1. Childhood Obesity: What to do After 5210 NEXT STEPS
Minnesota AAP
5/31/13
Jonathan Fanburg, MD, MPH
My experience with childhood obesity – 2004, MYOC, small changes can make a difference.

2. I have no financial
To Disclose

6. Highlights 5210 Basics Next Steps Put it into Play TOMORROW
Stuff you need to know
Next Steps
Engaging the Patient
Put it into Play TOMORROW

7. 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.”

8. Panda

9. (Polycystic Ovary Syndrome)
The Basics
Type 2 Diabetes
We actually know that obesity is not a good thing.
Impaired Glucose
Tolerance
Metabolic Syndrome
Dyslipidemia
Hypertension
Hyperandrogenism
(Polycystic Ovary Syndrome)
Growth and Puberty

10. The Basics Cholelithiasis (gall stones)
Obstructive Sleep Apnea (8% of obese kids)
Slipped Capital Femoral Epiphysis (SCFE)
Tibea Vera – Blounts Disease (bowed legs) (2.5%)
Pseudotumor cerebri (head aches)
Psych
Body image
Self esteem
Depression, Anxiety
Alienation from friends, distorted peer relationships

11. Ineffective Interventions
If you implement what I have talked about so far, you will not be effective.
I will now talk about what things you should already be doing and what things you can start doing in your office.
Ineffective Interventions

12. Evidence Based
Fun, Easy, Popular! 12

13. Evidence Based National Guidelines
Expert Committee 2007
Comprehensive review of literature – evidence for Pediatrics 2007;120;S229-S253
5210 are proven determinants of obesity. 1

14. Evidence Based National Guidelines2
US Preventative Services Task Force 2010
Reviewed 13 behavioral and 7 pharma trails.

15. GRADE B rec. USPSTF BMI is an Acceptable Measure
Moderate – Intensive Intervention
Counseling
Physical Activity
Behavioral Management Techniques
Parent Involvement
Pharma works modestly, but not recommended presently

16. 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

17. What Do I Do With PANDA???

18. Pediatric Obesity Clinical Decision Support Guide (5210 Flip Chart)
Outlines basic initial MEDICAL EVALUATION
in the office
Annual Physical
Separate Visit

19. Family History Counts BMI% PLUS…………… Family History
Obesity
Diabetes
Hyperlipidemia
Early Heart Disease
Comorbidity Symptoms

20. EXAM Endocrine causes of obesity is more likely in the short kid
Khagendra Magar
World’s shortest 18 year old.
2’ 5” tall from Nepal.
Endocrine causes of obesity is more likely in the short kid
or tall kid?

21. Facial hair and acne is sometimes
a sign of what?
Increased chocolate consumption
Increased androgens

22. NECK
NECK
This person has:
A rash from a necklace.
Bad eczema
Acanthosis Nigricans
Underarm

23. B. Skid burn from the carpet C. Rapidly stretching skin
This rash is from what?
A. Cutting behavior
B. Skid burn from the carpet
C. Rapidly stretching skin
Striae

24. Exam
Sometimes helps. Low pay off, but does help identify disease that deserves further medical evaluation.
Target:
Cardiac exam
Hepatomegally
Hip issues

25. 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?
Over age 10yrs – Choseterol, ALT
If risk factors (Fhx DM, ethnic risk (black, indian, hispanic), physical exam (striae)) – glucose
If findings, get the rest.

26. 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…………..

27. 5210 works better with help Let’s Go
Core Principles
Environmental and policy change can influence behavior change
Interconnectivity across sectors is essential
Strategies are evidence-based and continuously evaluated
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:
Required:
The practice will hang a Let’s Go! poster in the waiting room and ALL exam rooms.
Connect to your community and the community efforts – this has been really important for our Let’s Go! communities
Hang a poster in your waiting room, exam rooms, bathroom, staff area

29. 2. Accurately weigh and measure patients.
Required:
ALL providers regularly determine BMI percentile in patients 2-18 years during well visits.
1. Accurately weigh and measure patients and determine BMI, BMI% and weight classification for patients 2 years and older. From birth to age 2 it is recommended to use the weight for length measurement and watch for crossing percentiles.

30. 3. Have a respectful conversation around weight.
Required:
All providers regularly use the Let’s Go! Healthy Habits Questionnaire during 2-18 year well visits.
Have a respectful conversation around weight and healthy habits.
Use the 5210 healthy habits questionnaire to switch the conversation from weight to health ?

31. Registered Let’s Go! Practices
(As of 5/13)
133 Practices
667 Providers
220,681 Patients
Funding provided by
The Harvard Pilgrim Health Care Foundation
and MaineHealth

32. 5-2-1-0 It starts the conversation For some it’s all they need
For others – (esp. with BMI>95%) they need more

33. Summer/Fall 2013
AAP
NICHQ
Let’s Go
Maine AAP
AAP Section on Obesity
Let’s Go Online
Teaching Modules – Fall 2013

34. Next Steps Provides structure, format, and content to visit
Uses “19 Theme Visits”
For Engaged Patient

35. 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

36. THEMED VISITS A B C 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 B C

37. Total of 19 Themes 1 Theme 6 Themes 12 Themes
(Tested against approx 25 providers (Peds, Family, Int Med, PA, RN),
3 dietitians, 1 physical therapist, 2 counselors, and 1 linguist) A
1 Theme B
6 Themes C
12 Themes

38. 20 Minute Visit 5 5 1 5 4 Follow Up Wt/Check In Barriers Theme
BMI %ile
Barriers PE
Theme
Follow Up
20 Minute Visit 5 5 1 5 4

39. A
Category A theme will hopefully set the foundation for all of the other visits.
POSSIBLE FIRST THEMED VISIT
Purpose: Set the foundation
Discussion Theme
Material 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

40. B The 6 Highest Pay-off Themes NEXT COUPLE VISITS
THEMED VISITS B
The 6 Highest Pay-off Themes
NEXT COUPLE VISITS
Purpose: Introduce concepts that are important to cover early for success
Discussion Theme for Each Visit
Material 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

41. NYC 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

42. 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

43. C THEMED VISITS LATER IN PROGRAM 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

44. How to Pick a Theme ?
Age
BMI
Readiness to Change

45. Who has the Conversation with the Patient/Family?
PSYCHOLOGIST OR SOCIAL WORKER
VISITS
(PhD, LCSW, LCPC,)
Behavioral and Emotional Eating
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

46. FOLLOW-UP – its hard!!!!
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.
Patients often do not come in for weight related follow-up visits. Behavior change is not easy work for the patient or provider. Providers must proactively increase the odds of patient success, including follow-up visits. You might be able to better engage your patients using one of the following strategies:

47. FOLLOW-UP – its hard!!!!
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.

48. Red Flags to Treatment Abnormal Labs High BP
When is it time to consider additional medical work up and/or involving a specialist?
Abnormal Labs High 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.

49. Praise.
Open ended Question.

50. Praise.
Elicit Positive
Feeling.

51. Elicit Self Reflection.
Praise.
Empathy.
Elicit Self Reflection.
Identify Barriers

52. Reflective
Listening.
Elicit Barriers.

53. Eliciting Menu
Of Choices.
Patient’s Choice.
Open Ended.

54. Asking
Permission

55. Theme:
Physical Activity
Change Talk

56. Goal Setting.
(Could Pull Out
Readiness Scale).

57. Acknowledgement.
Redirection.

58. Theme:
Understanding
Health

59. Eliciting Environment
Engaging Parent.
Eliciting Environment
Barriers and
Parental Issues

60. Change Talk Parent/Patient Choses Theme, but Doc choses options
That might be best.
Change Talk

61. Themes Encountered Meaning of Health Physical Activity
Goal Setting – (could have used 1-10 scale)
Next Time – Could Target
Parenting
Beverages
Unintended Interruptions

62. Identify Solutions to barriers.
What Is Your Readiness To Change?
Reflective Listening.
Identify Barriers.
Identify Solutions to barriers.
Praise Effort.
Support.

63. www.LetsGo.Org Portland, ME Sept 11 – preconference on MI
Sept – conference
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

65. Question What is more important in children? A. Body Mass Index (BMI)
B. Body Mass Index percentile (BMI %ile)
C. What’s the difference?

66. What is this?
A. Spleen
B. Liver
C. Heart

67. Fatty Liver Disease (non-alcoholic liver disease)
NORMAL LIVER
FATTY LIVER with
Fibrotic Tissue
CIRRHOSIS

68. Sub objectives 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.

69. This patient is at risk for:
Snoring
Obstructive Sleep Apnea
Cardiomegally
All of the above