1. CMA Foundation Childhood Obesity Multicultural Communications Webinar
Asian Pacific Islander Community Webinar | November 8, 2012
Childhood Obesity – Strengthening the Capacity of Healthcare Providers to Work in Multicultural Communities in the Clinical Setting

2. The Partnership
In 2010, the Federal Office of Minority Health, provided funding support to the California Office of Multicultural Health to initiate a partnership with the CMA Foundation to increase awareness among healthcare professionals about the impact and importance of race, ethnicity and culture on pediatric overweight and obesity.
This collaboration lead to the update of the Child and Adolescent Obesity Provider Toolkit in 2011 and the development of a series of webinars to provide additional support to healthcare professionals addressing these issues in 2012.
This slide provides a background to participants regarding how the webinars fit with the Toolkit. Mayra, since you were on the Expert Panel that created the Toolkit, you may want to make a brief mention of that here as well.

3. Webinar Faculty Raynald Samoa, MD Assistant Professor City of Hope
Here is where you will introduce yourselves, or we can introduce you. We’ve done it both ways. How would you prefer to do this? It would also be good to provide some background for HealthCare Partners – What it is, how it is organized and how it works with the Latino community in LA County.
Raynald Samoa, MD Assistant Professor
City of Hope
Department of Diabetes, Endocrinology and Metabolism
Sophia Yen, MD, MPH Assistant Professor Division of Adolescent Medicine
Department of Pediatrics Lucile Packard Children's Hospital
Stanford University School of Medicine
Ricky Y. Choi, MD, MPH, Department Head of Pediatrics
Asian Health Services Community Health Center

4. Physician Champions - Obesity Prevention
Disclosure Statement
We have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this activity.
We do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

5. Webinar Objectives
Using a case presentation format, participants will be able to:
Identify how culture and ethnicity can influence Asian-American and Pacific-Island patients' decision making related to overweight and obesity.
Identify in which target areas (diet, physical activity) APIs are at greater risk for overweight and obesity.
Describe effective patient/provider communication techniques to help families understand behaviors they can take to help their child reach healthy weight/lifestyle/behaviors, particularly focusing on increasing healthy food choices.
You’ll want to review these with the participants.

6. Complexities of “Asian”
Afghanistan
Armenia
Azerbaijan
Bahrain
Bangladesh
Bhutan
Brunei
Burma
Cambodia
China
Cyprus
Georgia
Hong Kong
India
Indonesia
Iran
Iraq
 Israel
Japan
Jordan
Kazakhstan
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Lebanon
Macau
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen

7. Diversity of Pacific Islander
Micronesia
Tonga
Fiji
Papua New Guinea
Wallis and Fatuna
Cook Islands
Niue
Hawaii
Samoa
Maori
Aborigines
New Caledonia
Guam
Northern Marianna
Tahiti
Tokelau

8. Case
14 yo Chinese American male presents to clinic with mother for well child check. Noted to have BMI of 28. He gained 10 lb over the summer when he traveled to visit relatives in China. He lives with his parents and grandparents. He is getting As/Bs in school. At home prefers to spend free time playing video games over outdoor activities.

9. Case
While mother is concerned about his weight, grandparents are dismissive.
Grandmother does most of the cooking while parents work late.
Dietary history: He usually eats noodles for breakfast. Meals at home are family style. He prefers salty meat and eats 2 small bowls of rice at each meal, ramen noodles 2x a week.

10. Why is This Important
In the “State of Asian American, Native Hawaiian and Pacific Islander Health in California Report,” Pacific Islander children had the highest rates of 5th graders in the unhealthy zone for body composition of all ethnic groups in the state
In Hawaii, Samoan children had the highest prevalence of overweight, and 29% of all 4 & 5 year olds in Hawaii (multiethnic cohort) were either overweight or obese.
In a study conducted at a large community health center in New York City, 40% of Chinese US born boys, aged 6–11 years, were identified as overweight or obese.
The LA County Department of Public Health looked at Fitnessgram and found that 49% of Samoans in 5th, 7th, & 9th grades were obese.

11. Definitions of the Epidemic
In 2001, the Surgeon General declared
“overweight and obesity” a national epidemic.
Originally Different definitions, but now the same
BMI Adults /Children
>85th%-94th% overweight
>95th% obese
For adults
Overweight is defined as:
Obese is defined as BMI of 30 or greater
This has been extrapolated to represent
For children
Overweight is defined as >/=95th%
At risk for overweight is defined as >=85th% and <95th%
According to CDC 2000 growth charts by sex and age
AMA/HRSA/CDC expert committee 6.07 recommended that the definitions be the same.
and studies have shown that Chinese/Malay and INdian should be considered obese at lower BMIs for the same body fat…
e.g. 26/27 versus 30 in whites…

12. Body Mass Index (BMI) Weight (kilograms) BMI = [Height (meters)]2
or lbs
x703
in2

13. BMI of 18 for 4 y/o = high, but 12 y/o = normal
also, the weight dips and comes back at about 4 years old

14. CDC BMI charts not based on APIs
APIs had same % body fat as Caucasian at BMI 3-6 points higher
South Asians are thinner but have greater body fat and higher insulin sensitivity for any given BMI
33% of obese APIs (%BF >25 % for boys, >30 % for girls) not identified using WHO criteria
Br J Nutr Nov;106(9): Epub 2011 May 31.
Ethnic differences in the relationship between body mass index and percentage body fat among Asianchildren from different backgrounds.
Liu A, Byrne NM, Kagawa M, Ma G, Poh BK, Ismail MN, Kijboonchoo K, Nasreddine L, Trinidad TP, Hills AP.
Source
National Institute of Nutrition and Food Safety, Chinese Center for Disease Control and Prevention, Beijing, China.

15. BMI by Ethnicity Per 1996 Medical Expenditure Panel Survey:
APIA teens more likely to be overweight than Hispanics, blacks and white (non-Hispanic) teens
APIA teens had 4.35 X the odds of being overweight compared to whites/blacks
overweight in this case was >95th percentile

16. Consequences of Childhood Obesity
Low self-esteem
Asthma
Sleep apnea
Heart disease
Type 2 diabetes
Fatty liver
70% chance of being obese adults

17. What Contributes to Obesity among Children?
Genetic factors
Behavioral factors
Food intake
Physical activity
Environmental factors
Homes
Childcare or schools
Community IN
OUT
OUT IN

18. Which Foods Predispose to Weight Gain?
Fast food
High in saturated fat & sugar
Low in protein
2003 CHIS showed:
26% of 2-5 y/o APIAs ate 2 or more servings of “high-sugar foods” per day
vs. 23% of African Americans
cookies, candy, doughnuts, pastries, cake, or popsicles

19. Many Asian Teens Eat Fast Food 4+/wk
2009 CHIS showed:
17% of Asian teens vs 10% of whites

20. Eating out adds calories
fast-food restaurant increased calories by
126 calories in 2-11 y/o
309 calories in y/o
full-service restaurant
160 calories in 2-11 y/o
267 calories in 2-11 y/o

21. Which has more calories?
Juice
Soda

22. Answer?
Juice 14 cal/oz vs Soda 12 cal/oz
Juice has more calories!

23. Foods That Cause Weight Gain
Drinks with Calories
Juice, soda, sports drinks, 1%/2%/whole milk
Whole milk is OK until 2 years old
AFTER 2 years old, kids should drink non-fat milk
Water is best
Large portion size
All-you-can-eat
More than in “homeland”
Rice, Fatty meat

24. Physical Inactivity Watching TV Playing video games
Browsing the Internet

25. 19% of Asians 3-5 y/o Watch More TV Than Recommended
<1 2 3
4-5
6-20
19% of Asians 3-5 y/o Watch More TV Than Recommended
2005 CHIS, 19% of kids 3-5 y/o watched more TV than the AAP recommends
improved from 2001
12.2% 14,000
Less than 1 hour/day43.1% 50,000
2 hours/day25.7%)30,000
3 hours/day9.8%)11,000
4-5 hours/day7.9%)9,000
6-20 hours/day1.0%*

26. 2005 CHIS, y/o Asians
California Health Interview Survey

27. % Asian Teens that are Overweight/Obese
Teen Boys Worse Than Girls

28. CHIS
Asians had the lowest fruit/vegetable consumption!

29. Asians had the lowest amount of vigorous physical activity in the past week

30. Case
14 yo Chinese American male presents to clinic with mother for well child check. Noted to have BMI of 28. He gained 10 lb over the summer when he traveled to visit relatives in China. He lives with his parents and grandparents. He is getting As/Bs in school. At home prefers to spend free time playing video games over outdoor activities.

31. Case
While mother is concerned about his weight, grandparents are dismissive.
Grandmother does most of the cooking while parents work late.
Dietary history: He usually eats noodles for breakfast. Meals at home are family style. He prefers salty meat and eats 2 small bowls of rice at each meal, ramen noodles 2x a week.

32. Components for change
Motivation
Resources
Change
Culture

33. Cultural Context Most Asian Americans are new immigrants
66% born outside of the United States
Many parents experienced scarcity in childhood
Scarcity mindset: “finish every grain of rice”, meat
While some live in isolation, others live in multigenerational homes and close knit communities
Parents receive input/pressure on child rearing
Most APIs are new immigrants, so bring their cultural experiences to American living.
Scarcity: Vietnam war, recent modernization or still developing country, rural setting. But eating habits that are advantageous in scarcity contribute to obesity in the United States
Influences: you may be able to educate the parent that comes with the child at the office visit, but don’t be surprised if your talking points are over ruled by a strong willed grandparent or community member. Parents are under enormous pressure from multiple people

34. Cultural Context
Different sources of unhealthy foods/extra calories: salty meat, other high calorie drinks (boba milk tea), instant ramen noodles, white rice, snacks from grandparents
Traditional food may not be so healthy
Carbohydrates
Pork, shrimp, beef
Fried foods - Lumpia, Tempura
Recognize food is an intimate connection to culture and community
Foods are now so abundant that the old way of cooking with more vegetables and little meat is being replaced with much more fatty mea tand little vegetables in meals
Asian take out foods are unhealthy because of the similar replacement with unhealthy ingredients such as fatty meats

35. Cultural Context
“Plate method” difficult to translate into family style meals
Obesity not just a problem in the US.
Families may have limited knowledge of some fruits and vegetable that are available in the US.

36. Improving Patient Communication to Improve Health Outcomes
Patient Values
Goal Alignment
Resources
Patient Adherence
Health Outcomes
Provider Guidelines
Improving Patient Communication to Improve Health Outcomes
This makes it critical to identify how we improve communication with our ethnically diverse patients to improve health outcomes.

37. Recommendations 1) Breast Feeding % obesity in NON BF BF 4.5% 2.8%
4.5% 2.8%
Longer is better % obesity
2 mos 3.8%
3-5 mos 2.3%
6-12 mos 1.7%
>12 mos 0.8%

38. Recommendations
2) Healthy Meals - Careful dietary history including ethnic snacks (high calorie drinks) - Identify the person who prepares food for the child. Educate THAT person. - Suggest culturally acceptable food alternatives: Brown rice (vs white rice), ethnic vegetables, avoid fried food -More fish and chicken, less beef/pork - Eat >5 servings of vegetables/fruits per day
If it is mom’s mother in law, invite her to come in and talk. The mother/father may be disempowered
Explain that small changes can make a big difference
Don’t forget ramen
11 yo Obese male.  How should you change your diet?  "eat more veggies, fruits". How about less? "less snacks, meat, candy, junk food".  How about less rice?  "but I am Chinese!”
Some asians kids are led to believe that if they are smaller in stature, than academic prowess can over come. Parents may emphasize education over sports and physical activity. As over achievers they get frustrated easily with weight loss

39. Recommendations Healthy Meals (cont)
- Encourage family to try new fruits and vegetables
- Avoid fast food
- Stress appropriate serving size

40. Recommendations
3) Brawn helps brain – being fit is key 4) Emphasize importance of setting life long healthy diet and activity patterns 5) Recognize the other competing priorities (stresses of acculturation) and plug them into community activities 6) Screen Time Limit screen time to < 2 hrs/day. Don’t eat in front of a screen.

41. Recommendations 7) Strengths: Involve the whole family Family meals
Be physically active together
Plan active family fun

42. Conclusions
Overweight and obesity is an important concern in the API community
API children are less physically active, watch more screen time, eat more fast food, and eat fewer fruits and vegetables.
Ethnic/Cultural accommodations are important in promoting a healthy lifestyle

43. Questions?

44. Multicultural Resources in the Toolkit
EthnoMed –
Healthy Roads Media -
MiPiramide –
Hawaii Pediatric Weight Management Toolkit-
by contacting Chock
Consumer Health Materials in Spanish –
Think Culturally (Office of Minority Health) –
The Provider’s Guide to Quality & Culture –

45. Community Resources for Healthy Eating
Have your staff identify resources available in your community to help you help your patients. These may include the YMCA, health plans, school based programs, faith based organizations, local hospitals, parks and recreation programs and community centers.
Have the list easily available in your office.
Web based Resource List
Academy of Nutrition & Dietetics
Kids Health from Nemours
American Assoc. of Diabetes Educators
USDA Food & Nutrition Services
California Dietetic Association
YMCA of the USA
United States Department of Agriculture
NCES Health and Nutrition Education
I would like to add here a couple of sites that I use regularly:
NCES Health and Nutrition Education- great site to get patient education tear pads in English and Spanish, Posters, Food models to have in the office. The educators, nutritionists and dieticians find this to be of value.
choosemyplate.gov: great information for clinicians, parents and kids. Extensive Spanish section as well.