1. Healthy Weight Matters
Young Women & the Reproductive Consequences of Obesity
These 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. Acknowledgements
This 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. Acknowledgements
Many thanks to these agencies and individuals for their generosity in sharing their resources:
Corrine Giannini, RD, LDN
Shannon Kellner, RN, MPH
Merry-K Moos, FNP, MPH, FAAN
Alvina Long Valentin, RN, MPH
North Carolina Division of Public Health, Women’s Health and Physical Activity & Nutrition branches
Specific resources used to guide the development of this training:
Eat Smart Move More North Carolina resources
The 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 Connect
Brings together community partners to address challenges faced by pregnant or parenting teens using collaborative, multi-faceted strategies
One component of Young Moms Connect is training for health care providers on six maternal and child health best practices
North Carolina’s Project Connect/Young Moms Connect – Communities Supporting Young Families Summary
North 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 Practices
Early entry and effective utilization of prenatal care
Establishment and utilization of a medical home (for non-pregnant women)
Reproductive life planning
Tobacco cessation counseling using the 5 A’s approach
Promotion of healthy weight
Domestic violence prevention
We’ll talk about this one today.

6. Objectives
Understand the relationship between healthy weight status and opportunistic preconception health counseling
Understand trends in overweight/obesity for women of childbearing age
Increase awareness about the connections between weight status and birth outcomes
Improve 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 counseling
Increase awareness of reimbursement options for weight status counseling
Increase awareness of healthy weight resources for patients and providers
Please 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 conception
Timely counseling about risks and strategies to reduce the potential impact of the risks
Risk reduction strategies consistent with best practices
Preconception 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 1
CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)

10. “Opportunistic” care
Preconception care is for every woman of childbearing age every time she is seen
Every woman, every time
This 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 1
CDC 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 weight
Achieving and maintaining a healthy weight is one key component of preconception care
Women 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 obese
From 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 obese
43% of young women ages are overweight or obese
There is also a racial disparity in weight status
56% of white women are overweight or obese
73% of African American women are overweight or obese
56% of other minorities are overweight or obese
North 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 puzzle
Many 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. Consequences
U.S. society focuses on external consequences of overweight and obesity, i.e. how we look
As health professionals it can be helpful to re-frame discussions toward medical/physical consequences of overweight and obesity
For women of childbearing age the consequences of overweight & obesity span two generations
Risk of consequences increases progressively as BMI increases
Bullet 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 risks
Increased pre-pregnancy BMI is associated with increased risk of:
Preeclampsia
Gestational Diabetes
Gestational Hypertension
C-section
Induction of labor
Post-Partum hemorrhage
Source 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 likely
Obese 2 to 5.6 times as likely
Morbidly obese 3.3 to 7.2 times as likely
Did 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 hypertension
Overweight women 1.5 to 2.6 times as likely
Obese women 2.4 to 6.5 times as likely
Morbidly obese women 4.71 to 5.2 times as likely
3. 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 likely
Morbidly obese women 4.1 to 5.2 times as likely
Women 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 rates
Emergency
Overweight women1.5 times as likely
Obese women2 to 4.57 times as likely
Morbidly obese women 2.8 times as likely
Elective
Morbidly obese 3.1 times as likely
5. 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 admission
Shoulder dystocia
Late fetal death
NTDs (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 likely
Obese 1.5 to 3.1 times as likely
Morbidly obese 2.1 to 3.8 times as likely
2. 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 2.10
Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010.

19. The cycle repeats
Babies born to overweight mothers are more likely to become obese children
The 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 cancers
Problems getting pregnant
Greater risk of contraception/birth control not working
Irregular periods
Depression
Women 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 diabetes
Allow 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 weight
Most overweight patients believe they should lose weight, but this is seldom discussed during visits with health care providers
Most patients want more help with weight management than they are getting from their primary care physicians
You 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 attempts
Lack of motivation
Lack of knowledge
Lack of family or community support
Fear of embarrassment
Cost concerns
Racial disparities- Caucasian women had a more negative view of obesity than did African American women
In 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 counsel
Lack of knowledge
Fear of embarrassing patient
Frustration from prior attempts
Forgetting to talk about it or document it
Perception of patient motivation
Lack of belief the treatment will be effective
Possible influence of provider’s weight status
Negative 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 weight
Set small goals! Every little bit helps! Example: No more weight gain before next pregnancy
Use objective measures such as BMI
The 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 Index
An objective way to start the conversation about a patient’s weight
In focus groups, young women, 18-24, were impacted by seeing their BMI on a chart
Combined 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. BMI
A measure used to compare your weight to your height to assess your risk for weight-related health conditions
BMI= (_Weight in Pounds_) X 703
(Height in inches) x (Height in inches)
Opportunities: Family Planning Flow Sheet, Physical Activity & Nutrition Behaviors Monitoring Form
Try 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
Obese
30+
Below 18.5 = Underweight
18.5 – 24.9 = Normal Weight
25.0 – 29.9
Overweight
30.0 and above
Obese
Our 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 up
For patients under 20, first calculate BMI with regular chart
Then use this adolescent chart and find BMI on left
Then find age at bottom and see where the two numbers meet
Be 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 booklet
Review with client
Based on Eat Smart Move More
Order from Women’s Health Branch or NC Healthy Start Foundation
Let’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 Drink
Again, 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 activity
Offers different tools for people in different settings including:
Community
Family
Worksite
Health care

35. How can this work for you?
Think about a particular patient that you recently saw who is overweight or obese
Which 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 Behaviors
1. Breastfeeding
2. Rethink your drink
3. Choose to move more every day
4. Tame the tube
5. Enjoy more fruits and veggies
6. Prepare more meals at home
7. Right size your portions
Review 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 work
The program is offered to worksites and other groups interested in eating smart, moving more and achieving a healthy weight
Each of the one-hour lessons informs, empowers and motivates participants to live mindfully as they make choices about eating and physical activity
The 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.

40. Additional resources Everywomannc.com Nchealthystart.org
Beactivenc.org
Livestrong.com (free daily tracker: my plate – livestrong.com/myplate)
Shapeup.org
Letsmove.gov

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 children
Almost half of all pregnancies in North Carolina are unplanned
The next time you see your patient, she may be pregnant
Patient perspective:
Losing weight is a goal for many women
Women actively planning pregnancy are often not aware of risks to themselves or baby due to overweight/obesity
In 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 outcomes
Providers can help by assessing female weight status at every visit and discussing Eat Smart Move More tips
Weight management counseling reimbursements are available
Many resources are available for patients, including the Healthy Habits brochure, online food trackers and phone apps