Let’s Go! 1

What is New in Childhood

Obesity?

• Maine School Nurses Association

• 7/24/14

• Jonathan Fanburg, MD, MPH

www.letsgo.org

Let’s Go! 2

METABOLISM GENES

Socioeconomic

Status

CULTURE

Causes of Overweight & Obesity

BEHAVIOR ENVIRONMENT

The Bottom Line

ENERGY IN ENERGY OUT!!

EXCEEDS

>>

What Are the Health Risks of

Overweight and Unfit?

Type 2 diabetes

Joint problems

High blood pressure

High cholesterol

Asthma

Sleep apnea

Depression

Low self-esteem

Eating disorders

Heart attack

Stroke

Cancer

Gallbladder disease

Kidney stones

Osteoarthritis

Pregnancy complications

Health problems in childhood Potential increased risk as adult

The Basics

• We actually know that obesity is not a good thing.

Evidence Based National Guidelines

• Expert Committee 2007

– Comprehensive review of literature –

evidence for 5210 Pediatrics 2007;120;S229-S253

• 5210 are proven determinants of

obesity.

1

Evidence Based National Guidelines

• US Preventative Services Task Force 2010

– Reviewed 13 behavioral and 7 pharma trails.

2

USPSTF

• BMI is an Acceptable Measure

• Moderate – Intensive Intervention

• Counseling

• Physical Activity

• Behavioral Management Techniques

• Parent Involvement

• Pharma works modestly, but not recommended presently

Evidence Based National Guidelines

• White House’s Childhood Obesity Task Force 2010 – Let’s Move campaign

– Motivated partnerships for intervention

– private, public partnerships.

3

Affordable Care Act - 2014

• All Health Insurances have to include

coverage for preventative health

without copay or deductibles.

- Is obesity prevention or treatment? - Grandfathered plans?

Pediatric Obesity Clinical Decision Support Guide (5210 Flip Chart)

• Outlines basic initial MEDICAL EVALUATION

in the office

• Annual Physical

• Separate Visit

• BMI% PLUS……………

• Family History – Obesity

– Diabetes

– Hyperlipidemia

– Early Heart Disease

• Comorbidity Symptoms

Family History Counts

Endocrine causes of obesity is more likely in the short kid or tall kid?

EXAM

Facial hair and acne is sometimes a sign of what? A. Increased chocolate consumption B. Increased androgens C. Both of the above

Underarm

NECK

NECK

This person has: A. A rash from a necklace. B. Bad eczema C. Acanthosis Nigricans

This rash is from what? A. Cutting behavior B. Skid burn from the carpet C. Rapidly stretching skin

NORMAL LIVER

FATTY LIVER with Fibrotic Tissue

CIRRHOSIS

Exam

• Sometimes helps. Low pay off, but does help identify disease that deserves further medical evaluation.

• Target:

– Cardiac exam

– Hepatomegally

– Hip issues

Should I Get Labs???????

YES (Probably)

• Cholesterol Profile

• ALT or AST

• Fasting Glucose

(now HgbA1C)

MAYBE • Vitamin D

• TSH, free T4 – thyroid disease

• Cortisol, creatinine – Cushings

• DHEAS, free testosterone, insulin - PCOS

• Insulin levels – fasting? 2hr GTT?

• ? Ultrasound of liver ?

• ? Sleep study, Xray of hips, Cardiac MRI (not yet)

Initial Treatment • 5210 • Pick a piece, try it out. • Focus on Health INSTEAD of Weight • Choose words carefully • MOTIVATIONAL INTERVIEWING

– Ask permission – Elicit patient’s concerns – Provide positive feedback, celebrate successes. – Find discrepancies – Develop patient based plan – Explore Motivation and Confidence

• Solely 5210 can result in a healthy weight for some…………..

5210 works better with help

• Let’s Go

– Messaging heard in more then 3 settings, increases probability of self reported change in behavior by 27%.

Provide healthy choices for snacks and celebrations; limit unhealthy choices.

Provide water and low fat milk; limit or eliminate sugary beverages.

Provide non-food rewards.

Provide opportunities for children to get physical activity every day.

Limit recreational screen time.

Participate in local, state, and national initiatives that supports healthy eating and active living.

Engage community partners to help support healthy eating and active living at your site.

Partner with and educate families in adopting and maintaining a lifestyle that supports healthy eating and active living.

Implement a staff wellness program that includes healthy eating and active living.

Collaborate with Food and Nutrition Programs to offer healthy food and beverage options.

25

1. Connect to your community and the Let’s Go! community efforts:

Required:

• The practice will hang a Let’s Go! 5-2-1-0 poster in the waiting room and ALL exam rooms.

26

2. Accurately weigh and measure patients.

Required:

• ALL providers regularly determine BMI percentile in patients 2-18 years during well visits.

27

3. Have a respectful conversation around weight.

Required:

• All providers regularly use the Let’s Go! Healthy Habits Questionnaire during 2-18 year well visits.

5-2-1-0 • It starts the conversation

• For some it’s all they need

• For others – (esp. with BMI>95%) they need more

5210

4 Phases of Intervention

Medical Assessment

Next Steps

Specialty Clinic

AAP NICHQ Let’s Go Maine AAP AAP Section on Obesity

NEXT STEPS - Planned Themed Visits

18 Different Themes.

- Pick Themes Based on the Unique Patient. - Chose themes together.

- For the Patient who is Committed. - Requires periods of commitment (6-12mo?) - Not for Every Patient

Too Many Themes To Chose Between

Pick the Themes with Highest Pay Off 1st - Category A before B before C that are Best Match for patient that YOU are most comfortable with

A

B

C

1

6

11

Wt/Check In

BMI %ile Barriers PE Theme

Follow Up

A Category A theme will hopefully set the foundation for all of the other visits.

POSSIBLE FIRST THEMED VISIT Purpose: Set the foundation

Discussion Theme Material for Discussion

Understanding Health

(Set a foundation for good health.) Define the origins of health—some is genetic and

some family derived

Focus should be on maintaining or improving current health

Work with patients and families to understand that they are managing their health

WE ARE A TEAM

The 6 Highest Pay-off Themes

THEMED VISITS

B

NEXT COUPLE VISITS Purpose: Introduce concepts that are important to cover early for success

Discussion Theme for Each Visit Material for Discussion

Understanding Meaning of Healthy Food

Eat less processed food

Consume more fruit, vegetables, whole grains

Discuss where to get healthy foods

Discuss affordability of healthy foods

Eat foods that are closest to their natural state—can they be found in nature or at a farm?

Home Environment Create a supportive environment in house for success

Enlist other family members, same healthy meals for all, not just for patient

Be pro-active - get less healthy foods out of the house

Behaviors and Emotions Around Eating

Encourage mindful eating—are you actually hungry?

How do you know you are hungry?

Address typical triggers for eating. Eating when fighting

Eating when bored

Eating when sad, angry, or lonely Eating with Television

Most common solution= redirect to alternative activities to eating (e.g. go for a walk, play with a friend, do a craft)

Portion Sizes

(could be combined with label reading)

Use balanced plate tool—consider giving out a physical example. (Picture of a plate with appropriate portions.)

Sugary Beverages Consider using tools to review beverages, sports drinks, juices, teas—sugar bottle display? Consider graph depicting recommended sugar limits compared with amount in beverage.

Combine with discussions about calcium, milk, and water

NYC

Parenting Positive reinforcement is more powerful then punishments for behavior change. Target a high ratio of praise to commands/criticism.

Practice this skill at office or with peers.

Make comments specific, immediate, and genuine.

Start small – target 1- 3 behaviors for change initially.

Physical praise works as well (high fives, stickers, ect).

Be prepared for resistance. Kids test limits or act out to see if parents mean what they said. Consistency pays off as an individual caregiver and between caregivers.

5210

THEMED VISITS LATER IN PROGRAM C

Physical Activity Body Image

Label Reading Screen Time/Sleep

Meal Patterns Non Home Environment – school, childcare, afterschool

Snacks Holidays

Community Partners Bullying and Teasing

Unintentional Disruptions

Motivational Interviewing - CONCEPTS

1. Ask Permission 2. Elicit patient’s concerns 3. Provide positive feedback, celebrate successes. 4. Find discrepancies 5. Develop patient based plan 6. Explore Motivation and Confidence

Aggregation of Marginal Gains - 1% Improvements -

British Cycling Team

Let’s Go!

MEDICAL PROVIDER

VISITS

(NP, PA, MD, DO, RN)

•Purpose of Visits •Physical Activity •Television •Breastfeeding

DIETITIAN VISITS

(RD, Nutritionist, Health Educator)

•Understanding Healthy Food •Portion Sizes •Label Reading •Snacks •Meal Patterns •Calorie Balance

PHYSICAL THERAPIST VISITS

(OT, PT, CPT, AT, PhysEd)

•Physical Activity

PSYCHOLOGIST OR SOCIAL

WORKER VISITS

(PhD, LCSW, LCPC,)

•Behavioral and Emotional Eating

Who has the Conversation with the Patient/Family?

Let’s Go!

1. TIE the reason to something else – asthma, lab recheck

2. LOAD the plan for early program successes

3. CONSIDER having patient and family define the

frequency of follow up.

FOLLOW-UP – its hard!!!!

Let’s Go!

4. GIVE a prescription 5. RECOGNIZE that follow up is most likely to happen if

the patient perceives value to the visit. 6. CREATE an atmosphere of FUN in the office.

FOLLOW-UP – its hard!!!!

Red Flags to Treatment When is it time to consider additional medical work up and/or involving a specialist?

Abnormal Labs High BP

Abnormal glucose, cholesterol, AST/ALT

PE Findings

Significantly short height — chronic illness or hormone abnormalities.

Abnormal sleep patterns — sleep apnea.

Acanthosis Nigricans — insulin resistance.

Abnormal Menses — PCOS

Shortness of Breath or Exercise Intolerance — asthma.

Significant Anxiety or Depression

Other Reasons

High BMI%ile and not progressing after 6-12 months towards a healthier weight.

Patients with worsening comorbidities.

Rapidly increasing BMI %ile.

Let’s Go!

ONLINE TRAININGS - Available ONLINE Now (FREE)

www.LetsGo.org

Let’s Go!

• Sept 18 + 19 – MaineHealth - Portland

www.LetsGo.Org

• Portland, ME

Reggie Washington - Denver David Ludwig – Boston Childrens

Robert Lustig – UCSF Sandi Hassink – Nemours

Stephen Pont – AAP Victoria Rogers, Mike Dedekian,

Jonathan Fanburg, Val Ohara – Let’s Go