Science to Clinical Practice

S H A R I BA R K I N , M D, M S H S

P R O F ES S OR O F P E D I AT R I CS

W I L L I A M K WA R R E N FO U N DAT I ON C H A I R I N M E D I C I N E

VA N D E R B I LT U N I V ERS I T Y M E D I C A L C E N T E R

F E B R UA RY 2 7 , 2 0 1 5

Science to Clinical Application: Pregnancy (1) Science Potential Application How

Offspring exposed to both under- and over-nourished mothers have similar metabolic dysfunction, including obesity, insulin and leptin resistance Moderate exercise during pregnancy can mitigate the development of metabolic dysfunction

1. Set clear balanced nutritional patterns early in life, to maintain during pregnancy, reinforced consistently in clinical settings prior to pregnancy and during pregnancy

2. Encourage mild- moderate exercise daily

Link to clinical counseling in multiple settings (OB and Pediatric clinic visits) Making 30 minute exercise/play a common recommendation offered as part of the clinic visit

Pregnancy Interventions Education during pregnancy about nutrition and physical activity

Vary in approach: group versus individualized sessions ; health

coaching phone calls

Vary in dose and timing

Vary in outcome measures

Vary in populations

The Behaviors Affecting Baby and You (B.A.B.Y.) Study

110 prenatal care patients (60% Hispanic) randomized to 12 week exercise intervention arm versus health and wellness arm during the second trimester Matched physical activity goal to stage of motivational readiness (precontemplation, contemplation,

preparation, action, and maintenance)

Goal to increase time spent in moderate activity by 10% each week, ultimate goal of 30 minutes of moderate intensity on 5 or more days, achieving this in short bouts of 10 minute episodes.

One face-to-face visit, weekly mailed surveys and individually tailored reports

12 weekly telephone calls providing motivationally based individualized feedback.

Pregnancy Physical Activity Questionnaire (PPAQ)

Results: Exercise arm experienced smaller decrease (-1.0 MET) in total activity vs control arm (-10 MET)

Lisa Chasan-Taber, Marushka Silveira, Bess H. Marcus, Barry Braun, Edward Stanek, and Glenn Markenson. "Feasibility and Efficacy of a Physical Activity Intervention Among Pregnant Women: The Behaviors Affecting Baby and You (B.A.B.Y.) Study" Journal of Physical Activity and Health 8(Suppl 2) (2011): S228-S238.

Centering Pregnancy® National model of group prenatal care Adult learning theories that highlight the importance of group work and participatory process

Groups of 8-12 pregnant women at similar gestational ages meet 10 times over six months, facilitated by Nurse Practitioner or Midwife.

2 hour sessions Health and nutrition

Stress reduction

Relationships

Parenting

Participation defined as even one group session

47% reduction in preterm birth (7.9% versus 12.7%)

Picklesimer AH, Billings D, Hale N, et al. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population.Am J Obstet Gynecol 2012;206:415.e1-7.; Rising SS, Kennedy HP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health 2004;49: 398-404.

Information received during prenatal visits: group comparisons

Recalled receiving information on:

CPa n=106 n (%)

PEa n=619 n (%)

p-value

Appropriate amount of weight gain

89 (84.0) 473 (76.4) 0.085

Exercise or active living during pregnancy

83 (78.3) 434 (70.1) 0.085

Nutrition 92 (86.8) 453 (73.2) 0.003

Taking vitamins or mineral supplements

92 (86.8) 543 (87.7) 0.789

Taking prescription or non-prescription drugs

75 (70.8) 430 (69.5) 0.790

Alcohol consumption during pregnancy

77 (72.6) 350 (56.5) 0.002

Cigarette smoking and second hand smoke

71 (67.0) 299 (48.3) <0.001

Working during pregnancy 65 (61.3) 343 (55.4) 0.257

a CP= CenteringPregnancy®; PE=Prenatal Education (plus individual prenatal care)

Benediktsson et al. BMC Pregnancy and Childbirth 2013 13(Suppl 1):S5 doi:10.1186/1471-2393-13-S1-S5

Science to Clinical Application: Pregnancy (2)

Science Potential Application How

Maternal excess gestational weight gain interacts with pre-pregnancy weight to alter early infant growth trajectories

1. Set clear goals for appropriate weight gain during pregnancy

2. Appropriate weight loss after pregnancy

Utilize group visits and/or health coaches during pregnancy and after pregnancy Linking to effective community weight loss programs

Excess Gestational Weight Gain In 2009, Institute of Medicine revised recommendations for weight gain during pregnancy.

Pre-Pregnancy BMI

BMI (kg/m2) Recommended

Weight Gain (lbs)

Underweight <18.5 28-40

Normal Weight 18.5-24.9 28-40

Overweight 25.0-29.9 15-25

Obese ≥ 30.0 11-20

Institute of Medicine, 2009 8

9

Infant Growth Trajectory Mothers who are

Obese prior to pregnancy and Excess Gestational Weight Gain

Mothers who are Overweight prior to pregnancy and Excess Gestational Weight Gain

13% Difference in Weight/Length At 3 months of Age (p<0.001)

Overall Model: p<0.001

Heerman WJ, Bian A, Shintani A, Barkin SL. Interaction between maternal prepregnancy body mass index and gestational weight gain shapes infant growth. Acad Pediatr. 2014;14(5):463-70.

Practice-based Opportunities for Weight Reduction (POWER trial) Six primary care practices in Baltimore, 415 obese patients, mean age 54, mean BMI 36.6, 41% African-American, 64% women.

Three conditions: 1) Self-directed weight loss control group; 2) Remote support only (health coaches from Healthways); 3) In-person support (group and individual face-to-face sessions) as well as health coaching).

Control Remote In-Person

Average weight loss in pounds at 24 months

1.8 10.1 11.2

Lost at least 5% of body weight

19% 38% 41%

Appel LJ et al. Comparative effectiveness of weight-loss interventions in clinical practice. NEJM. 2011.

POWER dose and duration Dose delivery Duration Content Dose receipt

Control Met with a coach at baseline, and if desired at the end of yrs 1 and 2

Received brochures and recommendations

Remote

Phone call coaching

12 weekly sessions; then monthly calls for study duration

Refer to below Median number of calls: 14 in 6 months, 16 for18 months

In-person plus

Group sessions (90 min) Individual sessions (20 min Phone call coaching

Weekly contact for 12 weeks; 3 monthly contacts; then 2 monthly contacts for the study duration

Behavioral theory and strategies, basic nutrition and exercise guidelines, motivational interviewing, use of the web site.

Median number of group sessions: 6.5 in 6 months, 1 in the next 18 months; Median number of individual sessions: 4 in 6 months, 1 in 18 months; Median number of calls 5.

The POWER trial and the role of the provider

Partnering effective health coaching programs with primary care providers

Refer patients to effective programs, and provide endorsement

Provide patient accountability

“Cheerlead” patient effort during visits

Provide a limited role in weight management

Maintain long-term trusted relationship

Bennett WL, et al Insights form the POWER practice-based weight loss trial: a focus group study on PCP’s role in weight management. J. Gen Intern Med. 2014.

Science to Clinical Application: Infancy Science Potential Application How

Maternal poor nutrition during pregnancy with rapid infant catch-up growth leads to offspring increased adiposity, hyperphagia, and hyperinsulinemia

1. Promote infant appetite regulation 2.Change the pediatric paradigm for catch-up growth, slowing down weight velocity in early infancy

Train providers to discuss recognizing satiety cues consistently with parents; Re-assess expectations of early growth for providers and parents

Rothman R, Yin S, Perrin E, Sanders L, Barkin S ; Funding: NIH/NICHD R01 HD049794; NIH/NCATS U54 RR023499

Slowing Early Infant Weight Velocity

The Slimtime intervention included two nurse home visits (2-3 weeks after birth, after introduction of solids). The first intervention instructed parents on identifying hunger versus other needs and taught skills in soothing; the second intervention taught parents about hunger and satiety cues, as well as skills to handle infant rejection of healthy food through repeated exposure.

160 mother-newborn dyads were randomized to one of four treatment groups, receiving 0,1,or 2 interventions. Those dyads receiving both interventions had lower weight-for-length percentiles versus receiving just one of the interventions or no interventions.

Paul, I, Savage J, Birch L, et al.

Preventing Obesity during Infancy: A Pilot Study. Obesity. 2011.

Science to Clinical Application: Toddler Science Potential Application How

Toddlers imitate the world around them including how they eat and play

Toddler self-regulation Setting normative habits in nutrition and physical activity

1. Link patients with community-based programs

2. Include families and set family goals (rather than child only) utilizing the parents as partners rather than only as agents of change

3. Utilize social networks to reinforce healthy habits

Salud con la Familia (Health with the Family)

•Goal: To examine a family-based, community centered intervention to prevent/treat obesity for Latino parent-preschool child pairs.

•Enrolled 106 Latino parent- preschool child dyads in 12 week skills building sessions for both parent and child nutrition, physical activity, and use of their built environment.

Funders: State of Tennessee; Vanderbilt Institute of Clinical

and Translational Research; 2008-2010

Results: Weight trajectory change over time

41% of Latino preschoolers already overweight

Those that participated in the intervention group were 2x as likely to change their weight category to normal

Those in the control group increased their BMI.

Barkin, SL, Gesell, S, Poe, E, Escarfuller, J, Tempesti, T. Culturally Tailored, Family-Centered, Behavioral Obesity Intervention for Latino -American Preschoolers, Pediatrics 2012 Sep;130(3):445-56. doi: 10.1542/peds.2011-3762. Epub 2012 Aug 6.

Control Intervention

Mezzo-level: Creating New Social Networks Pre-

Program Network

Control Intervention

Post-Program Network

Gesell, S.B., Bess, K., Barkin, SL, Understanding the Social Networks that

Form Within the Context of an Obesity Prevention Intervention, Journal of

Obesity, 2012;2012:749832. Epub 2012 May 13.

Summary The clinic setting is one of many environments to prevent childhood obesity Providing group visits and/or health coaching calls Addressing nutrition, physical activity with pregnant women in all clinic settings Linking to effective weight loss programs for post-partum weight loss Addressing satiety versus hunger cues, soothing approaches during infancy starting

early in the pediatrician’s office Reassessing recommendations for appropriate weight gain during infancy and re-thinking catch-up growth parameters Including families in setting nutrition and physical activity goals during toddlerhood

(goals for both parents and children) Linking to trusted effective community programs