Healthy Weight Matters

1. Healthy Weight Matters Young Women & the Reproductive Consequences of Obesity

2. Acknowledgements • This training was developed by the North Carolina Preconception Health Campaign, a program of the North Carolina Chapter of the March of Dimes, under a contract and in collaboration with the North Carolina Division of Public Health, Women’s Health Branch. • This material was developed through support provided by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health, Office of Adolescent Health (grant #SP1AH000004).

3. Acknowledgements • Many thanks to these agencies and individuals for their generosity in sharing their resources: • Corrine Giannini, RD, LDN • Shannon Kellner, RN, MPH • Merry-K Moos, FNP, MPH, FAAN • Alvina Long Valentin, RN, MPH • North Carolina Division of Public Health, Women’s Health and Physical Activity & Nutrition branches • Specific resources used to guide the development of this training: • Eat Smart Move More North Carolina resources • The National Preconception Curriculum and Resources Guide for Clinicians (Module 1: Preconception Care: What it is and what it isn’t)

4. Young Moms Connect • Brings together community partners to address challenges faced by pregnant or parenting teens using collaborative, multi-faceted strategies • One component of Young Moms Connect is training for health care providers on six maternal and child health best practices

5. MCH Best Practices • Early entry and effective utilization of prenatal care • Establishment and utilization of a medical home (for non-pregnant women) • Reproductive life planning • Tobacco cessation counseling using the 5 A’s approach • Promotion of healthy weight • Domestic violence prevention

6. Objectives • Understand the relationship between healthy weight status and opportunistic preconception health counseling • Understand trends in overweight/obesity for women of childbearing age • Increase awareness about the connections between weight status and birth outcomes • Improve weight status assessment and counseling skills

7. Objectives (continued) • Improve service delivery (within a practice or across agencies/partners) to encourage patient weight status screening and weight management counseling • Increase awareness of reimbursement options for weight status counseling • Increase awareness of healthy weight resources for patients and providers

8. What is preconception care? • Identification of modifiable and non-modifiable risk factors for poor health and poor pregnancy outcomes before conception • Timely counseling about risks and strategies to reduce the potential impact of the risks • Risk reduction strategies consistent with best practices CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules

9. Components of preconception care • Giving protection • (eg.: folic acid, immunizations) • Managing conditions • (eg.: diabetes, maternal PKU, obesity, hypertension, hypothyroidism, STIs, sickle cell) • Avoiding exposures known to be teratogenic • (eg.: medications, alcohol, tobacco, illicit drugs) CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules

10. “Opportunistic” care • Preconception care is for every woman of childbearing age every time she is seen • Every woman, every time CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules

11. Weight status prior to pregnancy • Women of childbearing age who are overweight or obese are at higher risk of poor maternal and birth outcomes than women who enter pregnancy at a healthy weight • Achieving and maintaining a healthy weight is one key component of preconception care

12. Obesity in North Carolina • In 2010, nearly two-thirds (65%) of adults in North Carolina were either overweight or obese • From 2001 to 2010, the proportion of N.C. adults who were overweight or obese increased from 59% to 65% NC Behavioral Risk Factor Surveillance System, 2011

13. Women & weight in North Carolina • 58% of women in NC of childbearing age (18-44) are overweight or obese • 43% of young women ages 18-24 are overweight or obese • There is also a racial disparity in weight status • 56% of white women are overweight or obese • 73% of African American women are overweight or obese • 56% of other minorities are overweight or obese NC Behavioral Risk Factor Surveillance System, 2010

14. Obesity among North Carolina mothers

15. Pieces of the puzzle http://www.eatsmartmovemorenc.com/ESMMPlan/Texts/ESMMPlan_Reduced.pdf

16. Consequences • U.S. society focuses on external consequences of overweight and obesity, i.e. how we look • As health professionals it can be helpful to re-frame discussions toward medical/physical consequences of overweight and obesity • For women of childbearing age the consequences of overweight & obesity span two generations • Risk of consequences increases progressively as BMI increases Kellner, S. Maternal weight: An opportunity to impact infant mortality in North Carolina. 2010.

17. Pregnancy risks • Increased pre-pregnancy BMI is associated with increased risk of: • Preeclampsia • Gestational Diabetes • Gestational Hypertension • C-section • Induction of labor • Post-Partum hemorrhage Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010.

18. And for the baby….. • Macrosomia • Preterm delivery • Poor APGAR scores • NICU admission • Shoulder dystocia • Late fetal death • NTDs (Anencephaly and spina bifida) Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010.

19. The cycle repeats • Babies born to overweight mothers are more likely to become obese children • The likelihood that overweight children will become obese adults is almost nine times higher than the risk for children who are not overweight

20. Beyond pregnancy… • Women who are overweight or obese are more likely to have: • A higher risk of uterine cancer (2-5 times greater) • Increased risk of death from uterine and breast cancers • Problems getting pregnant • Greater risk of contraception/birth control not working • Irregular periods • Depression P-Sunyer FX.. Medical hazards of obesity. Ann Intern Med. 1993;119;655-660.

21. How do you define healthy weight? • A weight range that correlates with a less than average risk for health conditions like heart disease, high blood pressure, and diabetes Giannini C, 2009

22. Providers and weight • Most overweight patients believe they should lose weight, but this is seldom discussed during visits with health care providers • Most patients want more help with weight management than they are getting from their primary care physicians Potter MB, Vu JD, Croughan-Minihane M. Weight management: what patients want from their primary care physicians. Fam Pract. 2001 Jun;50(6):513-8.

23. Why don’t patients ask for help? • Frustration from prior attempts • Lack of motivation • Lack of knowledge • Lack of family or community support • Fear of embarrassment • Cost concerns • Racial disparities- Caucasian women had a more negative view of obesity than did African American women • Bardia A, Holtan SG, Slezak JM, Thompson WG. Diagnosis of Obesity by Primary Care Physicians and Impact on Obesity Management. Mayo Clin Proc. 2007;82(8):927-932.

24. Why don’t providers bring it up? • Lack of time to counsel • Lack of knowledge • Fear of embarrassing patient • Frustration from prior attempts • Forgetting to talk about it or document it • Perception of patient motivation • Lack of belief the treatment will be effective • Possible influence of provider’s weight status • Bardia A, Holtan SG, Slezak JM, Thompson WG. Diagnosis of Obesity by Primary Care Physicians and Impact on Obesity Management. Mayo Clin Proc. 2007;82(8):927-932

25. Tips for talking with patients • Don’t ignore weight • Set small goals! Every little bit helps! Example: No more weight gain before next pregnancy • Use objective measures such as BMI

26. BMI: Body Mass Index • An objective way to start the conversation about a patient’s weight • In focus groups, young women, 18-24, were impacted by seeing their BMI on a chart • Combined with the words “overweight” and “obese” their awareness of their weight was raised and they felt motivated for change

27. BMI • A measure used to compare your weight to your height to assess your risk for weight-related health conditions • BMI= (_Weight in Pounds_) X 703 (Height in inches) x (Height in inches) • Opportunities: Family Planning Flow Sheet, Physical Activity & Nutrition Behaviors Monitoring Form

28. BMI

29. Body mass index for adolescents U.S. Office on Women's Health The BMI chart is designed for adults ages 20 and up For patients under 20, first calculate BMI with regular chart Then use this adolescent chart and find BMI on left Then find age at bottom and see where the two numbers meet

30. Healthy Habits for Life! • Interactive booklet • Review with client • Based on Eat Smart Move More • Order from Women’s Health Branch or NC Healthy Start Foundation • Let’s take a look…

31. Rethink Your Drink

32. Choose To Move More Everyday

33. Track It!

34. Eat Smart Move More (ESMM) • A statewide campaign that promotes increased opportunities for healthy eating and physical activity • Offers different tools for people in different settings including: • Community • Family • Worksite • Health care

35. How can this work for you? • Think about a particular patient that you recently saw who is overweight or obese • Which target behavior do you think would be the easiest for them to change? • Do you think this would be a good place to start? • Can you see yourself using these tips?

36. Eat Smart Move More • For more information visit: http://www.eatsmartmovemorenc.com/

37. Improving service delivery • Are you motivated to begin or continue calculating your patients’ BMI’s? • Who will have this responsibility? • What change in practice can you make based on our discussion today? • What other tools do you need to begin?

38. Eat Smart, Move More, Weigh Less • Eat Smart, Move More, Weigh Less is a 15-week weight management program that uses strategies proven to work • The program is offered to worksites and other groups interested in eating smart, moving more and achieving a healthy weight • Each of the one-hour lessons informs, empowers and motivates participants to live mindfully as they make choices about eating and physical activity • The program provides opportunities for participants to track their progress and keep a journal of healthy eating habits and physical activity behaviors

39. Eat Smart, Move More, Weigh Less • http://www.esmmweighless.com/ • Trained instructors located in ________:

40. Additional resources • Everywomannc.com • Nchealthystart.org • Beactivenc.org • Livestrong.com (free daily tracker: my plate – livestrong.com/myplate) • Shapeup.org • Letsmove.gov

41. Reimbursement options • CPT code 97802. Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (service must be provided by a licensed dietitian/nutritionist or registered dietitian). • CPT code 97803. Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes (service must be provided by a licensed dietitian/nutritionist or registered dietitian).

42. Healthy weight before and between pregnancies Provider perspective: • Your patient’s weight today can impact her health and the health of her future children • Almost half of all pregnancies in North Carolina are unplanned • The next time you see your patient, she may be pregnant Patient perspective: • Losing weight is a goal for many women • Women actively planning pregnancy are often not aware of risks to themselves or baby due to overweight/obesity

43. Summary • Healthy weight is a critical component of preconception care • Overweight and obesity is associated with increased risk for poor maternal and infant outcomes • Providers can help by assessing female weight status at every visit and discussing Eat Smart Move More tips • Weight management counseling reimbursements are available • Many resources are available for patients, including the Healthy Habits brochure, online food trackers and phone apps