Presentation on theme: "Healthy Weight Matters"— Presentation transcript:
1 Healthy Weight Matters Young Women & the Reproductive Consequences of ObesityThese slides are intended to be used to train health care providers about the importance of healthy weight for women of reproductive age. They were developed to train health care providers in Bladen, Nash, Onslow, Rockingham and Wayne counties in both large group training sessions and smaller in office in-services. They are accompanied by a Trainer’s Guide, which includes extensive information about the tools and materials that should be used in conjunction with this slide set. These training materials can be adapted for large trainings and smaller in-office in-services. The key content for both types of training is found on the PowerPoint slides and in the notes section of the slides. The other training methods listed in the “module at a glance” are optional as training time allows.
2 AcknowledgementsThis 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 AcknowledgementsMany thanks to these agencies and individuals for their generosity in sharing their resources:Corrine Giannini, RD, LDNShannon Kellner, RN, MPHMerry-K Moos, FNP, MPH, FAANAlvina Long Valentin, RN, MPHNorth Carolina Division of Public Health, Women’s Health and Physical Activity & Nutrition branchesSpecific resources used to guide the development of this training:Eat Smart Move More North Carolina resourcesThe National Preconception Curriculum and Resources Guide for Clinicians (Module 1: Preconception Care: What it is and what it isn’t)If time allows give special attention to the Eat Smart Move More website as an excellent resource in our state and state that we’ll discuss it in depth later on during training.
4 Young Moms ConnectBrings together community partners to address challenges faced by pregnant or parenting teens using collaborative, multi-faceted strategiesOne component of Young Moms Connect is training for health care providers on six maternal and child health best practicesNorth Carolina’s Project Connect/Young Moms Connect – Communities Supporting Young Families SummaryNorth Carolina’s Project Connect: Communities Supporting Young Families is funded by the Office of Adolescent Health with the Pregnancy Assistance Fund.Funding: $1,768,000 annually from September 2010 – August 2013. Offers support to pregnant and/or parenting women ages years with health maintenance, parenting skills and parental self-sufficiency. The goals of Project Connect are: 1) To support community strategies to create effective systems of care; 2) To incorporate evidence-based practices, strategies and models; 3) To improve the health of pregnant and parenting women by providing comprehensive support services that are easy to access and meet their needs.Each community will:Establish a Community Advisory Council that will guide their project in implementing an action plan.Integrate six identified maternal health best practices.Implement or expand an evidence-based home visitation program, using the Parents as Teachers or Healthy Families America models.Create an integrated system of care in their communities.Women’s Health Branch will provide trainings for health care providers and coordinate a social marketing campaign related to the six identified maternal health best practice areas in the 5 project counties. Have local coordinator say a few words about the project in the local county at this point, if available.
5 MCH Best PracticesEarly entry and effective utilization of prenatal careEstablishment and utilization of a medical home (for non-pregnant women)Reproductive life planningTobacco cessation counseling using the 5 A’s approachPromotion of healthy weightDomestic violence preventionWe’ll talk about this one today.
6 ObjectivesUnderstand the relationship between healthy weight status and opportunistic preconception health counselingUnderstand trends in overweight/obesity for women of childbearing ageIncrease awareness about the connections between weight status and birth outcomesImprove 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 counselingIncrease awareness of reimbursement options for weight status counselingIncrease awareness of healthy weight resources for patients and providersPlease raise your hand if you are familiar with the term preconception health or preconception care? Please share what you think it means.
8 What is preconception care? Identification of modifiable and non-modifiable risk factors for poor health and poor pregnancy outcomes before conceptionTimely counseling about risks and strategies to reduce the potential impact of the risksRisk reduction strategies consistent with best practicesPreconception refers to a woman’s health status and risks before a first pregnancy or shortly before any pregnancy.CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)
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)Today we will be discussing the importance of healthy weight prior to and in between pregnancies.Source: The National Preconception Curriculum and Resources Guide for Clinicians. CDC Module 1CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)
10 “Opportunistic” carePreconception care is for every woman of childbearing age every time she is seenEvery woman, every timeThis is not necessarily doing more; it’s reframing the things you already do every day with the long-term lens of healthy women for healthy pregnancies for healthy birth outcomes and healthy women.Opportunistic care: provide counseling at every visit (sick, wellness, chronic condition, pediatric visit, prenatal, post-partum etc.).Source: The National Preconception Curriculum and Resources Guide for Clinicians. CDC Module 1CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)
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 weightAchieving and maintaining a healthy weight is one key component of preconception careWomen who are underweight also have increased risks related to birth outcomes but the training today will focus on the more prevalent conditions of overweight and obesity.
12 Obesity in North Carolina In 2010, nearly two-thirds (65%) of adults in North Carolina were either overweight or obeseFrom 2001 to 2010, the proportion of N.C. adults who were overweight or obese increased from 59% to 65%Keep in mind that BRFSS is self-reported data so the actual numbers are likely higher.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 obese43% of young women ages are overweight or obeseThere is also a racial disparity in weight status56% of white women are overweight or obese73% of African American women are overweight or obese56% of other minorities are overweight or obeseNorth Carolina has a weight problem. This is true for all ages, both genders and it affects minority groups more. It means people in our state are suffering-- they are forced to live with and manage chronic diseases like diabetes and high blood pressure at younger ages.The health of babies born in North Carolina is directly affected by this obesity epidemic. Ideally, every woman starting a pregnancy should begin at a healthy weight (BMI ). In NC, the reality is very different.More BRFSS 2010 data: Women = 57% overweight or obese; Women = 60% overweight or obese.NC Behavioral Risk Factor Surveillance System, 2010
14 Obesity among North Carolina mothers The percentage of obese African American mothers in North Carolina is shown below in relation to whites. Over time, both groups have increasing percentages of mothers who are obese, with consistently higher percentages seen in African American mothers. The disparity is increasing over time.The percentage of overweight and obese mothers in the state has increased steadily over time, with approximately 34 percent of women having BMIs in the overweight or obese category between 1997 and 1999, then increasing to 39 percent and 41 percent in the subsequent time intervals.Source: North Carolina Pregnancy Risk Assessment Monitoring System Survey Data. N.C. State Center for Health Statistics ( , , )
15 Pieces of the puzzleMany of you are familiar with the socio-ecological model, which explains various spheres of influence regarding any given “behavior”. This model applies the socio-ecological model to healthy weight, demonstrating that although we often think of weight as a series of individual behaviors, in reality it is a complex issue which has many sectors of influence. Today we will focus primarily on the individual factors, but also talking a bit about behavioral settings and your role as providers in the “sectors of influence.”
16 ConsequencesU.S. society focuses on external consequences of overweight and obesity, i.e. how we lookAs health professionals it can be helpful to re-frame discussions toward medical/physical consequences of overweight and obesityFor women of childbearing age the consequences of overweight & obesity span two generationsRisk of consequences increases progressively as BMI increasesBullet 3: Increased risk to mom for herself during pregnancy as well as for chronic conditions later in life.Entering pregnancy overweight or obese also increases risks for the infant of macrosomia, late fetal death and childhood obesity.Kellner, S. Maternal weight: An opportunity to impact infant mortality in North Carolina
17 Pregnancy risksIncreased pre-pregnancy BMI is associated with increased risk of:PreeclampsiaGestational DiabetesGestational HypertensionC-sectionInduction of laborPost-Partum hemorrhageSource is meta-analysis, which found the following to be the Greatest Risks for moms (note the dose/response relationship in these associations):1. Preeclampsia (high blood pressure/excess protein in urine after 20 weeks of pregnancy)Overweight 1.3 to 2.28 times as likelyObese 2 to 5.6 times as likelyMorbidly obese 3.3 to 7.2 times as likelyDid you know that this disorder is responsible for 15% of preterm births in the US each year, making it the leading known cause of prematurity?2. Gestational hypertensionOverweight women 1.5 to 2.6 times as likelyObese women 2.4 to 6.5 times as likelyMorbidly obese women 4.71 to 5.2 times as likely3. Gestational diabetes (condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy, especially 3rd trimester)Overweight women 1.3 to 2.71 times as likelyMorbidly obese women 4.1 to 5.2 times as likelyWomen with a history of gestational diabetes have a 40 to 60 percent chance of developing diabetes in the 5 to 10 years after delivery. Additionally, the children of pregnancies where the mother had gestational diabetes are also at increased risk for obesity and diabetes.4. C-section ratesEmergencyOverweight women1.5 times as likelyObese women2 to 4.57 times as likelyMorbidly obese women 2.8 times as likelyElectiveMorbidly obese 3.1 times as likely5. There is a higher rate of lactation failure among overweight/obese women. Breastfeeding can also be considered primary prevention for obesity. (Source for this is Kathryn Sullivan in WHB).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 admissionShoulder dystociaLate fetal deathNTDs (Anencephaly and spina bifida)Source is meta-analysis, which found the following to be the Greatest Risks for newborns (note the dose/response relationship in these associations):Macrosomia (baby too large for gestational age)Overweight 1.2 to 2 times as likelyObese 1.5 to 3.1 times as likelyMorbidly obese 2.1 to 3.8 times as likely2. NTDs & pre-pregnancy BMI: Maternal obesity was associated with significantly increased risk for offspring with spina bifida, heart defects, and other defects with ORs ranging from 1.33 to 2.10Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010.
19 The cycle repeatsBabies born to overweight mothers are more likely to become obese childrenThe 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 cancersProblems getting pregnantGreater risk of contraception/birth control not workingIrregular periodsDepressionWomen who are overweight or obese face other health risks not associated with pregnancy as well.Notes:Uterine cancer affects women even in their 20s.The risk increases as BMI increases.Infertility- Many overweight women have difficulty getting pregnant. Of course, knowing this, we also know women who get pregnant soon after having gastric bypass surgery – and this is not healthy so soon after - for mom or baby.Ineffective contraception: We know the patch can be ineffective and some suspect that other methods may also be affected by overweight, but at this time we don’t have the same hard evidence as we do for the patch.P-Sunyer FX.. Medical hazards of obesity. Ann Intern Med. 1993;119;
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 diabetesAllow participants to answer this question for themselves. Common answers include: When my jeans fit. When I feel good.Then show definition and facilitate discussion about medical vs. social definitions of weight.Emphasize that no matter how weight is defined for individual patients and regardless of whether or not they as providers like BMI as a tool, the fact is that individuals who are at healthy weights are healthier in general.It’s fine to “feel” good, but objectively speaking patients at healthy weights have fewer health risks than those who are not at healthy weights.Giannini C, 2009
22 Providers and weightMost overweight patients believe they should lose weight, but this is seldom discussed during visits with health care providersMost patients want more help with weight management than they are getting from their primary care physiciansYou as a health care professional can make a difference. With female patients that are thinking about becoming pregnant, just had a baby or are between pregnancies you can think about things you are already likely doing already from a preconception health frame: (1) assess and discuss her current weight status; and (2) provide her with the Eat Smart Move More messages and resources. We will discuss those messages in depth in a few minutes.Potter MB, Vu JD, Croughan-Minihane M. Weight management: what patients want from their primary care physicians. Fam Pract Jun;50(6):513-8.
23 Why don’t patients ask for help? Frustration from prior attemptsLack of motivationLack of knowledgeLack of family or community supportFear of embarrassmentCost concernsRacial disparities- Caucasian women had a more negative view of obesity than did African American womenIn this study, many Caucasian women felt that their weight made them unattractive to men, whereas many African American women felt that their men “liked them with some meat on their bones.”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):
24 Why don’t providers bring it up? Lack of time to counselLack of knowledgeFear of embarrassing patientFrustration from prior attemptsForgetting to talk about it or document itPerception of patient motivationLack of belief the treatment will be effectivePossible influence of provider’s weight statusNegative and unsympathetic perceptions that obesity represents a lack of patient discipline, self-control or will power rather than a chronic disease.HCP who themselves are overweight or obese may be embarrassed to address patient’s overweight. Instead, they should use this as a tool to show compassion, find a connection with a patient and talk through barriers and dreams of what life would be like at a healthier weight.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):
25 Tips for talking with patients Don’t ignore weightSet small goals! Every little bit helps! Example: No more weight gain before next pregnancyUse objective measures such as BMIThe time for provider intervention, particularly for women of childbearing age, is NOT when women are obese. It’s when they are overweight. The earlier the conversations happen with women the better. Many, many overweight young women in today’s society do not know they are clinically overweight because their frame of reference is such that they look like everyone else so they assume they are healthy.BMI can be used like blood pressure. You are in a healthy range or you are high or you are low. This helps remove some of the judgment.What else removes judgment?Using the categories – like “you are in the obese category” rather than “you are obese.” What else?
26 BMI: Body Mass IndexAn objective way to start the conversation about a patient’s weightIn focus groups, young women, 18-24, were impacted by seeing their BMI on a chartCombined with the words “overweight” and “obese” their awareness of their weight was raised and they felt motivated for change(NC Preconception Health Campaign focus groups for development of Healthy Habits booklet.)It is important to remember, however, that BMI is not a direct measure of body fat and that BMI is calculated from an individual's weight which includes both muscle and fat. As a result, some individuals may have a high BMI but not have a high percentage of body fat. For example, highly trained athletes may have a high BMI because of increased muscularity rather than increased body fatness. Although some people with a BMI in the overweight range (from 25.0 to 29.9) may not have excess body fatness, most people with a BMI in the obese range (equal to or greater than 30) will have increased levels of body fatness. We should help providers think through the reality for the majority of their patients because most people are not athletes.There are secondary measures such as waist circumference. Those measures are beyond the scope of this presentation.It is also important to remember that weight is only one factor related to risk for disease. If you have questions or concerns about the appropriateness of your weight, you should discuss them with your healthcare provider.
27 BMIA measure used to compare your weight to your height to assess your risk for weight-related health conditionsBMI= (_Weight in Pounds_) X 703(Height in inches) x (Height in inches)Opportunities: Family Planning Flow Sheet, Physical Activity & Nutrition Behaviors Monitoring FormTry to think of BMI like taking BP. Currently in HDs, state contract addenda require and/or recommend BMI calculation in women’s health clinics. Our recommendation is for screening everyone and recording BMI on chart – the forms have space and indication for BMI.We are missing opportunities by only calculating BMI on women we “perceive” to be overweight/obese in our “clinical judgment.” Think about how our cultural norms around healthy weight have changed. Many, many people who are overweight think that they are just fine because everyone around them is obese, etc.BMI is a good way for all of us to think objectively about our weight and help our patients think about it objectively, too. We’re the ones they trust about health – it’s our job to help people think of weight as being related to health rather than appearance. It’s our job to provide them with the “reality” of health risks related to OW/OB vs. their own self-perceived views of weight.
28 BMI Underweight <18.5 Healthy weight 18.5 - 24.9 Overweight Obese30+Below 18.5 = Underweight18.5 – 24.9 = Normal Weight25.0 – 29.9Overweight30.0 and aboveObeseOur job is to help patients to not get stuck on what category they fall into, but rather focus on moving in the right direction towards a healthier weight
29 Body mass index for adolescents The BMI chart is designed for adults ages 20 and upFor patients under 20, first calculate BMI with regular chartThen use this adolescent chart and find BMI on leftThen find age at bottom and see where the two numbers meetBe sure to remind teen or young adult patients that as we age, our metabolism slows and we tend to gain weight more readily and its harder to lose. Having a healthy BMI as an adolescent is very beneficial to your health as you get older.U.S. Office on Women's Health
30 Healthy Habits for Life! Interactive bookletReview with clientBased on Eat Smart Move MoreOrder from Women’s Health Branch or NC Healthy Start FoundationLet’s take a look…Ask participants to pull this booklet out of their binder (section 3, consumer resources). Demonstrate how to use this booklet as a workbook with patients. Explain that the messages included are evidence based. Facilitate a discussion among participants, helping them think through how they would use each page with patients.Explain energy balance: energy intake (food consumption) vs. energy output (moving more/exercising).Women’s Health Branch website:NC Healthy Start Foundation:
31 Rethink Your DrinkAgain, help providers think about how they could use this booklet with their patients. Have them open their booklets to page 7.
32 Choose To Move More Everyday Direct patients to page 10.If time allows, have participants practice each of the pages that addresses one of the Eat Smart Move More tips with a partner, pretending their patient has identified that particular area as something they are ready to work on.
33 Track It!Direct participants to page 14 of the Healthy Habits booklet.Most of us don’t know how much we really eat each day, or our true activity levels. Writing these things down can help us pay better attention to our habits and also serve as a reminder to keep on track. Keeping track has been shown to help improve weight loss.Encourage participants to talk to patients about finding a tracking system that works for them; some may find that online tools are most helpful. Others find that paper works best. There are additional resources for tracker tools on the back of the Healthy Habits booklet.
34 Eat Smart Move More (ESMM) A statewide campaign that promotes increased opportunities for healthy eating and physical activityOffers different tools for people in different settings including:CommunityFamilyWorksiteHealth care
35 How can this work for you? Think about a particular patient that you recently saw who is overweight or obeseWhich 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?Seven ESMM Target Behaviors1. Breastfeeding2. Rethink your drink3. Choose to move more every day4. Tame the tube5. Enjoy more fruits and veggies6. Prepare more meals at home7. Right size your portionsReview the seven target behaviors. Emphasize that for young mothers or expectant mothers, discussing breastfeeding and local support options is a key step in regaining a healthy weight postpartum.
36 Eat Smart Move More For more information visit:
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?Refer to Handout: Service Delivery Improvement
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 workThe program is offered to worksites and other groups interested in eating smart, moving more and achieving a healthy weightEach of the one-hour lessons informs, empowers and motivates participants to live mindfully as they make choices about eating and physical activityThe 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 Trained instructors located in ________:Trainer to add information for relevant county where training is taking place.
41 Reimbursement options CPT code 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 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 childrenAlmost half of all pregnancies in North Carolina are unplannedThe next time you see your patient, she may be pregnantPatient perspective:Losing weight is a goal for many womenWomen actively planning pregnancy are often not aware of risks to themselves or baby due to overweight/obesityIn thinking about data presented earlier about the high rates of overweight and obesity among women of childbearing age, it’s clear that we need to be thinking about intervention before pregnancy.
43 Summary Healthy weight is a critical component of preconception care Overweight and obesity is associated with increased risk for poor maternal and infant outcomesProviders can help by assessing female weight status at every visit and discussing Eat Smart Move More tipsWeight management counseling reimbursements are availableMany resources are available for patients, including the Healthy Habits brochure, online food trackers and phone apps