Successful Wellness by
Eating & Exercising
Together (SWEET)
Eric I. Schwartz, MD, MBA
Chief Medical Officer
Henry J. Austin Health Center
Trenton, NJ
Overview
 Obesity
in the community
 Evidenced-based strategies



Nutrition
Behavior
Fitness
 SWEET


Program
Design of program
Outcomes
 Next
Steps
Overweight & Obesity in the
Community
30.4% of US adolescents are overweight (BMI≥85th
percentile), It increases to 40.4% in African American
and 43.8% in Mexican-American adolescents
 2,393 sixth graders in NJ in 2002, 20% obese and
18% overweight
 Socio Economic Impact:

2



High SES – 10% obesity
Low SES – 27% obesity
Clinically - DM, HTN, sleep apnea, arthritis, lipid
abnormalities, depression, gallstones
1. Ogden C.L., Flegal K.M., Carroll M.D., Johnson C.L., Prevalence and trends in overweight among US children and
adolescents, 1999–2000. JAMA (2002) 288 : pp 1728-1732.
2. Source: Childhood Weight status, NJ Dept of Health & Senior Services, Sept 2004, vol 1
Nutrition

No high quality RCTs in literature (sm numbers, short
f/u)
 Traffic Light Diet – break foods into:




Red (high fat or simple sugars -4 servings/wk)
Yellow (ex. rice, pasta, plain breakfast cereal in moderation)
Green (low calorie, high fiber) – no restrictions
Low fat/low calorie vs. low glycemic index


Smaller portions with regular meal & snack pattern
Replace sweetened beverages with water, sugar-free
drinks
 Involve the family
Epstein LH, et al. Childhood Obesity. Ped Clin NA 1985;32:363-9.
Kirk S, et al. Pediatric Obesity Epidemic:Treatment Options J of ADA. 2005;5:44-51.
Cooperman N, Jacobson MS. Adol Med 2003;14:11-21.
Glycemic Index (GI)

Glycemic (sugar)response after consumption of food.
Carbohydrates increase blood glucose and plasma
insulin release and can lead increase risk of insulin
resistance & DM

Typical GI diet limits to 130 gms of carb and 70 gms of
fat
 Low GI (<50) – fruit, low fat milk
 Mod GI (50-70) – sweet potato, corn, whole grain
pasta
 High GI (>70) – White bread, baked potato, french
fries
Ludwig DS. The glycemic index:physiological mechanisms related to obesity, diabetesand CV disease. JAMA
2002;287:2414-2423.
Behavior Modification

4 Components







Goal setting (education alone won’t work)
Self monitoring (awareness of cues)
Stimulus control
Incentives (within context of supportive family
environment)
Behavioral contract in 2 tiered phases – if meet
initial goals (simple behavior, food choices) move
to next tier
Role playing – for difficult scenerios
Motivational Interviewing – pros/cons of behavior
change so can customize and “buy into” a course
of change
Source: Kirk S, et al. Journal of ADA 2005;44-51. and Wisotsky W, Swencionis C. Adolescent Med 2003;14:37-48.
DiLillo V, etal. Incorporating motivational interviewing into behavioral obesity treatment. Cognit Behavor Pract 2004;10:120-130.
Fitness/Activity
 Increasing
activity and decreasing
sedentary time are two distinct
interventions
 2 hours of TV/day (American Academy of
Peds)
activity time – rest/play in
intermittent bouts
 Accumulate


Elementary school age – 30-60 min most days
Adolescents – 20 min/3 times a week
Source: Kavey RE, et al. American Heart Association guidelines for primary prevention of atherosclerotic CV
disease beginning in childhood. Circulation 2003;107:1562-1566.
Assessing Readiness


Direct programs at motivated children and families
Aim for weight maintenance rather than weight
loss
 Readiness (family lists pros/cons of wt change)





Precontemplation (not considering behavior change)
Contemplation (thinking about behavior change)
Preparation (planning to change)
Action (initiating behavior change)
Interview questions can be found @ Bright
Futures in Practice: physical Activity
www.brightfutures.org/physicalactivity
Wiscotsky W, Swencionis C. Cognitive behavior approaches in management of obesity. Adol Med
2003;14:37-43.
SWEET Program

Successful Wellness by Eating & Exercising
Together (SWEET)
 Staffed by Dietitian, Child Psychologist,
Physician, and Outreach/Data Coordinator
 Funded by RWJ Foundation – NJ Health
Initiatives (2004-2007)
 8-week program for children and their families



Nutrition education and 1 meal/week
Behavior modification (logs, incentives, roleplaying)
Fitness opportunity – Wacky Gym 3x/week and
maintenance
SWEET (II)
Recruitment through:
 School nurses
 Physician referral
 DYFS
 Word of Mouth
 Typical
group will have 8-12 children and
family members
Outcomes
Groups 1-5 (Oct 04-Nov 05)
 41 children in total participated
 only 25 (61%) completed entire program
 BMI decreased on avg 0.4
Changes made:
 Screen for readiness
 Changed staff (RD, Outreach Coordinator)
 Changed site from YWCA to school-based site
Outcomes (II)
Groups 6-10 (Jan 06-March 07)
 Group 8, 4-wk summer session – 7 children
- non compliance, little impact
 Otherwise, 35 children participated




31 (94%) completed program
29 (83%) decreased BMI
Avg. BMI loss: -0.72
9 children (26%) decreased BMI by >1
Group 6 Data
BMI Change
2.00
1.50
1.00
0.50
0.00
-0.50
-1.00
1
2
3
4
5
6
7
8
9
Group 7 Data
Group 7 BMI Change
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
1
2
3
4
5
6
7
8
9
Group 9 Data
BMI Change
0.5
0
-0.5
-1
-1.5
-2
-2.5
-3
-3.5
-4
1
2
3
4
5
6
7
8
9
10
Group 10 Data
BMI Change
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
-1.4
-1.6
1
2
3
4
5
6
7
Maintenance Group (March 07)
 Occurs
monthly
 In March, 14 children participated

From groups 7,9,&10
 13
of 14 (93%) decreased BMI from initial
visit

Avg. BMI change: - 1.35
Maintenance Group (Wt)
300.00
250.00
200.00
Wt (initial)
150.00
Wt (Main)
100.00
50.00
0.00
1
2
3
4
5
6
7
8
9 10 11 12 13 14
Maintenance Group Height
70.00
60.00
50.00
40.00
Ht (init ial)
30.00
Ht (main)
20.00
10.00
0.00
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Maintenance Group BMI Change
B M I C hang e
1.00
0.00
-1.00
-2.00
-3.00
1
2
3
4
5
6
7
8
9
10 11 12 13 14
Success Stories
of our S.W.E.E.T. participants




JM: Started program with elevated BP, was refused to participate in
sports – went through program – normalized BP, went on to play
football. Mom made several changes including providing a fruit &
vegetable at every family dinner.
KH: Lost weight, lowered BMI (83.5 on 3/29/06 – 76.5 on 8/9/06)
– lost “tummy weight” completely – continues 1 year later to
participate in Wacky Gym and Maintenance Phase Reunions.
NS: Lost significant weight (169.8 on 3/29/06 – 158.0 on 8/9/06)
despite being one of the oldest participants (senior in high school) –
did exceptionally well – returned to two Maintenance Phase
Reunions.
AD: Mom reported when child first entered program she never ate
fruit/vegetables until she came to S.W.E.E.T. – she now
incorporates vegetables in family dinners and now is encouraged to
try new foods.
What we learned
 Screening
for readiness before accept into
program
 Study each group’s dynamics and address
strengths and weaknesses (ex. mentors,
buddies)
 Self-esteem of participants not a major
issue
 Importance of cultural competency
(bilingual/bicultural translator), diet, and
activity
Next Steps
 Standardize
curriculum
 Introduce program into after-school
curriculum
 Advocate for reimbursement from
Managed-care companies
 Study various components for program
(diet, behavior intervention) in a
randomized-controlled fashion.
 Advocate for required measurement &
reporting of BMI
CNN…Six States get an “A”
 PA,
1.
2.
3.
4.
5.
6.
CA, SC, Illinois, Tenn, & Oklahoma
Set nutrition standards in schools
Require measurement & reporting of BMI
Recess & physical education classes
Add weight “wellness” to school curriculum
Support obesity research
Support insurance coverage for obesity
University Of Baltimore Obesity Initiative, Jan 31, 2007
Questions?