1. Childhood Obesity among American Indians and Alaska Natives: Positive Communication Strategies California Medical Association Foundation Webinar October 30, 2012 Kelly Moore MD FAAP Associate Professor University of Colorado Denver Colorado School of Public Health Centers for American Indian and Alaska Native Health

2. 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.

3. Webinar Objectives Using a case presentation format, participants will be able to: Identify how culture and ethnicity can influence patient decision making related to childhood overweight and obesity within the American Indian Community. Describe effective patient/provider communication techniques to help families understand behaviors they can take to help their child reach a healthy weight, particularly focusing on increasing healthy food choices. Determine how and when to access support in their communication, particularly involving nutritionists and dietitians.

4. Background Prior to 1970s underweight & dietary deficiencies were major health issues 1969 National Conference on Nutrition, Growth and Development of North American Indian Children Suboptimal nutrition and low weight-for- height were common All surveys reported growth rates well below the national reference References: Moore et al. Nutrition, growth and development of North American Indian Children. Washington, DC: U.S. Dept of HEW, 1972; Am J Clin Nutri 1981;34(2):266-77; Carlile et al. Contemporary nutritional status of North American Indian children. In Moore, Silverberg, Read eds. Washington, DC. U.S. Dept of HEW, 1972; J Am Dietetic Assoc 1998;98(2):170-6; Prev Med 2003;37:S3-S12.

5. Background By late 1970s public health efforts drastically reduced prevalence of underweight and growth retardation in American Indian children Efforts included food assistance programs, improved health care, and prevention and treatment of infectious and chronic diseases

6. Transition 1960s Average AI preschool child had lower wt/ht than average US preschool child 1/3 Navajo preschoolers wt/ht <3 rd % Apache preschoolers 40% ht <10%, 18% wt <10% 1970s Improved health and food availability 1980s 11.2% 0-4 yr AI children BMI>95% 2000 31.2% obesity AI preschoolers (12.8% non Hispanic white preschoolers) Higher rates of weight gain <2 yrs Schell LM, Gallo MV, Overweight and Obesity Among Native American Infants, Children and Youth. Am J Human Biology 2012;24 (304-313).

7. Change in obesity prevalence during 19982003 and 20032008 among children aged 2 - 4 years, by race/ethnicity Pediatric Nutrition Surveillance System, United States, 1998--2008

8. Overweight and Obesity in High School Students Youth Risk Behavior Survey 2001-2009 Everett Jones S, Anderson K, Lowry R, Conner H. Risks to health among American Indian/Alaska Native high school students in the United States. Prev Chronic Dis 2011;8(4):A76. http://www.cdc.gov/pcd/issues/2011/jul/10_0193.htm. Accessed 7/30/12.http://www.cdc.gov/pcd/issues/2011/jul/10_0193.htm

9. Recognized Obesity Risk Factors Poverty Substandard housing Food insecurity Single parent households Geographic isolation Lack of access to health care

10. Unique Contributing Factors to Obesity Lack of access to health care providers with specific cultural knowledge and skills Forced cultural change and displacement leading to cultural disintegration Historical transitions in location Transitions in food sources Other community and individual stressorssocial injustice, trauma, racism References: Pediatrics. 2008;121(5):e1241-e1249. Joe JR, Young RS, eds. Diabetes as a Disease of Civilization: The Impact of Culture Change on Indigenous Peoples. New York, NY: Mouton de Gruyter; 1994. Am J Public Health. 2005;95:851-859. Lancet. 1994;343 (8893):324–327. Am J Prev Med. 1998;14(4):245–258. Int J Obes Relat Metab Disord. 2002;26(8):1075 –1082. Psychiatry Res. 2006;142(1):31–37.

11. Growing up in such conditions could teach the child of parents with lower SES that the world is a hostile, depressing, and alienating place, and the child could also learn that smoking and consumption of larger amounts of alcohol and food help reduce the resulting distress. Redford Williams, JAMA 1998;21:1746

12. Additional Cultural Considerations with American Indians Child Rearing Anglo-American: parent-focused responsibility Native American: community-focused child rearing - children are to be shared; discipline and nurturing responsibility of all Education Anglo-American: formal education stressed, individual achievement is stressed Native American: education occurs in all facets of life, individuals should learn from one another Pediatrics Vol. 91 (5) Supp, May 1993 pp. 1063-1070

14. Overweight Sensitivity Do no harm Obesity Ideal Weight Personal Improvement Focus on Weight Diets or Bad Foods Exercise Overweight Healthier Weight Family Improvement Focus on Lifestyle Healthier Food Choices Play or Activity

15. ABCs of Counseling & Motivating Overweight Children & Families Ask Open-Ended Questions How concerned are you about your childs weight? Why? What are some of the things you might like to change? Body Language Put patient at ease. Use eye contact. Convey respect. Counsel in a private setting. Care and Empathy Do not criticize. Acknowledge patients feelings. Answer questions without signs of judgment.

16. 2 - 5 Years Old Communicate with Parent Child in Room 6 - 12 Years Old Communicate with Parent or Both The First Encounter Consider Taking Parent to Your Office to Discuss in Private First Over 12 Years Old Communicate with Teen or Both The First Encounter Consider Having Parent Leave Exam Room First Who do you communicate with?

17. 4 Key Messages Readiness to Change Tool Get More Energy! Poster

18. Albuquerque, New Mexico – July 2005 Everyone appeared to have general awareness of the connection between healthy eating and diabetes Challenges to Healthy Living Time Fast food Work Cost of healthy foods Grocery store marketing of unhealthy foods Pow Wows/Traditional Gatherings Television Depression American Indian Family Focus Groups Parents are role models. Youve got to do it yourself.

19. American Indian Family Focus Groups - Poster Reaction Ive seen it a thousand times. Yeah the same messages over and over again. Didnt like: Energy, Cut Back Colors Ruler Suggested: Family photos Reflect pride and community

21. Encouraging a Healthy Weight for Your Child - Overall they liked this handout for the research, resources and suggestions. Body Image: Learning to Like What You See - The least liked of all the articles, perceived as judgmental and negative. Eating and Exercise: What Works for You - Overall reaction was positive and they thought that this handout would grab their attention. They all wanted to keep a copy. American Indian Family Focus Groups – Tip Sheet Reaction

22. American Indian Family Focus Groups Communication Techniques Reaction Parents tended to want physicians to ask permission when it involved their child Wanted a physician to address the issue of diabetes if their children were found to be at risk Understood readiness to change and valued exploring ambivalence but didnt like the ruler Wanted to spend more time with their physicians in discussion I think it helps to have a dialogue, to make it more personalized.

23. Education Strategies There is general awareness about healthy living and diabetes Some educational materials need to be culturally adapted with depression addressed Communication techniques were well received, but wanted more time with providers Messages need to include pride, family, community & traditional ways of living Environmental Strategies Grocery store advertising, pricing and point of decision labeling School, community & work site interventions Community changes and policy American Indian Family Focus Groups – Conclusions

25. Acknowledgements American Indian Family Focus Group Participants Scott Gee MD Sandra G Hassink MD Association of American Indian Physicians Envision New Mexico Kaiser Permanente