Errin Weisman DO
Deaconess Family Medicine Residency
PGY2
US RATES AMONG CHILDREN 2-19 reported by the CDC in 2008
Obese
68.3
Overweight
14.7
17
Healthy weight
or underweight
Ranks 21st (with 1 being the best) in overall prevalence with 29.9% of children
considered either overweight or obese. (10-15% are obese)
Weight status of children from low-income families participating in WIC, 31.1% of lowincome children age 2-5 are overweight or obese in Indiana.
Indiana’s prevalence of overweight and obese children has fallen since 2003
GOOD
NOT SO GOOD
INDIANA’S PLACE
Indiana is one of only 12 states with a policy prohibiting or limiting foods of low
nutritional value in child care centers.
Stats from Child Policy Research Center, NICH, Data Resource Center for Child & Adolescent Health
http://www.childhealthdata.org/docs/nsch-docs/indiana-pdf.pdf
IN
US
CLASSIFICATION SYSTEM
Recent Paradigm shift
*Until 2005, term obese in children was discouraged/stigmatizing
*In 2007AMA proposed term changes
SO…WHY SHOULD WE CARE?
Multiple studies show obese children are more likely to be obese, have
issues with cardiovascular disease, components of the metabolic
syndrome, and several types of cancer in adulthood than are healthyweight children
At greatest worry, it is becoming increasingly apparent, however, that
overweight and obese children are at high immediate risk of conditions
previously not seen in children like T 2DM, HTN, hyperlipidemia, asthma,
nonalcoholic fatty liver disease, and perioperative respiratory distress
under general anesthesia than are their healthy-weight counterparts
T 2DM now accounts for almost half of all new diabetes cases among
children
Overweight and obese children reported greater difficulty making friends
and more prone to low self-esteem than did healthy-weight children
SO.. HOW DO WE HELP
1)Identification of These Kids
2)Identifying Risk Factors
3)Motivational Interviewing and Brief Counseling
with Parents (both Prevention and Management)
- Involve Stages of Change
- Assess for Change
4) Establish plan and Set up Follow Up
Identifying these children start them on the path to help!
1) EFFECTIVE IDENTIFYING
1) CHART OUT GROWTH CURVES
Recent survey of almost 2000 FPs showed only 45% compute BMI at most or
every well child visit
2) IDENTIFY ANY CAUSES
2) POTENTIAL RISK FACTORS
MOTIVATION INTERVIEWING
Provide Information and Assess Parental Concerns and Behaviors
EXAMPLES
• “Your child’s BMI is in the range which is associated with health problems. What
concerns, if any, do you have about your child’s weight?”
• “We checked your child’s BMI, which is a way of looking at weight and taking into
consideration how tall someone is. Your child’s BMI is in the range where we start
to be concerned about extra weight causing health problems.”
• “About how many times a day does your child drink soda, sports drinks, or
powdered drinks like Kool-Aid?”
• “How often is your child playing, running, participating in organized exercise each
week?”
• Your child watches 4 hours of television on school days. What do you think about
that?
• “On a scale of 0 to 10, with 10 being very important, how important is it for you to
reduce the amount of fast food he eats?”
BEWARE!!!
“It’s just baby fat”
“We are big boned people”
“Your child is fat. Stop going to McDonalds”
ARE THEY READY TO MAKE A CHANGE
Precontemplation
Contemplation
Preparation
Relapse/
Recycle
Action
Maintenance
ASSESS FOR CHANGE
EXAMPLES
“We’ve talked about eating too often at fast food restaurants, and how television
viewing is more hours than you’d like. Which of these, if either of them, do you
think you and your child could change?”
“On a scale of 0 to 10, with 10 being very confident, assuming you decided to change
the amount of fast food he eats, how confident are you that you could succeed?”
“What would it take you to move to an 8? “Well, I really want him to avoid diabetes.
My mother died of diabetes, and it wasn’t pretty; maybe if he started showing
signs of it; maybe if I could get into cooking a bit more.”
ESTABLISH A PLAN & SET UP FOLLOW UP
PLAN: Involving child in cooking or meal preparation, ordering healthier foods at fast
food restaurants, and trying some new recipes at home.
FOLLOW-UP: Let’s schedule a visit in the next few weeks/months to see how things
went.
NO PLAN with F/U: Sounds like you aren’t quite ready to commit to making any
changes now. How about we follow up with this at your child’s next visit?
NO PLAN with F/U: Although you don’t sound ready to make any changes, between
now and our next visit you might want to think about your child’s weight gain and
lowering his diabetes risk.
FEW EXTRAS TO REMEMBER
AAP recommends that overweight kids 10yrs and up should have a lipid panel. If you
identify risk factors, you should also add a fasting glucose, ALT and AST every 2
years.
AAP recommends for obese child 10yrs and old lipid panel, fasting glucose, ALT, and
AST every 2 years regardless of their risk factors at that point.
Remember to counsel parents on prevention measures (because they are not obese
now doesn’t mean they will stay that way)
IT TAKES THE ENTIRE FAMILY TO CHANGE!
DFMR
Allopathic Family Medicine Residency in Evansville, IN
18 Residents
Serve Low income, Mostly Medicaid or self pay, mixed of Caucasian, African American
and Hispanic families in the intercity of Evansville IN
Ob services, Peds care, Adult care, Nursing home, Inpatient service + other core
rotations.
Work within the Deaconess Health System
PAST ATTEMPTS?!?
Data collection phase
• Use coding from auditing charts
• Age 2-16, BMI greater than 85%
• 2004= 11%
• 2007= 14%
• Currently= ~19% (but now use 2-19yo model)
•
We offered some exercise classes (few came)
•
We had an RD in the building (few came)
•
Minimal training to residents about approaching obesity and the prevalence in
the population we serve.
Resident
identifies
RD & SW appt
Involve in
Grant Program
We have identified
issues with
Physician
recognition of
Childhood obesity
LESSONS WE LEARNED
1) Better communication between Residents, Social Workers, RD, front desk, grants
coordinator needed
2) We have to Market and Dedicate to this cause
3) Incentives to Family
4) More follow through with families
5) Reviewing the literature, NO ONE has the perfect answer yet
NEXT ATTEMPT
95210 Program
Local link with the YMCA for FREE membership for the entire family once they
completed the initial visits (NO ONE FOLLOWED THROUGH)
Exercise classes did start to have children and families coming (HOWEVER, children
that came were not overweight or obese, parents did not participate and
unhealthy snacks were served)
No child increased in BMI (38 of 38)
Of the 38 children identified, 18 (47%) returned for a follow up with the RD. 13
(72.2%) showed some reduction in BMI
3 (7.8%) then returned for a follow up with the clinical social worker.
Of the initial participants, RD categorized only 5 as “ready for change.”
CURRENTLY…
With the Help from Welborn Grant
1) We did training with the residents (Dr. Gupta from Riley came and spoke)
2) Data now collected on referrals and “obesity” listed in the chart
3) To take advantage of best time, Classes are offered when children are out of
school (Spring Break, Summer, Xmas break)
4) Continued work on re-vamping classes for nutrition
5) Tracking Outcomes better
6) Working towards the Riley POWER model
7) Developing a one on one family group program with RD that involves shopping for
food and meal planning
DFMR INTERNAL REFERRAL PROCESS TO PEDS
OBESITY PROGRAM
Resident
identifies
RD & SW appt
Involve in
Grant Program
FUTURE HOPES
1) Integrate the Riley POWER program
2) Solidify a team
3) Work on customized care with specific goals, weekly contact, track the entire
family for outcomes
CONCLUSION
1) As a country, our children are becoming more overweight and obese
2) Use the BMI classification system and identify children’s BMI percentile
3) Know why it is important to bring their child’s obese up during visits. Because we
will be treating them as adults with the MI, HTN, DM2 Insulin Dep 20 year old
4) Screen for Risk Factors and do proper screening
5) Try using motivational interviewing
6) No one has the perfect solution yet, find your community resources to help you!
REFERENCES
AAFP CME Bulletin about Childhood Obesity: Assessment, Prevention, and Treatment.
Released 2012
Sandeep Gupta, MD and Amanda Garant, MS, RD, CD Riley POWER Program 317948-9088. Some of their PP pictures and ideas were used.
Barlow SE; Expert Committee. Expert Committee recommendations regarding the
prevention, assessment, and treatment of child and adolescent overweight and
obesity: summary report. Pediatrics. 2007;120 Suppl 4:S164-S192.
Centers for Disease Control and Prevention. CDC grand rounds: childhood obesity in
the United States. MMWR Morb Mortal Wkly Rep. 2011;60(2):42-46. Erratum in
MMWR Morb Mortal Wkly Rep. 2011;60(5):142.
Krebs NF, Himes JH, Jacobson D, et al. Assessment of child and adolescent
overweight and obesity. Pediatrics. 2007;120 Suppl 4:S193-S228 [Review].
Rao G. Childhood obesity: highlights of AMA Expert Committee recommendations. Am
Fam Physician. 2008;78(1):56-63, 65-66.
Bindon J, Dressler WW, Gilliland MJ, et al. A cross-cultural perspective on obesity and
health in three groups of women: the Mississippi Choctaw, American Samoans,
and African Americans. Coll Anthropol. 2007;31(1):47-54.
RESOURCES FOR MORE INFO
Examining the relationships between family meal practices, family stressors, and the
weight of youth in the family
http://www.ncbi.nlm.nih.gov/pubmed/21136225
Family mealtimes: a contextual approach to understanding childhood obesity
http://www.ncbi.nlm.nih.gov/pubmed/22652025
Healthy eating index-C is positively associated with family dinner frequency among
students in grades 6-8 from Southern Ontario, Canada
http://www.ncbi.nlm.nih.gov/pubmed/20197788
Household routines and obesity in US preschool-aged children.
http://www.ncbi.nlm.nih.gov/pubmed/20142280
Key Issues in the Prevention of Obesity
http://bmb.oxfordjournals.org/content/53/2/359.full.pdf
RESOURCES FOR MORE INFO
Parenting Styles and Home Obesogenics
http://www.ncbi.nlm.nih.gov/pubmed/22690202
Overweight and Obesity Data from the CDC
http://www.cdc.gov/obesity/data/childhood.html
Pediatrics : Recs for Prevention of Obesity
http://pediatrics.aappublications.org/content/120/Supplement_4/S229.full.pdf+ht
ml?sid=2c1e4978-da61-4306-8d9a-ed9e2d1722c6
RESOURCES FOR PARENTS AND PATIENTS
4H Programs: Health-promoting youth programs, available at http://www.4-h.org/
Big Brothers Big Sisters of America: Mentoring program committed to promoting
healthy lifestyles, available at http://www.bbbs.org/
Centers for Disease Prevention and Control Tips for Parents: Information, resources,
links,
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/tips_for_parents.htm
Dietary Guidelines for Americans 2010: Compendium of information on healthful
diets, pitfalls, advice, and links to other resources,
http://www.dietaryguidelines.gov/
Smart-Mouth.org: Videos, games, information, links,
http://www.cspinet.org/smartmouth/
Text4Baby: 3 free text messages/week to pregnant women or new mothers;
actionable, evidence-based information relevant to stage of pregnancy or child’s
development; http://www.text4baby.org/
RESOURCES FOR PARENTS AND PATIENTS
UCLA Fit for Healthy Weight Program: Information, programs, tools, links to other
resources, http://www.fitprogram.ucla.edu/
Weight-control Information Network: Helping Your Child: Tips, information, links,
http://win.niddk.nih.gov/publications/child.htm
YMCA: Fitness programs for children (some at reduced fees), education to promote
healthy choices, http://www.ymca.net/
National School Lunch and Breakfast Programs: Free or reduced-cost balanced meals
in public and nonprofit private schools, http://www.fns.usda.gov/cnd/lunch/ and
http://www.fns.usda.gov/cnd/breakfast/
Supplemental Nutrition Assistance Program: Assistance with grocery costs,
http://www.fns.usda.gov/snap/