RX: Physical Activity Use Of A Portable Gym System In Overweight Adolescents

1. RX: Physical ActivityUse Of A Portable Gym System In Overweight Adolescents Dominique R. Williams, MD, FAAP Medical Director, Children’s Hospital of the King’s Daughters, Healthy You for Life Assistant Professor, Department of Pediatrics, Eastern Virginia Medical School Norfolk, Virginia

2. I do not have any financial disclosures; neither do I intend to discuss off-label use of medications or devices.

3. Learning Objectives Identify barriers to physical activity Review the use of therapeutic contact Discuss study findings and clinical implications Describe CHKD Healthy You for Life

4. Patricia Belford-Cohen, LCSW Kira Davies, DPT, SCS Joseph Gill Lynn Kistler, MS, RD Jill Layne, LCSW Regina Burkard Mary Jo Haney, RD, CSP Kim Kranz, PT, DScPT, OCS, SCS Ellen Pelton, MS Dominique R. Williams, MD, FAAP, Medical Director Barbara “Babs” Benson, RN, Program Manager Jessica Rodriguez, Community Outreach Coordinator Health Center at Oakbrooke - Chesapeake Health and Surgery Center at Oyster Point– Newport News Health Center at Neurodevelopmental Center (NDC) - Norfolk CHKD Healthy You for Life

6. CHKD Healthy You for Life Health Classes Available once clinic assessment completed Open to children 8-16 years old 8 week academic class 6-week membership to YMCA, contingent upon class attendance Clinic • Open to children 3-16 years old • BMI >85th percentile • Consultation with • Physician • Physical Therapist and Exercise Specialist • Registered Dietitian • Licensed Clinical Social Worker

7. Multidisciplinary Approach • Social Workers • Individual and/or family counseling • Coordinate care with other providers RegisteredDietitians • Assess risk for food insecurity • Advice based on labs, medical conditions • Monitor nutrition goals Physical Therapists Exercise Specialists • Functional movement assessment • Fitness plan based on needs, interests

8. deBono et al (2012); Eisenmann et al (2011); Faith et al (2002); Schmalz DL (2010); Hartline-Grafton (2011); Gooze et al (2012).

9. Motivational Interviewing Principles Tools Establish rapport Set an agenda Ask open ended questions, provide menu of solutions Use reflective listening Develop discrepancies, elicit change talk Patient-centered Resist arguing, persuasion, confrontation Understand motivation Listen to the family Empower the patient and affirm attempts to change Schwartz RP. (2010). Pediatric Annals 39:3, doi: 10.3928/00904481-20100223-06.

10. Communication Styles Following Listening; gathering information; obtaining a history Includes asking permission, open-ended questions Directing Patients are told what to do and how to do it Includes menu building, action reflections Guiding Patient led and tutored to find their way to solutions Best suited for health behavior change discussions Schwartz (2010)

11. Approaching the Family Ask permission to discuss weight, lifestyle Advise about risks, benefits, improvements Assessreadiness for change, barriers Assist with and Agree on plan, goals Arrange follow up Source: Canadian Obesity Network, Jay et al (2010); Quinn et al (2009); Stewart et al (2011); Vallis et al (2013)

12. Advise About Risks & Benefits

13. Joint Pains Sleep Disturbances Low Self-Esteem Poor Body Image Difficulty Establishing Peer Groups Short Term Effects

14. School Absences Inattentiveness and Hyperactivity Fatigue and Daytime Somnolence Teasing and Bullying Mood or Adjustment Disorders School Related Effects

15. Insulin Resistance or Diabetes • Obstructive Sleep Apnea • Menstrual Irregularities • High Blood Pressure • Lipid Abnormalities • Fatty Liver Disease Long Term Effects

16. Assess for Readiness for Change& Presence of Barriers

17. Readiness for Change The goal is to move from one stage to the next Patients and their families may move back and forth There may be differences in readiness – food, fitness, feelings

18. Adapted from National Obesity Forum, Patient Motivation - Readiness for Change, http://www.nationalobesityforum.org.uk

19. Parental Readiness for Change Rhee et al. Pediatrics 2005; 116:e94 - e101

20. Skelton and Beech. (2011). Obes Review, 12, e273-281.

21. MONEY MINDMECHANICAL METABOLIC Barriers

22. MONEY

23. MIND

24. Stankor I, Olds T, and Cargo M. (2012). Overweight and obese adolescents: What turns them off physical activity? International Journal of Behavioral Nutrition and Physical Activity, 9:53. doi: 10.1186/1479-5868-9-53.

25. Source: Center for Science in the Public Interest (2003); Foley Freisleben LLC (2012); Kalb (2010) Marketing Corpulence

26. Social & Cultural Norms She’s a brick house…36-24-36

27. MECHANICAL

28. Stankor I, Olds T, and Cargo M. (2012). Overweight and obese adolescents: What turns them off physical activity? International Journal of Behavioral Nutrition and Physical Activity, 9:53. doi: 10.1186/1479-5868-9-53.

29. METABOLIC

30. Assist with Making a Plan & Agree on Goals

31. Specific Measurable Achievable Rewarding Timely SMART Goals

32. Small Changes Theory Lutes and Steinbaugh (2010)

33. Arrange Follow Up

34. Electronic Communication &Therapeutic Contact Therapeutic Contact Telephone call Handwritten note Office visits Electronic communication Electronic Communication • Short message services (SMS) • Email • Apps for smartphones, tablets Emerging evidence base with randomized trials May affect attrition, adherence more than BMI, weight Have a plan for protected health information and HIPAA Clearly define usefulness, timeliness, and “rules”

35. Emphasize the Medical Home Adult Medicine • Waddenet al. Two year randomized trial of obesity treatment in primary care setting. N Eng J Med 2011; 365: 1969-79. Pediatric Medicine • Taveraset al. Randomized control trial to improve primary care to prevent and manage childhood obesity: the High Five for Kids Study. Arch Pediatr Adolesc Med 2011; 165(8): 714-22. • Kwapiszewski and Wallace. A pilot program to identify and reverse childhood obesity in a primary care clinic. Clin Pediatr 2011; 50(7): 630-5.

36. Multidisciplinary Community Partnerships Healthy City Initiatives: Portsmouth, Norfolk, Eastern Shore Specialty Services: Nutrition, Social Work, Physical Therapy, Personal Training, Exercise Specialist Insurance Programs: VA Premier, Optima, Anthem Community Programs: YMCA, GOTR, Mentors

37. Portable Gym System • Convenience sample of 100 patients, ages 10-17 years • Action stage of readiness for change • Demonstrated by physical therapist, exercise specialist • Exclusion Criteria: remediation, developmental delay, previous suicide attempt, in foster care, medical history, patient decline receipt of bag

38. Moving Forward Next Steps Consider short-term use Foster increase confidence Randomize sample Objectively measure PA Conclusions • Differences in attrition • Differences in physical activity • BMI velocity • Cardiovascular fitness

39. Moving Forward Therapeutic Contact Continue to identify factors that contribute to attrition and physical activity Focus on specific form of therapeutic contact Physical Activity • Determine age appropriateness • Use of bag in previously physically inactive patients • Measures of cardiovascular fitness and endurance

40. Program Manager Babs Benson, RN (757) 668-7035 Barbara.Benson@chkd.org FAX: (757) 668-7809 Medical Director Dominique R. Williams, MD (757) 668-9177 Dominique.Williams@chkd.org Community Outreach Coordinator Jessica Rodriguez (757) 668-7860 Jessica.Rodriguez@chkd.org www.chkd.org/HealthyYou Healthy You for Life

41. Thank You