6 5210 Basics Stuff you need to know Next Steps Engaging the Patient Put it into Play TOMORROW
11 year old well visit – obese Doc #1. Give HPV, Menactra, and Tdap and make appt for next year. Doc #2. Ask, “Is it ok if we talk about your weight?” Doc #3. Say, “I have some concerns about your health and want to set you up to see my partner.”
Evidence Based National Guidelines Expert Committee 2007 –Comprehensive review of literature – evidence for 5210 Pediatrics 2007;120;S229-S253 5210 are proven determinants of obesity. 1
Evidence Based National Guidelines US Preventative Services Task Force 2010 –Reviewed 13 behavioral and 7 pharma trails. 2
USPSTF BMI is an Acceptable Measure Moderate – Intensive Intervention Counseling Physical Activity Behavioral Management Techniques Parent Involvement Pharma works modestly, but not recommended presently
Evidence Based National Guidelines White House’s Childhood Obesity Task Force 2010 – Let’s Move campaign –Motivated partnerships for intervention – private, public partnerships. 3 As White House tackles obesity, lawmakers eye soda as culprit
Pediatric Obesity Clinical Decision Support Guide (5210 Flip Chart) Outlines basic initial MEDICAL EVALUATION in the office Annual Physical Separate Visit
BMI% PLUS…………… Family History – Obesity – Diabetes – Hyperlipidemia – Early Heart Disease Comorbidity Symptoms Family History Counts
Endocrine causes of obesity is more likely in the short kid or tall kid? EXAM
Facial hair and acne is sometimes a sign of what? A.Increased chocolate consumption B.Increased androgens
Underarm NECK This person has: A.A rash from a necklace. B.Bad eczema C.Acanthosis Nigricans
This rash is from what? A. Cutting behavior B. Skid burn from the carpet C. Rapidly stretching skin
Exam Sometimes helps. Low pay off, but does help identify disease that deserves further medical evaluation. Target: – Cardiac exam – Hepatomegally – Hip issues
Should I Get Labs??????? Cholesterol Profile ALT or AST Fasting Glucose (now HgbA1C) TSH, free T4 – thyroid disease Cortisol, creatinine – Cushings DHEAS, free testosterone, insulin - PCOS Insulin levels – fasting? 2hr GTT? ? Ultrasound of liver ? ? Sleep study, Xray of hips, Cardiac MRI (not yet) ? Vitamin D?
Initial Treatment 5210 Pick a piece, try it out. MOTIVATIONAL INTERVIEWING – Ask permission – Elicit patient’s concerns – Provide positive feedback, celebrate successes. – Find discrepancies – Develop patient based plan – Explore Motivation and Confidence Solely 5210 can result in a healthy weight for some…………..
5210 works better with help Let’s Go – Messaging heard in more then 3 settings, increases probability of self reported change in behavior by 27%.
28 1. Connect to your community and the Let’s Go! community efforts:
30 3. Have a respectful conversation around weight.
Funding provided by The Harvard Pilgrim Health Care Foundation and MaineHealth
5-2-1-0 It starts the conversation For some it’s all they need For others – (esp. with BMI>95%) they need more
AAP NICHQ Let’s Go Maine AAP AAP Section on Obesity Let’s Go Online Teaching Modules – Fall 2013 Summer/Fall 2013
Let’s Go! Next Steps Provides structure, format, and content to visit Uses “19 Theme Visits” For Engaged Patient
Let’s Go! Next Steps, cont. Periods of Commitment Visits are over an extended period of time (?6- 12 mo?) ”Touch Points” MOST IMPORTANT: Patient/Family/Provider Triad decides on theme Clinician may need more training/skills - MI
Critical Concepts for Choosing Themes: Themes with greater pay off should happen earlier The patient’s/family’s culture should be considered and incorporated into the visits Provider’s expertise and knowledge base Use Universal Messaging across all visits, such as 5210 A BC THEMED VISITS
A B C (Tested against approx 25 providers (Peds, Family, Int Med, PA, RN), 3 dietitians, 1 physical therapist, 2 counselors, and 1 linguist)
A Category A theme will hopefully set the foundation for all of the other visits. POSSIBLE FIRST THEMED VISIT Purpose: Set the foundation Discussion ThemeMaterial for Discussion Understanding Health (Set a foundation for good health.) Define the origins of health—some is genetic and some family derived Focus should be on maintaining or improving current health Work with patients and families to understand that they are managing their health
The 6 Highest Pay-off Themes THEMED VISITS B NEXT COUPLE VISITSPurpose: Introduce concepts that are important to cover early for success Discussion Theme for Each VisitMaterial for Discussion Understanding Meaning of Healthy Food Eat less processed food Consume more fruit, vegetables, whole grains Discuss where to get healthy foods Discuss affordability of healthy foods Eat foods that are closest to their natural state— can they be found in nature or at a farm? Home Environment Create a supportive environment in house for success Enlist other family members, same healthy meals for all, not just for patient Be pro-active - get less healthy foods out of the house
Behaviors and Emotions Around Eating Encourage mindful eating—are you actually hungry? How do you know you are hungry? Address typical triggers for eating. Eating when fighting Eating when bored Eating when sad, angry, or lonely Eating with Television Most common solution= redirect to alternative activities to eating (e.g. go for a walk, play with a friend, do a craft) Portion Sizes (could be combined with label reading) Use balanced plate tool—consider giving out a physical example. (Picture of a plate with appropriate portions.) Sugary Beverages Consider using tools to review beverages, sports drinks, juices, teas—sugar bottle display? Consider graph depicting recommended sugar limits compared with amount in beverage. Combine with discussions about calcium, milk, and water NYC
Parenting Positive reinforcement is more powerful then punishments for behavior change. Target a high ratio of praise to commands/criticism. Practice this skill at office or with peers. Make comments specific, immediate, and genuine. Start small – target 1- 3 behaviors for change initially. Physical praise works as well (high fives, stickers, ect). Be prepared for resistance. Kids test limits or act out to see if parents mean what they said. Consistency pays off as an individual caregiver and between caregivers. 5210
THEMED VISITS LATER IN PROGRAM C Physical Activity Body Image Label Reading Screen Time Meal Patterns Non Home Environment – school, childcare, afterschool Snacks Holidays Community Partners Bullying and Teasing Unintentional Disruptions
Let’s Go! How to Pick a Theme ? Age BMI Readiness to Change
Let’s Go! MEDICAL PROVIDER VISITS (NP, PA, MD, DO, RN ) Purpose of Visits Physical Activity Television Breastfeeding DIETITIAN VISITS (RD, Nutritionist, Health Educator) Understanding Healthy Food Portion Sizes Label Reading Snacks Meal Patterns Calorie Balance PHYSICAL THERAPIST VISITS (OT, PT, CPT, AT, PhysEd) Physical Activity PSYCHOLOGIST OR SOCIAL WORKER VISITS (PhD, LCSW, LCPC,) Behavioral and Emotional Eating Who has the Conversation with the Patient/Family?
Let’s Go! 1. TIE the reason to something else – asthma, lab recheck 2. LOAD the plan for early program successes 3. CONSIDER having patient and family define the frequency of follow up. FOLLOW-UP – its hard!!!!
Let’s Go! 4. GIVE a prescription 5. RECOGNIZE that follow up is most likely to happen if the patient perceives value to the visit. 6. CREATE an atmosphere of FUN in the office. FOLLOW-UP – its hard!!!!
Red Flags to Treatment When is it time to consider additional medical work up and/or involving a specialist? Abnormal Labs Abnormal LabsHigh BP Abnormal glucose, cholesterol, AST/ALT PE Findings Significantly short height — chronic illness or hormone abnormalities. Abnormal sleep patterns — sleep apnea. Acanthosis Nigricans — insulin resistance. Abnormal Menses — PCOS Shortness of Breath or Exercise Intolerance — asthma. Significant Anxiety or Depression Other Reasons High BMI%ile and not progressing after 6-12 months towards a healthier weight. Patients with worsening comorbidities. Rapidly increasing BMI %ile.
Let’s Go! Change Talk Parent/Patient Choses Theme, but Doc choses options That might be best.
Let’s Go! Themes Encountered Meaning of Health Physical Activity Goal Setting – (could have used 1-10 scale) Next Time – Could Target – Parenting – Beverages – Physical Activity – Unintended Interruptions
Let’s Go! What Is Your Readiness To Change? Reflective Listening. Identify Barriers. Identify Solutions to barriers. Praise Effort. Support.
Let’s Go! Sept 11 – preconference on MI Sept 12 + 13 – conference www.LetsGo.Org Portland, ME Robert Schwartz – Wake Forest Reggie Washington - Denver David Ludwig – Boston Childrens Robert Lustig – UCSF Sandi Hassink – Nemours Robin Hamre – CDC Chris Boling/Stephen Pont – AAP Many more
NORMAL LIVER FATTY LIVER with Fibrotic Tissue CIRRHOSIS
EVIDENCE BASED: National guidelines for assessment and treatment of Childhood Obesity – 5210 For Providers. PRACTICE BASED: “NEXT STEPS” - Planned visits using patient tailored themes as a method for goal setting.
This patient is at risk for: A.Snoring B.Obstructive Sleep Apnea C.Cardiomegally D.All of the above