Childhood Obesity:
What to do After 5210
NEXT STEPS
• Minnesota AAP
• 5/31/13
• Jonathan Fanburg, MD, MPH
Let’s Go!
www.letsgo.org
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I have no financial
To Disclose
Let’s Go!
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Let’s Go!
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Let’s Go!
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Let’s Go!
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Let’s Go!
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11 year old well visit – obese
• Doc #1.
Give HPV, Menactra, and Tdap and make appt
for next year.
• Doc #2.
Ask, “Is it ok if we talk about your weight?”
• Doc #3.
Say, “I have some concerns about your health
and want to set you up to see my partner.”
Panda
The Basics
• We actually know that obesity is not a good thing.
The Basics
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Cholelithiasis (gall stones)
Obstructive Sleep Apnea (8% of obese kids)
Slipped Capital Femoral Epiphysis (SCFE)
Tibea Vera – Blounts Disease (bowed legs) (2.5%)
Pseudotumor cerebri (head aches)
Psych
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Body image
Self esteem
Depression, Anxiety
Alienation from friends, distorted peer relationships
Ineffective Interventions
Evidence Based National Guidelines
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• Expert Committee 2007
– Comprehensive review of literature –
evidence for 5210 Pediatrics 2007;120;S229-S253
• 5210 are proven determinants of
obesity.
Evidence Based National Guidelines
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• US Preventative Services Task Force 2010
– Reviewed 13 behavioral and 7 pharma trails.
USPSTF
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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
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• White House’s Childhood Obesity
Task Force 2010 – Let’s Move
campaign
– Motivated partnerships for intervention
– private, public partnerships.
What Do I Do With PANDA???
Pediatric Obesity Clinical Decision
Support Guide (5210 Flip Chart)
• Outlines basic initial
MEDICAL EVALUATION
in the office
• Annual Physical
• Separate Visit
Family History Counts
• BMI% PLUS……………
• Family History
– Obesity
– Diabetes
– Hyperlipidemia
– Early Heart Disease
• Comorbidity Symptoms
EXAM
Endocrine causes of obesity is more likely in the short kid
or tall kid?
Facial hair and acne is sometimes
a sign of what?
A. Increased chocolate consumption
B. Increased androgens
NECK
NECK
This person has:
Underarm
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
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???????
• Cholesterol Profile
• ALT or AST
• Fasting Glucose
(now HgbA1C)
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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)
? Vitamin D?
Initial Treatment
• 5210
• Pick a piece, try it out.
• MOTIVATIONAL INTERVIEWING
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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%.
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.
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2. Accurately weigh and measure patients.
Required:
• ALL providers
regularly determine
BMI percentile in
patients 2-18 years
during well visits.
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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.
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Funding provided by
The Harvard Pilgrim Health Care Foundation
and MaineHealth
5-2-1-0
• It starts the conversation
• For some it’s all they need
• For others – (esp. with BMI>95%)
they need more
AAP
NICHQ
Let’s Go
Maine AAP
AAP Section on Obesity
Let’s Go Online
Teaching Modules – Fall 2013
Next Steps
• Provides structure, format, and content to visit
• Uses “19 Theme Visits”
• For Engaged Patient
Let’s Go!
Next Steps, cont.
• Periods of Commitment
• Visits are over an extended period of time (?612 mo?) ”Touch Points”
• MOST IMPORTANT: Patient/Family/Provider Triad
decides on theme
• Clinician may need more training/skills - MI
Let’s Go!
THEMED VISITS
Critical Concepts for Choosing Themes:
_Themes with greater pay off should happen earlier
_The patient’s/family’s culture should be considered and
incorporated into the visits
_Provider’s expertise and knowledge base
_Use Universal Messaging across all visits, such as 5210
A B C
(Tested against approx 25 providers (Peds, Family, Int Med, PA, RN),
3 dietitians, 1 physical therapist, 2 counselors, and 1 linguist)
A
B
C
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
THEMED VISITS
B
The 6 Highest Pay-off Themes
NEXT COUPLE VISITS
Discussion Theme for Each Visit
Purpose: Introduce concepts that are
important to cover early for success
Material for Discussion
Understanding Meaning of Healthy  Eat less processed food
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  Encourage mindful eating—are you actually
Eating
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.)
NYC
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
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
C
THEMED VISITS LATER IN PROGRAM
Physical Activity
Body Image
Label Reading
Screen Time
Meal Patterns
Non Home Environment – school, childcare, afterschool
Snacks
Holidays
Community Partners
Bullying and Teasing
Unintentional Disruptions
How to Pick a Theme ?
Age
BMI
Readiness to Change
Let’s Go!
Who has the Conversation with
the Patient/Family?
PSYCHOLOGIST
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
OR SOCIAL
WORKER
VISITS
(PhD, LCSW,
LCPC,)
•Behavioral and
Emotional Eating
PHYSICAL
THERAPIST
VISITS
(OT, PT, CPT, AT,
PhysEd)
•Physical Activity
Let’s Go!
FOLLOW-UP – its hard!!!!
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.
Let’s Go!
FOLLOW-UP – its hard!!!!
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.
Let’s Go!
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
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Other Reasons
High BMI%ile and not progressing after 6-12 months towards a healthier weight.
Patients with worsening comorbidities.
Rapidly increasing BMI %ile.
Praise.
Open ended Question.
Let’s Go!
Praise.
Elicit Positive
Feeling.
Let’s Go!
Praise.
Empathy.
Elicit Self Reflection.
Identify Barriers
Let’s Go!
Reflective
Listening.
Elicit Barriers.
Let’s Go!
Eliciting Menu
Of Choices.
Patient’s Choice.
Open Ended.
Let’s Go!
Asking
Permission
Let’s Go!
Theme:
Physical Activity
Let’s Go!
Goal Setting.
(Could Pull Out
Readiness Scale).
Let’s Go!
Acknowledgement.
Redirection.
Let’s Go!
Theme:
Understanding
Health
Let’s Go!
Engaging Parent.
Eliciting Environment
Barriers and
Parental Issues
Let’s Go!
Parent/Patient
Choses Theme, but
Doc choses options
That might be best.
Let’s Go!
Themes Encountered
• Meaning of Health
• Physical Activity
• Goal Setting – (could have used 1-10 scale)
• Next Time – Could Target
– Parenting
– Beverages
– Physical Activity
– Unintended Interruptions
Let’s Go!
What Is Your Readiness To Change?
Reflective Listening.
Identify Barriers.
Identify Solutions to
barriers.
Praise Effort.
Support.
Let’s Go!
• Sept 11 – preconference on MI
• Sept 12 + 13 – conference
www.LetsGo.Org
• Portland, ME
Robert Schwartz – Wake Forest
Reggie Washington - Denver
David Ludwig – Boston Childrens
Robert Lustig – UCSF
Sandi Hassink – Nemours
Robin Hamre – CDC
Chris Boling/Stephen Pont – AAP
Many more
Let’s Go!
Let’s Go!
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 What is more important in children?
 A. Body Mass Index (BMI)
 B. Body Mass Index percentile (BMI %ile)
 C. What’s the difference?
What is this?
A. Spleen
B. Liver
C. Heart
NORMAL LIVER
FATTY LIVER with
Fibrotic Tissue
CIRRHOSIS
 EVIDENCE BASED:
National guidelines for assessment and
treatment of Childhood Obesity – 5210 For
Providers.
 PRACTICE BASED:
“NEXT STEPS” - Planned visits using patient
tailored themes as a method for goal setting.
This patient is at risk for:
A.
B.
C.
D.
Snoring
Obstructive Sleep Apnea
Cardiomegally
All of the above