Successful Wellness by Eating & Exercising Together (SWEET)

1. Successful Wellness by Eating & Exercising Together (SWEET) Eric I. Schwartz, MD, MBA Chief Medical Officer Henry J. Austin Health Center Trenton, NJ

2. Overview • Obesity in the community • Evidenced-based strategies • Nutrition • Behavior • Fitness • SWEET Program • Design of program • Outcomes • Next Steps

3. 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% overweight2 • Socio Economic Impact: • 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

4. 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.

5. 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.

6. Behavior Modification 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. • 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

7. Fitness/Activity • Increasing activity and decreasing sedentary time are two distinct interventions • 2 hours of TV/day (American Academy of Peds) • Accumulate activity time – rest/play in intermittent bouts • 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.

8. 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.

9. 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, role-playing) • Fitness opportunity – Wacky Gym 3x/week and maintenance

10. SWEET (II) Recruitment through: School nurses Physician referral DYFS Word of Mouth Typical group will have 8-12 children and family members

11. 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

12. 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

13. Group 6 Data

14. Group 7 Data

15. Group 9 Data

16. Group 10 Data

17. 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

18. Maintenance Group (Wt)

19. Maintenance Group Height

20. Maintenance Group BMI Change

21. 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.

22. 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

23. 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

24. CNN…Six States get an “A” • PA, 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

25. Questions?