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. www.letsgo.org

I have no financial To Disclose

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

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.”

Panda

(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

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

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

Evidence Based Fun, Easy, Popular! 12

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 2 US Preventative Services Task Force 2010 Reviewed 13 behavioral and 7 pharma trails.

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

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

What Do I Do With PANDA???

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

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

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?

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

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

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

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

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 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%.

1. Connect to your community and the Let’s Go! community efforts: Required: The practice will hang a Let’s Go! 5-2-1-0 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

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.

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 ?

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

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

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

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

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

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

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

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

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

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

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

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

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

How to Pick a Theme ? Age BMI Readiness to Change

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

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:

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.

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.

Praise. Open ended Question.

Praise. Elicit Positive Feeling.

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

Reflective Listening. Elicit Barriers.

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

Asking Permission

Theme: Physical Activity Change Talk

Goal Setting. (Could Pull Out Readiness Scale).

Acknowledgement. Redirection.

Theme: Understanding Health

Eliciting Environment Engaging Parent. Eliciting Environment Barriers and Parental Issues

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

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

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

www.LetsGo.Org Portland, ME 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

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

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

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

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.

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