Integrated Treatment of Child Obesity and Overweight in the Primary Care Pediatric Setting

1. Session # D2a October 17, 2014 Integrated Treatment of Child Obesity and Overweight in the Primary Care Pediatric Setting Jennifer Fontaine, Psy.D. Timothy Marean, M.D. Marc Perkel, M.A. Collaborative Family Healthcare Association 16th Annual Conference Friday, October 17, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • We have not had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Identify current AAP guidelines for assessment and treatment of pediatric obesity. • List three motivational interviewing techniques to use with families having trouble with adopting healthy lifestyle behaviors. • Identify the steps involved in screening for comorbid conditions of obesity, such as diabetes, hyperlipidemia, fatty liver disease. • Describe best practices for speaking to families about the diagnosis of childhood obesity using example phrases provided by the presenters. • Discuss how to effectively manage resistance from patients and resistant family members.

4. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

5. Recognize the Problem • Initial diagnosis by primary provider • 2 years or older • BMI > or = 95th percentile obese, between 85th and 95th percentile overweight

6. Comorbid Conditions • Obstructive sleep apnea • Asthma • Hypertension

7. Comorbid Conditions • Nonalcoholic fatty liver disease (NAFLD), GER, gall bladder disease • Slipped capital femoral epiphysis (SCFE), Blount disease, foot pain

8. Comorbid Conditions • Depression, anxiety, disordered eating • Polycystic ovary syndrome (PCOS) • Type 2 diabetes (T2DM)

9. T2DM Screening - Tests • Fasting glucose, or A1C in non-fasting individual

10. T2DM Screening - Who to Screen • Overweight PLUS any TWO of the following: • FH of T2D in a 1st or 2nd degree relative • High-risk race/ethnicity (Native American, African-American, Latino, Asian American, Pacific Islander) • Signs of insulin resistance on exam or conditions associated with insulin resistance (Acanthosisnigricans, hypertension, dyslipidemia, PCOS, or small-for-gestational age birth weight) • Maternal history of DM or GDM during the child's gestation

11. T2DM Screening - When • When to begin screening: At age 10 years, or at onset of puberty if this occurs < 10 years old • How often to repeat: Every three years Klish et al, UpToDate, 2011 and Diabetes Care 2013; 36 Suppl 1:S11

12. T2DM Screening • Who to test for diabetes at any point: Those with signs/symptoms of diabetes (e.g. polyuria, polydipsia, etc.)

13. Screening for dyslipidemia • 2 to 8 years • Selective screening using fasting lipid profile (FLP) two times for those with BMI = 95th percentile (or other selective screening criteria)

14. Screening for dyslipidemia • 9 to 11 years • Universal screening with a nonfasting lipid screening using non-HDL-C levels (or FLP x 2). • 12 to 16 years • Selective screening using fasting lipid profile (FLP) two times for those with BMI = 85th percentile

15. Screening for dyslipidemia • 17 to 21 years • Universal screening once during this time period with a nonfasting lipid screening using non-HDL-C levels (or FLP x 2). de Ferranti, UpToDate, 2013 and Daniels et al, National Heart Lung and Blood Institute, 2011

16. Screening for NAFLD • Tests: • ALT • Abdominal ultrasound • Who to screen: • Obese patient WITH symptoms and/or signs of NAFLD Klish et al, UpToDate, 2013

17. Initial TX Advice • Counsel about potential complications • Initial steps to improve BMI

18. Goals • 95-98th percentile BMI: • 2-5 years • Weight maintenance, if weight loss occurs if should not exceed 1 lb/mo. • 6-11 years • Weight maintenance or gradual loss of ~1 lb/mo • 12-18 years • Weight loss no more than average of 2 lb/wk.

19. Goals • 99th percentile and higher BMI: • 2-5 years • Weight loss not to exceed 1 lb/mo. • 6-11 years • Weight loss not to exceed average of 2 lb/wk • 12-18 years • Weight loss not to exceed average of 2 lb/wk

20. Goals • Ultimate goal for all BMI percentile is < 85th percentile Spear et al, Pediatrics 2007;120/S254

21. Patient Referrals • Dietitian • Psychologist

23. Statistics • One in three kids eats fast food every day. • Childhood obesity has tripled in Colorado. 23 percent of kids are now overweight or obese. • One third of Colorado youth will eventually suffer from obesity related diseases and are predicted to have a lower life expectancy than their parents. Source: http://www.cpr.org/news/story/colorado-battles-rising-childhood-obesity

24. Statistics • Childhood obesity is responsible for $14.1 billion in direct annual medical costs in the U.S. • Children treated for obesity are four times more expensive for the health care system than the average insured child. Source: http://livewellcolorado.org

25. FORMING NEW HABITS • We know that making behavioral changes, lifestyle adjustments, and forming new habits can be very difficult. • We all have a lot of trouble changing the way we do certain things, whether it’s what we eat, how we spend our free time, how much we exercise, work, study, or whatever it may be. • The behavioral health research tells us that it takes approximately 60 days to turn a new behavior into a habit that can stick for life.

26. MEDICAL AND EMOTIONAL RISKS • In 2014, our children are at much greater risk than ever before for developing overweight, obesity, and all of the medical problems that go along with obesity. • These include Type II Diabetes, high blood pressure, and high cholesterol, among others. • Being overweight is also associated with a shorter life span. • Not only does obesity lead to medical problems, it can also have a very negative impact on self-esteem and mental health issues as well.

28. TV AND FAST FOOD • The rise of electronics, television, and video games has led to our children becoming much more sedentary, and much less physically active. • Due to our busy lifestyles, families are eating fast food more than ever before. • These two factors are thought to account for a large part of the reason we are seeing such a dramatic increase in childhood obesity. • We also know that genetics play a major role in the body shape and size of a child.

29. HEALTHY KIDS PROGRAM Evans Pediatric Clinic Guide to a Healthy Lifestyle • A Performance Improvement (PI) project was launched in Spring 2013 to address concerns of the rising obesity in children and adolescents within the Fort Carson army population. • A collaborative approach including behavioral health, medicine, and nutrition was created for this project to provide best practices to patients. • Children and Adolescents are automatically screened in and receive a referral to the Internal Behavioral Health Specialist (a Psychologist) within the clinic if they meet specific criteria. Parents can also opt in for the program and healthy habits are included for every child.

30. CORECONCEPTS Motivation/Rationale • Reasons to make lifestyle changes (health, longevity, self-esteem, quality of life) • What it takes to create a habit (how the brain learns and develops a habit) • What is the individual patient’s reason for wanting to make a lifestyle change (customization of the plan) • Education • Energy Balance Model (calories in/calories out) • Calorie intake chart • Calorie expenditure chart • Portion size handout • Traffic Light Eating handout • Sample meal plan (dietician’s website)—Referral to Dietician • Grocery shopping and cooking as a family activity • Label reading

31. CORECONCEPTS • Setting Goals • Where do you want to start? (customization of a plan and motivational interviewing) • Setting small goals and being successful leads to increased confidence and more healthy behavior • The patient follows up with the IBHC to track behavior and goals • Self-Monitoring • Patients who self-monitor have more significant decreases in BMI than those who do not • Eating plan tracking device • Physical activity tracking device • Individually tailored sessions offered for families who have additional interest

32. HEALTHY KIDS BROCHURE • Incorporates Traffic Light Eating plan which associates colors with various foods to encourage patients to make better choices. • High Sugar foods – provides calories with low nutritional value • Sugar, Syrup, Jam/Jellies, condensed Milk, Soda, sweetened fruit juice, canned fruit in syrup. Sugar-coated cereals, cakes, doughnuts, cookies, chocolate, candy. Limit to 1-2 choices a week, look for low sugar alternatives. • Foods with Protein or starch – provides higher calories with higher nutritional value • Lean Meat, Poultry, Oily Fish, Shellfish, Eggs, Cheese, Beans, Yogurt, Peanut Butter, Nuts, Bread, Rice, Pasta (whole grain), Potatoes. Limit choices daily; choose whole grain, fiber, higher protein. • Fruits and Vegetables – provides lower calories with high nutritional value. Contains vitamins, minerals, and fiber • Bananas, Apples, Pears, Grapes, Strawberries, and other Fresh Fruit. Carrots, Broccoli, Corn, Lettuce, Mushrooms, and other Fresh Vegetables. Eat for snacking, should be half your meal. Choose fresh or frozen over canned/dried. HIGH ENERGY LOW NUTRIENTS HIGH ENERGY HIGH NUTRIENTS LOW ENERGY HIGH NUTRIENTS

34. HEALTHY KIDS BROCHURE PORTION SIZE TIPS • Portion size is important! Measuring food portions makes it easier for our child to grow while staying at a healthy weight. • To measure portion size exactly, use measuring cups and spoons (or a food scale). When these tools are not available use these tips: PALM OF HAND OR DECK OF CARDS = 3 OZ. OF MEAT TENNIS BALL = 1 MEDIUM PIECE OF FRUIT FIST OR CUPPED HAND OR BASEBALL = 1 CUP GOLFBALL OR PING PONG BALL = 2 TABLESPOONS

35. HEALTHY KIDS BROCHURE TIPS FOR EATING RIGHT - AFFORDABLY ENERGY BALANCE • Plan Menus and Make a list • Use Coupons and Rewards • Buy Store Brands • Buy on Sale • Compare Unit Prices • Read Food Labels • Shop Seasonally • Pay Attention at Checkout (ensure items ring up correctly)

36. HEALTHY KIDS BROCHURE WEIGHT MANAGEMENT GOALS • Making small lifestyle changes is important for your health, living a long life, self-esteem, and quality of life: • The reason I want to make eating and exercise changes is because ______________________________________________________. • Choose a healthy breakfast ____ days a week. • Chose whole wheat or whole grain products throughout the day ____ days a week • Drink calorie-free beverages or fat-free milk with meals and snacks ___ days a week. • Eat ___ servings of fruit and vegetables ____ days a week. • Eat 3 meals per day ___ days a week. • Limit Fast food to ____ times a week. • Limit TV and Video games to ___hrs per day ____ days per week. • Eat snacks and meals in the kitchen or dining room only ____days a week. *Remember to turn off the TV, iPads, mobile phones. • Exercise at your level ____ minutes a day ____ days a week.

37. HEALTHY KIDS BROCHURE QUICK LOOK AT ENERGY BALANCE Making lifestyle changes can be difficult, because we know it's hard to break unhealthy habits, and it also takes time to create new healthy habits. It take the brain about two months to turn a new behavior into a habit. Source: http://caloriecount.about.com

38. MOTIVATIONAL INTERVIEWING MI Concepts • Rolling with Resistance • Validation • Reflection

40. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!