Healthy Children and Families

1. Healthy Children and Families PonratPakpreo, MD, MPH CHER Community Dietician Presentation April 30, 2013

2. Objectives • Understand the current epidemic of pediatric obesity. • Gain better understanding of the multifactorial contributors to pediatric obesity from a biopsychosocial model. • Review potential screening questions, tools and tips to assess and manage pedatric obesity and overweight. • Share and brainstorm ideas of what to do locally.

3. The Incredible Family!

4. Obesity Trends* Among U.S. AdultsBRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

7. Body Mass Index for Children and Adolescents • Underweight • BMI-for-age, gender <5th percentile  • Healthy Weight • BMI-for-age, gender 5th to 84th percentile • Overweight • BMI-for-age, gender 85th percentile to 94th percentile  • Obese • BMI-for-age, gender >95th percentile • BMI > 30 kg/m2 Centers for Disease Control

8. Body Mass Index for Children and Adolescents • “Morbid” Obesity Proposed • BMI > 99% or BMI 30 – 32 kg/m2 10 to 12 years old • BMI > 99% or BMI > 34 kg/m2 14 to 16 years old • “Extremely Obese” Proposed • BMI at or above 120% of the 95th percentile for children of the same age and sex Centers for Disease Control

9. National Childhood Obesity Awareness Month http://www.healthierkidsbrighterfutures.org/

10. Childhood Obesity Rates • Approximately 17% (or 12.5 million) of children and adolescents aged 2—19 years are obese (NHANES 2010). • There are significant racial and ethnic disparities in obesity prevalence among U.S. children and adolescents. In 2007—2008, Hispanic boys, aged 2 to 19 years, were significantly more likely to be obese than non-Hispanic white boys, and non-Hispanic black girls were significantly more likely to be obese than non-Hispanic white girls.

11. NHANES (2010)

12. Childhood Obesity Rates • Pediatric Nutrition Surveillance System 2009 • 27.5 million children, 2-4 years old, 30 states and District of Columbia. • 1 of 7 low-income, preschool-aged children is obese . • Obesity and extreme obesity among U.S. low-income, preschool-aged children went down for the first time in recent years. • Extreme obesity significantly decreased among all racial groups except American Indians/Alaska Natives. The greatest decrease was among 2-year old and Asian/Pacific Islanders.

14. Obesity in Kids • 1 in 3 American children are overweight or obese. • Higher risk of heart disease, bone and joint problems, sleep apnea, diabetes, psychological problems including those related to bullying, and other preventable medical conditions. • Children of overweight or obese parents are twice as likely to be obese. • Obese children and adolescents are more likely to become obese adults.

15. It’s not just about food…

16. Biological, psychological, and social factors exist along a continuum of natural systems • Relationships are central to providing health care. • Use self-awareness as a diagnostic and therapeutic tool. • Elicit the patient’s history in the context of life circumstances. • Decide which aspects of biological, psychological, and social domains are most important to understanding and promoting the patient’s health. • Multidimensional treatment (Multidisciplinary?). Biopsychosocial Model George Engel, MD

18. “Daisy”, 16 y/o, 5’4”, 300lbs • Type II DM, HTN, SCFE, PCOS • Doesn’t like to be active • Stress eating • Reactive Attachment Disorder, Depressed, etc. • “Runs in my family” • MVA and immobilized at age 12 y/o • “I like food” • “Worst Case Scenario” pantry • Food bank, scary neighborhood, bullied at school • “We don’t know how to cook” Cnn.com

19. It’s more than education…

20. Behavior Change • Education • Motivation • Support • Barriers • Resources

21. Motivational Interviewing Resources: • CMS: Decision memo for intensive behavioral therapy for obesity (CAG-00423N). www.cms.gov • www.motivationalinterview.org • Kaiser Permanente, Motivating Change Online Programs. www.kphealtheducation.org/resources/

22. CMS Suggestions for Behavior Change • Assess: Ask about behavioral health risks and factors affecting choice of behavior change, goals, methods. • Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits. • Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest and willingness to change the behavior. • Assist: Using behavior change techniques (self-help and /or counseling), aid the patient in achieving agreed upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate. • Arrange: Schedule Follow-up contacts (in person or by telephone) to provide ongoing assistance /support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment. CMS decision, November 29, 2011

23. Obesity: Behavior Change 5’sInitial Visit • Ask: Is your weight a concern? • Assess: What is the patient’s readiness or interest in change? • Advise: Clear, specific, individualized, non-judgmental recommendation. • Assist: Assist patient in developing a specific plan for behavior change (setting goals). Offer resources and/or referrals • Arrange: Arrange for follow-up to check on patient’s progress in changing their behavior. Tip: Print out their goals and hand it to the patient (and parent)

24. The 5 A’s and Providers • Providers are less likely to Assess, Assist, Arrange than they are to Ask and Advise. • It can be brief, but obesity counseling can be more time intensive. • Multidisciplinary team approach (dietician, exercise physiologist, behavior coach). • More successful with more visits (12 to 26 per year).

25. The 5 A’s and Providers • More successful with more intensive interventions. • Self-monitoring, setting weight-loss goals, addressing barriers to change, strategizing about maintaining long-term changes in lifestyle • Strategies that increase the likelihood of patients themselves identifying weight as a problem or providers identifying patient’s weight as targeted/addressed problem tend to increase weight management counseling.

26. Obesity: Behavior Change 5’sFollow-Up Visits • Ask: How did you do with your goals? • Assess: What were the successes and barriers to barrier change? Are they ready to move on to continued goal setting? • Advise: Clear, specific, individualized, non-judgmental recommendation (stay on same goal or add new goals). • Assist: Assist patient in developing a specific plan for behavior change. Offer resources and/or referrals • Arrange: Arrange for follow-up to check on patient’s progress in changing their behavior. Tip: Print out their goals and hand it to the patient (and parent)

27. Fast Tips

28. Obesity in Kids • Healthy nutrition and regular physical activity help kids and families stay fit, whether you are normal weighted or overweight. • Your health risks increase when you are overweight or obese, but you can lower those risks by improving your nutrition and increasing your physical activity.

29. Changing a Culture • Growing healthy kids is about a family’s lifestyle, how you look at food and activity, how you incorporate it in your daily lives and special events. • Things have changed since we were kids, more convenience foods, challenging schedules, changing neighborhoods, more technology and diversions that keep kids sedentary….let’s get back to basics.

30. General Advice for Parents • Parents have the greatest influence in a child’s life. • Check-in with yourself: what are your attitudes and beliefs about weight, food and exercise? • “Do as I do, not what I say!”: Model the healthy behaviors you want your children to exhibit (no special foods for mom or dad, the “secret stash”…your kids know where it is! Walk the walk and talk the talk!) • We’re teaching kids every moment, including when we sit down to eat or when we choose to sit outside and watch them play or join their play. (They are always watching and listening…even when they don’t seem to be!) • These are the habits they will learn to keep in their daily lives. Make them healthy habits.

31. It’s a Family Thing • Focus on the family. Don’t set overweight children apart. Involve your whole family and work to gradually change your family's physical activity and eating habits. • Focus on good health, not a certain weight goal. • Don’t be in denial about your child’s weight, but don’t make weight the focal point. • Teach and model healthy and positive attitudes toward food and physical activity without emphasizing body weight. • If your child shows signs of becoming overweight or has risk factors, work with your pediatrician to start prevention as early as possible. Don’t be satisfied with “They’ll grow out of it.” What is it that they are growing into?

32. Create Your Healthy Environment:Food choices • Parents do most of the grocery shopping, bring in healthy foods, keep unhealthy items out or limit them. • Mealtimes should be family times. Create a relaxed atmosphere around mealtime.  Eat slowly and enjoy your food. Eat together as a family, and don’t watch TV during meals. • Families that do not eat together tend to consume more fried foods and soda and less fruits and veggies than families that share meals.

33. General Advice about Eating • Kids love routine….Serve meals and snacks at regular times during the day, and eat together as frequently as possible. • Don’t scrutinize the amounts your child eats or nag your child to eat at mealtime.   This can interfere with your child’s response to hunger and feeling full.  These two responses are an important basis for healthy eating behaviors. • Serve them a sensible portion. • Turn off the TV while eating, pay attention to your body and hunger • Snacks can be healthy, several small meals/snacks a day • Let the child decide whether and how much to eat: “No Thank You Bite” • You don’t need to clean the plate • Don’t use food as a comfort measure (treats when we’re sad, kid’s fast food meal to make up for broken promises, etc.) • Binge eating, emotional eating, stress eating

34. Keep Track of the number of servings a day. http://www.permanente.net/homepage/kaiser/pdf/40863.pdf

35. Create Your Healthy Environment:Get Moving • Encourage physical activity.  • Make sure your kid gets outside during daylight hours.  This encourages physical activity, and rules out the inactive pursuits of TV and other media. • Build activity into your family's daily life with household chores, walking to school, parking farther from buildings and taking the stairs. • Decreasing inactivity works better for long-term weight loss than focusing on vigorous aerobic exercise. It's also an easier lifestyle change for your family to make!

36. General Advice about Physical Activity • Kids need 8 to 10 hours* of sleep. • Not enough sleep is associated with obesity • Limit television-viewing time.  There is a direct relationship between the amount of time spent watching TV and degree of overweight . • TV-viewing can directly cause obesity through replacing physical activity, increased eating while watching, and reduced metabolism while watching. • Television can also have an indirect effect; advertisements can influence kids to increase their calorie intake by eating and drinking more junk food/beverages. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

37. Ages and Stages

38. PreConception • If you are a woman in the childbearing years, you should maintain a healthy weight, which helps prevent obesity in your future children.  • Entering pregnancy with a healthy weight also helps prevent gestational diabetes and lowers kids’ risks of developing diabetes. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

39. Prenatally • Mothers-to-be do not actually need to “eat for two.”  Overeating in pregnancy and gaining excessive weight can put both mother and child at risk for obesity. • Good nutrition is critical in pregnancy.  Undernourished fetuses are also at increased risk of later obesity. • Get good prenatal care. • Work with your midwife or obstetrician, and also with a nutritionist, if recommended, to maintain healthy eating habits and a healthy weight all through your pregnancy. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

40. Infants • Breastfeed for at least a year.  • Babies need a higher percentage of their calories as fat.  The best fats for infants are the fats found in breastmilk. • Breastfeeding is a mother’s first experience with paying attention and responding to baby’s feelings of hunger and fullness.  There is no bottle to measure your baby’s intake, so it’s all based on your baby’s cues.  • If your baby is bottle-feeding, it’s important not to focus on the number of ounces, but rather baby’s cues about hunger and fullness. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

41. Infants • Introducing solid foods: • Eating habits started in infancy continue through the lifespan, so emphasize grains, vegetables and fruits and regular family meals at the table. • Your baby can start eating solids at around 4-6 months of age.  Your pediatrician can talk to you about how to tell whether your child is ready.  If your baby gags or chokes at the first feeding, wait a week or so before trying again. • Children learn by imitation.  Consider your family’s eating patterns (parents, siblings, and extended family).  Is your baby learning what you want them to learn about eating?  • Focus on your child’s cues about their hunger and fullness, rather than on how much is left in the jar of baby food.  http://www.med.umich.edu/yourchild/topics/fightobesity.htm

42. The second year (1 year old) • 1-year-olds can transition from formula or breast milk to whole cow’s milk. • 1-year-olds still need more of their calories to come from fat.  • Kids are on the move, and need to eat frequently.  Use snacks as a chance to get super-healthy foods into your child.  • Focus on fruits and vegetables, and whole grains and keep juice to less than four ounces (half a cup) a day.  • Avoid “typical snacks”: juice, processed crackers, cookies and sugary yogurt and granola bars.  They are high in calories, unhealthy fats, and low in nutrients and fiber. These foods can be eaten as an occasional treat.  • Avoid foods that can cause choking. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

43. Juice and Transitioning Milk • American Academy of Pediatrics' guidelines on juice: • Sipping juice all day can lead to tooth decay. • 1 to 6 years old: fruit juice should be limited to 4 to 6 ounces per day (about a half to three-quarters of a cup). • 7 to 18 years old, fruit juice be limited to no more than 8 and 12 ounces a day. • All children and teens should be encouraged to eat whole fruits instead of juice. • To reduce the amount of milk or juice your child takes in, try diluting your child's milk or juice with water, and each day gradually adding more water until your child is drinking plain water to quench their thirst. This will help them make the change little by little. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

44. Preschool (2 to 5 years old) • Continue to emphasize fruits and vegetables. • Protein can come from beans, grains, lean meat, fish, poultry, and tofu.  • Choose 2% milk unless your pediatrician advises milk with more or less fat for your child. • Kids develop food habits and preferences by age 2-3—mainly thru the family environment.  They will have their habits formed by following your role modeling, and through your positive and negative responses to their choices. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

45. School Age • Eating in front of the TV, or any screen, is associated with greater risk of obesity. • Keep unhealthy foods out of the house or out of your kids’ control • Set firm rules about healthy snack choices. Teach them. • Don’t allow eating in bedrooms.  • Children home alone after school need guidelines for snacks and food safety . • Consider soda pop an occasional treat rather than a regular beverage.  Water should be the beverage of choice. • Choose 1% or 2% milk for your child unless your pediatrician advises milk with more or less fat for your child. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

46. Adolescents • Teens are growing fast, and may need more calories—so try to keep it high in nutrients, and low in saturated fats, cholesterol and sodium. • Teach your adolescent about nutrition—they are making more choices for themselves.  • Choose healthy foods for family meals and keep unhealthy foods out of the house. • Make sure your teen eats breakfast. • Guide your teen in choosing the healthier options at fast food restaurants and convenience stores. • Encourage your teen to choose bottled water from the vending machine at school rather than soda pop. • Milk continues to be an excellent source of protein, calories and calcium. Choose skim milk unless your pediatrician advises milk with more fat for your child. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

47. The “Picky Eater” • Treat Food Jags Casually • Consider what they eat over several days • Set reasonable time limits for start and end of a meal. • Trust your child’s appetite, rather than forcing them to eat (leads to overeating) • Stay positive, avoid criticizing. • Serve food plain • Avoid being a short-order cook • Limited choices: Provide just 2 or 3 choices and let your child decide. • Substitute a similar food • Focus on your child’s positive eating behavior. Nibbles for Health, USDA

48. Trying New Foods • Offer new foods at the beginning of the meal when kids are hungry. • Have your child choose a new food as you shop. • Taste test: talk about new food. • “No Thank You Bite”: try for a bite, but don’t force your child to taste. Keep it positive. • Encourage your whole family to try new foods. Keep quiet if you do not like the food. • Prepare new foods in different ways (be creative). • Try again. Some kids need to try new foods several times before they like it. • Relax: Everyone has different favorite foods. Nibbles for Health, USDA

49. How can I help my child lose weight, or stay a healthy weight? • Don’t be discouraged. Obesity develops over time and cannot be solved overnight.    Do not expect dramatic change.  That is unrealistic.  • The best way to have a healthy weight is prevention. Be sure your family has healthy habits from the beginning, and prevent yourself and your children from becoming overweight. It is much easier to maintain a healthy weight than it is to lose weight. • Work with your child’s doctor on weight loss. http://www.med.umich.edu/yourchild/topics/fightobesity.htm

50. Goal Setting • Set short-term goals for changes in your child’s diet and exercise on a weekly basis.  Update your goals each week.  Write them down.  Examples of goals include setting a time limit on TV watching, and taking a walk every day. • Make sure the goals you set are realistic.  For example, exercising an hour every day is unrealistic for a child who is de-conditioned, and not used to even minimal physical activity.  • Use rewards when your child meets their weekly goals.  Rewards could be special time with you doing an activity your child enjoys or a special toy. • **Have your child keep a record of their food intake and exercise.  This will allow them to be more self-aware of their behavior.  Then look at the record together, one-on-one, and go over it.  Give them positive feedback. Don’t hyperfocus. http://www.med.umich.edu/yourchild/topics/fightobesity.htm