rocking motion backwards before transitioning to

standing

Gait Related13, 14, 26

– In 2009, Shultz et al reported on gait biomechanics in overweight children.

• 10 normal weight children compared to 10 overweight children with BMI>95%ile

• Overweight participants compared with the normal weight group had significantly greater sagittal, frontal and transverse plane peak joint moments at the hip, knee, and ankle at both self selected and fast walking speeds

– Increase risk of joint loading, skeletal malalignment and injury in overweight children

• When adjusted for weight, the ankle DF moment was greatest in the overweight group in both walking speeds

– Indicates need for larger braking mechanism during ambulation

Gross Motor Related19

• In 2011, Nervik et all reported on the relationship between obesity and gross motor development in children who are typically developing and determine whether BMI predicts gross motor skill difficulty.

– 50 children aged 3-5 years using the Peabody Developmental Motor Scales, 2nd Edition

• 24% were considered to be overweight or obese (12 kids)

– 58% of overweight or obese children scored below average on the PDMS-2 compared to the 15% of healthy weight children

– High BMI was associated with low gross motor skills identified by the PDMS-2 gross motor quotient (p<0.002)

• Indicates that as BMI increases, gross motor skills decline

Gross Motor Related Contd24

• In 2012, Roberts et al reported on the examination of the relationship between gross motor skill level and weight status in a large national representative sample of kindergarten-aged children

– 4650 children, mean age 5 years 6 months (31% classified as overweight or obese)

– Gross motor skill items were a combination from many developmental tests

– Children of healthy weight and overweight jumped further and hopped longer than children in obese category (P<0.05)

– Children in obese category had lower overall gross motor composite scores than children of healthy or overweight categories (P<0.05)

– Adds support to literature for lower gross motor skill level with higher weight categories

Gross Motor Related Contd21

• In 2013, Nunez-Gaunaurd et al reported on the comparison of motor proficiency, strength, endurance and physical activity among children from minority backgrounds who are healthy weight, overweight or obese.

– 86 children, aged 10-15, mostly Hispanic ethnicity (45% classified as overweight/obese)

– BOT-2 Short Form, Sit-to-stand(STS), Timed-Up and Down Stairs and 6-Minute Walk Test (6-MWT) completed

– Children of healthy weight had significantly higher standard scores on the BOT-2 short form compared to overweight and obese groups (P=0.003).

– Most children in the obese category (68.4%) scored less than 17% on BOT-2 short form indicating below-average performance, compared to 40% of overweight and 27% of healthy weight children.

– Negative correlations of BMI and BOT-2 short form, sit-to-stand and total abdominal curls (P<0.05 in all cases) with the overweight and obese groups

Research at UMMCH • Retrospective chart review of 35 individuals receiving PT as part of a multi-

disciplinary tertiary care pediatric weight management clinic • Initial and 6-month follow-up anthropometrics (height, weight, BMI, and

BMI percentile) and outcome measures were collected:

• BOT-2 Body Coordination percentile rank and standard score

• BOT-2 Strength and Agility percentile rank and standard score

• wall sit (sec) • broad jump (in) • number of sit-ups in 30 sec • number of push-ups in 30 sec

• Changes over 6 months were evaluated by paired t-tests. A repeated measures ANOVA was used to determine if changes in BOT-2 scores were observed after adjusting for change in BMI over 6 months.

Nicole M. Hybben, P.T., D.P.T., Justin R. Ryder, Ph.D., Susan Jacobsen, P.T., M.P.H., Sara Dooley, P.T.,C/N.D.T., Norrie McKnight, P.T., D.P.T., Aaron S. Kelly, Ph.D., Claudia K. Fox, M.D., M.P.H. (2015). Individualized Physical Therapy Within a Multi-disciplinary Pediatric Weight

Management Clinic Improves Gross Motor Function in Youth with Obesity. Annual Obesity Conference Poster.

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Results Change Clinical Characteristics and Gross Motor Function

Clinical Characteristics n Baseline 6 Month % Change P - Value

Height (cm) 35 148.2 ± 16.4 151.0 ± 16.4 1.9 <0.001

Weight (kg) 35 73.9 ± 26.6 75.0 ± 25.7 1.5 0.267

BMI (kg/m2) 35 32.7 ± 7.5 32.3 ± 7.1 -1.2 0.147

BMI-percentile (%) 35 98.9 ± 1.3 98.7 ± 1.4 -0.2 0.121

Gross Motor Function

BOT-2 Body Coordination (% rank) 7 7.7 ± 5.1 14.3 ± 10.6 85.7 0.04

BOT-2 Body Coordination (score) 7 34.7 ± 3.5 38.3 ± 4.5 10.4 0.001

BOT-2 Strength and Agility (% rank) 33 6.0 ± 5.4 15.5 ± 11.8 158.3 <0.001

BOT-2 Strength and Agility (score) 32 31.1 ± 8.7 38.4 ± 5.8 23.5 <0.001

Wall-Sit (sec) 15 15.8 ± 9.2 35.9 ± 17.4 127.2 <0.001

Broad Jump (in) 18 34.5 ± 7.8 39.6 ± 4.7 14.8 0.006

Number of sit-ups in 30 sec 11 3.5 ± 7.0 6.5 ± 8.1 85.7 0.041

Number of push-ups in 30 sec 10 1.2 ± 3.5 1.4 ± 3.3 16.7 0.575

Data are presented as mean ± SD

P - values for clinical characteristis were conducted via paired t-test

P - values for gross motor function were conducted via ANCOVA adjusting for change in BMI.

UMMCH Conclusions and Discussion

• These data suggest that individualized PT, as part of a multi-disciplinary pediatric weight management clinic, can improve gross motor function and strength independent of weight-loss in youth with obesity, though randomized controlled studies are needed to draw more definitive conclusions.

• It has been shown in longitudinal data that gross motor skill acquisition is inversely related to BMI, thus it can be hypothesized that early intervention with PT is key to stopping this cycle of further decline in age appropriate skills.

• Integration of individualized and targeted PT into pediatric weight management programs may improve gross motor function in youth with obesity.

PT DIAGNOSIS AND CLINICAL IMPRESSION EXAMPLES

Common PT Diagnoses

• Gross motor impairment

• R/L patellofemoral pain

• Impaired strength affecting LE alignment leading to pain (or placing at high risk for pain with initiation of activity)

• Impaired functional activity tolerance for age appropriate participation

• Mechanical low back pain

13 yo female, BMI 41.8

• R/L patellofemoral pain secondary to alignment, strength and range of motion impairments – ***is referred for a physical therapy evaluation and

treatment as indicated secondary to R knee pain and exercise intolerance, which limits her ability to safely exercise and participate in age appropriate activities. With current knee pain and her combined LE alignment, range of motion and strength impairments, she is at high risk for injury and ongoing pain if these are not addressed with skilled Physical Therapy Treatment and targeted home exercise program initiation.

7 yo male, BMI 30.83

• Impaired balance and activity tolerance affecting gross motor function – ***referred for a physical therapy evaluation and

treatment as indicated secondary to balance and endurance impairments, which limits his ability to safely participate in age appropriate activity. He had multiple falls and impaired static standing balance during the evaluation today indicating risk of future falls and injury. He also demonstrate poor endurance overall with frequent shortness of breath and elevated resting BP and HR. He will benefit from an OP PT episode to target his impairments and educate him and his family on an appropriate home exercise program that is safe and effective.

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9 yo male, BMI 29.73

• gross motor impairment secondary to strength, balance and endurance impairments – ***referred for a physical therapy evaluation and

treatment as indicated secondary to concerns for gross motor delay, which limits his ability to safely keep up with his age matched peers. *** demonstrates significant strength and balance impairments limiting his safety with all functional and gross motor activities. He is at high risk for injury. It is imperative that he initiate an outpatient physical therapy treatment episode of care to assist in providing interventions to target his impairments and initiation of a safe home exercise program.

16 yo female, BMI 47.49

• impaired gait and functional activity tolerance secondary to impaired LE alignment, strength impairment and elevated resting BP

– ***referred for a physical therapy evaluation and treatment as indicated secondary to exercise intolerance and inactivity, which limits her ability to safely participate in age appropriate activities and exercise to assist in weight loss. With her poor LE alignment, mild weakness and balance impairment combined with her inexperience with safe aerobic exercise, elevated resting BP and high BMI, she is at risk for cardiopulmonary exercise intolerance and orthopedic injury. It is recommended that she be followed by skilled outpatient physical therapy in the Pediatric Weight Management Clinic to appropriately grade exercise and teach her proper technique to initiate a successful and safe exercise program.

GOAL SETTING STRATEGIES

Motivational Interviewing8

• A guiding style of assisting a patient in behavioral

changes vs. a directive style

• Works best with patients in the Contemplation or

Preparation Phases of behavior change

– Contemplation: “I want to, but…”

– Preparation: starting to make a change

• With this style, you want the patient to express their

reasons for changing vs. the provider telling them

why they should change

Motivational Interviewing Examples8

• Open ended questions

• “On a scale of 0-10, with 0 as not important at all and 10 as extremely important, how important would you say it is for you to _____?”

– Instead of asking “why are you a “5” and not a “6”?”; Ask “why are you a “5” and not a “3”? Because it elicits positive talk, not negative.

• Exercise program history question

– Typical question:“Tell me how it went this week with your exercises?” Instead, try “Tell me about the positive things about your exercise program”.

– Instead of telling a patient when to fit their exercise program into their day, ask “how might you do this so it fits into your life?”

Open Ended Question Examples for Goal Setting8

• “Given all that we have discussed, what specific goals would you like to make?”

• “What changes are you willing to start today?”

• “May I offer some suggestions?”

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Motivational Interviewing Examples and Resources8

• http://www.apta.org/Podcasts/2012/11/27/BehaviorChange/

• http://www.apta.org/Podcasts/2012/12/21/BehaviorChange/

• http://www.kphealtheducation.org/roadmap/roadmap.html

• http://www.youtube.com/watch?v=URiKA7CKtfc

• http://www.motivationalinterview.org

TREATMENT OUTSIDE OF “TYPICAL PT TREATMENT”

Influence Environmental Changes31

• Family support – Activity programs that include the entire family

are more successful than those only targeting the child

• Screen time reduction – American Academy of Pediatrics recommends

only 1-2 hours of screen time daily

– By reducing screen time alone, children are more likely to become physically active • Start with reducing by 30 minutes a week

Break Barriers to Exercise

1. Time

2. Cost of Gym Membership

3. Motivation

4. Knowledge

Breaking Time Barrier

• Limit screen time (child, parent and family) • Take 10 minute activity breaks during homework for

better mental clarity • Encourage 10 minutes of activity before taking a nap

to re-assess real fatigue or boredom • Fit in PT home program exercises into daily routine,

i.e. wall sit or calf stretch while brushing teeth • Incorporate active movement during seated

games/puzzles/toy, i.e. bear walk, crab walk, jumping, scavenger hunt for pieces

• Encourage being in charge of walking dog daily

Breaking Cost Barrier

• Exercise does NOT need to be at a gym – There are low cost alternatives such as Boys and

Girls Clubs and YMCA membership reductions for families with low income

• Ask about parks and walking trails near home

• Be creative with exercise routines for indoor and outdoor – I.E. Empty water bottles filled with rocks/sand for

bowling, hula hoops, jump ropes, indoor olympics, etc

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Breaking Motivation Barrier31

• Set weekly or monthly short term goals that include 1-3 changes maximum with education provided on working towards their long term goal

• Use reward system such as a sticker chart – Reward cannot be food or money – More successful if parent-child activity or time spent

together such as going to a movie, musical, trip to a new park or farmer’s market

– Check into free events offered through local community center or YMCA

• Encourage a buddy system with a friend or family member

Breaking Knowledge Barrier

• Be creative

• Find out what they like – Do not give sit-ups, push-ups, run/walk intervals unless

appropriate for your home program and they like it

• Aerobic exercise for this population has 2 criteria – Fun

– Makes the child/adolescent breath hard

• A majority of families do not realize that their child needs 60 minutes of MODERATE INTESITY aerobic exercise daily as recommended by the Center for Disease Control and Prevention (CDC).

Ideas to get Started

• Skip instead of walking

• Red light green light to/from park

• Act out games

• Turn on the music and make up dance moves

• Pretend to be a super hero moving through the house saving the day picking up toys as they go

• Indoor or outdoor Olympics (make up own events)

• Jump rope or hula hoop

• Chase bubbles

• Balloon games

• Scavenger hunts indoor and outdoor timed

EXERCISE PROGRAMS IN RESEARCH

Fun and Fit (Gruenfeld, E.A. et al)12

• Developed in 2009 at North Shore Medical Center (NSMC) in Salem, MA

• Multifaceted program including behavioral intervention, cardiovascular exercise and games, strength training, relaxation and yoga and nutrition education

• Afterschool program 4 times a year – 8 weeks long and involve 2 sessions per week for

1.5 hours each

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Fun and Fit Program12

• Staff: RN director, coordinator, exercise physiologist, fitness specialist, lead facilitator and registered dietician

• Session includes:

– 1. Arts activity

– 2. Cardiovascular portion where participants use treadmill, elliptical, bike or rowing machine for 45 minutes with warm-up and cool-down

– 3. Participation in one of the following for 30 additional minutes: guided relaxation, yoga and meditation, nutrition education, strength training with weights, circuits, bands and exercise balls or exercise-related games

Fun and Fit Outcome Measures12

• Rockport Fitness Walking Test

• One minute sit-up test

• One minute squat test

• Maximum number of push-ups

• MET readings from cardiovascular machines

Fun and Fit Results and Conclusions12

• Improvement in all fitness measures was statistically significant

• No change in BMI percentile with both male and female groups combined – Female group did have a significant reduction in BMI

(p=0.04)

• Qualitative results obtained from a post narrative report – Improved self esteem, likely to change eating habits

post program, likely to increase activity in their lives post program

Treating Non-Alcoholic Fatty Liver Disease (NAFLD) (de Piano et al)7

• Background:

– Several studies have shown how increasing aerobic exercise on a regular basis can improve metabolic parameters associated with NAFLD

• Purpose:

– Compare the effects of 2 kinds of exercise in NAFLD obese adolescents (aerobic training (AT) + resistance training (RT), and AT alone) over 1 year of treatment

• Participants

– 58 obese adolescents who entered the Interdisciplinary Obesity Program of the Federal University of Sao Paulo, Paulista Medical School

• 15-19 years of age

• BMI 36.55 ± 4.6 kg/m2

• Split into 2 groups – With and without NAFLD

NAFLD Outcome Measures7

• BMI

• Fasting Lipid Panal

– Triglycerides

– HDL

– LDL

– VLDL

• Glycemia (blood sugar values)

• Liver enzymes

– ALT

– AST

• Abdominal ultrasound for visceral and subcutaneous fat tissue at rectus abdominus

NAFLD Program7

• All participants

– Once a week dietetic lessons

– Three day dietary record at initial and 12 months

– Once a week psychological intervention

• AT group

– Personalized aerobic training program including a 60 minute session 3 times a week under the

supervision of an exercise physiologist

• AT was on a treadmill or cycle ergometer

• AT + RT group

– 3 times a week program included 30 minutes of aerobic training and 30 minutes of resistance

training

• AT was running on a treadmill

• RT designed based on ACSM recommendations including all main muscle groups

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NAFLD Results7

AT Group

• Without NAFLD: – Significant improvements in

body mass, BMI and fat mass (kg)

• With NAFLD: – Same as above, plus

significant reduction in fat mass (%) and visceral fat

AT + RT Group

• Without NAFLD:

– Significant improvement in

body mass, BMI, fat mass (kg

and %), glycemia, total

cholesterol and LDL-cholesterol

• With NAFLD:

– Same as above plus a reduction

in subcutaneous fat

– Significantly lower levels of ALT

(liver enzyme) compared to AT

group with NAFLD

Influencing Cardiovascular Changes (Meyer et al)18

• Background:

– Child and adolescent obesity relates to early atherosclerosis and obesity-related

cardiovascular disease

• Purpose:

– Determine the effects of 6 months’ physical activity In obese children and adolescents

on FMD, IMT and obesity-related cardiovascular disease risk factors

• FMD: ultrasound evaluation of brachial artery flow mediated dilation (FMD)

• IMT: ultrasound evaluation of carotid artery intima-medial thickening (IMT)

• Impaired FMD is considered a key indicator of atherosclerotic disease

• Participants:

– Treatment group: 96 obese children with BMI >97%ile for German pediatric population

aged 11-16 years

– Control group: 35 children aged 12-16 years without any cardiovascular risk factors

– Randomly assigned to 6 months exercise or 6 months non-exercise

Meyer et al Outcome Measures18

• Body fat mass measure via bioelectrical impedance

• Resting blood pressure

• Modified Bruce protocol – cycling

• Echocardiogram and vascular measurements

• IMT (carotid artery intima-medial thickening)

• FMD (brachial artery flow mediated dilation)

Meyer et al Program18

• Exercise 3 times a week

– Monday: swimming and aqua aerobic training (60 minutes)

– Wednesday: sports games (90 minutes)

– Friday: walking (60 minutes)

– Supervised by coaches and physiotherapists

– Progressively intensified per participant tolerance

Meyer et al Results18

• Baseline: – Significant differences in cardiovascular risk factors at

baseline between obese and control groups

– Obese groups presented with significantly lowered FMD compared to control groups

• Post treatment: – Obese exercise group had significantly improved FMD

and IMT (indicating good vascular changes); in addition to significant reduction in body weight, waist/hip ratio, BP, insulin resistance, triglycerides and rise if physical fitness

High Intensity Intermittent Exercise (Sim, et al)25

• Background:

– Exercise has been shown to influence the concentration of a number of appetite-related hormones

and feelings of hunger and satiety.

– A recent study reported reduced ad-libitum energy intake at a lunch and dinner meal following a

bout of high intensity (75% of VO2 max) compared with a bout of low-intensity cycling (40% VO2

max) in obese adolescents.

– Prolonged and continuous high-intensity exercise may not be sustainable in a sedentary overweight

population.

• Purpose:

– Investigate the acute effects of high intensity intermittent exercise (HIIE) compared with continuous

moderate-intensity exercise of equicaloric cost on subsequent energy intake, appetite-related

hormones and perceptions of appetite in a group of sedentary, overweight men.

• Participants: 17 men with BMI 27.7 ± 1.6 kg/m2, 30 ± 8 years

– Baseline VO2 max 39.2 ± 4.8 ml/kgmin

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Sim et al Program25

• All participants completed 4 experimental trials using a randomized counterbalanced design; 30 minutes each – MC: continuous exercise performed at moderate intensity

(60% VO2max)

– HI: intermittent exercise consisting of alternating high and lower intensity at a ratio of 1:4 (60 sec at 100% VO2max: 240 sec at 50%VO2max)

– VHI: intermittent exercise consisting of alternating very-high and lower intensity efforts performed at a ratio of 1:4 (15 sec at 170% VO2 max: 60 sec at 32% VO2 max)

– CON: control trial involving supine rest

Sim et al Outcome Measures25

• Post-exercise ad-libitum energy intake

• Changes in plasma concentrations of appetite-related hormones following a standard caloric load and ratings of perceived appetite

Sim et al Results25

• Ad-libitum energy intake was lower after HI and VHI compared with CON (P<0.05)

– VHI was also lower than MC (P=0.028)

• Free living energy intake in the subsequent 38 hours remained less after VHI compared with CON and MC (P<0.05)

• Lower active ghrelin (P<0.05), higher blood lactate (P<0.014) and higher blood glucose (P<0.020) after VHI compared with all other trials

Take Home Points

• Supervised and structured exercise 2-3 times a week for 60-90 minutes can help influence positive changes to endurance, strength, liver enzymes, cardiovascular risk factors and self esteem

• Structured exercise on treadmills or cycle ergometers is not real life for many of our patients

• A good portion of our patients are not able to tolerate a full 60-90 minutes of continuous activity because of other impairments so we need to be able to help them reach this point for continued work towards a healthy lifestyle.

• Physical therapy treatment can assist in our youth’s transition to a safe and effective exercise program that can lead to a healthy lifestyle. They need to be functional and safe before starting in a community program.

COMMUNITY RESOURCES

• Boys and Girls Clubs

– Boys and Girls Clubs in Minneapolis/St. Paul

• Membership Fee: Small fee, assistance available if qualify, see website for more details

• Ages: 6-18

• Transportation: Some sites are designated school bus drop off sites; will need to pick your child up

• Summer hours available, see specific location for information

• Specific Classes (no extra cost): Lifetime Fitness Hour and Triple Play emphasis activity; as well as other organized sports

• Website: www.boysandgirls.org

• Big Brother, Big Sister

– Ages: 7-12

– Cost: free if accepted; Application Required

– Specific Program: Wellness for Life

– Website: www.bigstwincities.org

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YMCAs

• Membership fee varies

– Assistance to help cover partial fee for low income

• Free Kids and Family Group Exercise classes for members

– Examples: Kids/Family Water Exercise, Zumba Kids, Latin Hip Hop for Kids and Family, Bootcamp for Kids and Family

– Times vary

• Free programs for youth, varies by location for members

– HYPE (Healthy Youth Positively Engaged) for pre-teen and teen ages, Little Lotus Kids Yoga, Toddler Time

– Some are available for after work and school hours

• Many summer programs, day camps and overnight camps

– Cost variable

– Assistance available for some program fees for low income

• Watch for other free events for members, such as Healthy Kids Day

Health Powered Kids

• Make a free account at www.healthpoweredkids.org

• Created by Alina Health

• Great resource for schools with large group games and activities

• Lessons about all aspects of a healthy lifestyle

PROVIDERS AND CLINICS IN MINNESOTA HEALTH SYSTEM

Providers

• Medical Doctors and Nurse Practitioner – Claudia Fox, MD, MPH – Muna Sunni, MBBCh – Gail Turnburg, RN, CPNP

• Dieticians – Jessica Graumann, MS, RD, LD – Mindi Khan, MPH, RD, LD – Alisa Morley, MS, RD, LD

• Psychologist – Amy Gross, PhD, LP, BCBA-D

• Physical Therapists – Sara Dooley, PT, DPT – Norrie McKnight PT, DPT

• Nurse Coordinators – Allison Johnson – Discovery Clinic – Hilary Sigfrid – Maple Grove

Clinic Locations • Burnsville

– Specialty Clinic for Children - Burnsville 303 E Nicollet Blvd, Suite 372 Burnsville, MN 55337 952-892-2910

• Minneapolis – Pediatric Specialty Care Discovery Clinic

2512 Building Third Floor 2512 S. Seventh St. Minneapolis, MN 55454 612-365-6777

• Maple Grove – Pediatric Specialty Care – Fairview Maple Grove Medical Center

14500 99th Ave N Maple Grove, MN 55369 763-898-1000

• Saint Paul – University of Minnesota Physicians Pediatric Specialty Clinic - St. Paul

225 North Smith Ave Saint Paul, MN 55102 651-265-7575

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