Focus on Health and Habits, Not Weight · 2019-07-11 · avoidance of health care services, decreased physical activity, and increased weight gain, which worsen obesity and create

Better Health for All© 2018 County of Santa Clara Health System

FOCUS ON HEALTH AND HABITS,NOT WEIGHT

Karina Perez, MS, RDNPediatric Healthy Lifestyle Center


Mission

To provide high-quality, evidenced-based, family-centered, community-linked preventative care, lifestyle management and medical interventions for children and youth at risk for Type 2 Diabetes and other lifestyle-related conditions

THE PEDIATRIC HEALTHY LIFESTYLE CENTER


Pediatric patients referred by their primary care providers who are:• Under 2 years of age who have elevated weight for height

• Over 2 years of age with a BMI >85th% with associated comorbidities or BMI >95%

And/or have lifestyle-related medical illnesses such as• Insulin resistance, Pre-Diabetes or Type 2 Diabetes

• Abnormal cholesterol levels

• Non-alcoholic fatty liver disease

• Hypertension

PHLC: WHO WE TREAT


PHLC Outcomes: Lifestyle Behaviors

Orientation Class

Initial consult visit by MD

Follow up visits with both RD and MD

5-7 visits over 1 year to graduate

METHODOLOGY/DELIVERY

• Families learn what to expect in our program• Introduction to the 10 Healthy Steps• Re-direct weight focus

Families graduate based on • ability to practice the 10 Healthy Steps• normalization of labs• stabilization of BMI

• Patient receives an obesity-focused physical exam and screening for obesity-related diseases

• Alternating visits between MD and RD• Dietitian provides MNT • MD reviews labs

• MD bills for dietitian time for RD visits


Medical staff is trained not to talk about weight

Lifestyle Questionnaire

Family-centered goal setting around health behaviors

Community-linked resources

Subspecialist and mental health referrals

PHLC APPROACH AT VISITS


FRAMEWORK: “10 STEPS To a Healthier You”

6Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity (Pediatrics Vol. 120 Supplement December 2007 p. S164-S192)

Eat fruits and vegetables everyday

Drink water instead of soda/sweet drinks

Eat fruit instead of drinking juice

Eat healthy snacks instead of processed

Drink 3 servings of 1% milk

Eat family meals and limit eating out

Eat breakfast everyday, don’t skip meals

Be active for 1 hreveryday (outside)

Limit screen time to 1 hr or less

Get enough sleep


CONSEQUENCES OF FOCUSING ON WEIGHT

Pont SJ, et al. Pediatrics Dec 2017

Weight Focused Weight FocusedPower Struggles

Parent experiences pressure

Parent tries to fix the problem (child)

Pressure- Resistance

Restriction-Sneaking


“Weight stigma is often propagated and tolerated in society because of beliefs that stigma and shame will motivate people to lose weight.”

“However, rather than motivating positive change, this stigma contributes to behaviors such as binge eating, social isolation, avoidance of health care services, decreased physical activity, and increased weight gain, which worsen obesity and create additional barriers to healthy behavior change”

OBESITY STIGMA

Pont SJ, et al. Pediatrics Dec 2017


Parents are less concerned about their children being overweight at younger ages1

Parents are more concerned about the way the child looks at age 8 years or older2

PARENTAL PERCEPTIONS AND CONCERNS

1 Killion et al., Int J Pediatr Obes. 2006. 2Rhee KE et al: parental readiness to make changes for over-weight children. Pediatrics 2005


TRAJECTORY OF CHILDHOOD OBESITY

Ward ZJ, et al. N ENGL J MED. 2017

ADULT

TODDLER (2 y.o)

75% obese children will be obese adults

Body Mass Index-for-age percentiles 2 to 20 yrs

ADULT

~50% non-obese children will be

obese adults


“a generational shift in social norms related to body weight.”

Fewer US adults are trying to lose weight

As overweight/obesity has increased, less children (decrease) have tried to lose weight

TRENDS IN WEIGHT LOSS EFFORTS

Hawkins DR., et al. JAMA Pediatrics August 2018 Burke MA, et al. Obesity June 2010


Focusing on weight is notan effective strategy

as a motivator for change

THE PROBLEM

12

Change the conversation of Who’s Healthier?

13


SHIFTING OUR CONCERN TO:

New England J Med Vol. 352(11) March 2005, pp. 1138-1145

NICHQ: Childhood Obesity Action Network

Chronic Disease Prevention in Children

Pre-Diabetes T2DM

High Blood Pressure

FattyLiver

HeartDisease

LipidProblems


1. Focus on healthy living and healthy habits rather than on weight

2. Promote a positive body image among adolescents

3. Encourage more frequent family meals

4. Encourage families not to talk about weight but rather to talk about health

5. Inquire about bullying

6. Carefully monitor growth to rule out disordered eating/eating disorders.

NEW AAP GUIDELINES 2016

15

Golden NH, Schneider M, Wood C, AAP COMMITTEE ON NUTRITION. Preventing Obesity and Eating Disorders in Adolescents. Pediatrics. 2016;138(3):e20161649


Pediatric Healthy Lifestyles Center

Conducted by the Center for Population Health Improvement

Outcome Evaluation


This evaluation examined outcomes for:

GOALS

Program Participation

Lifestyle Behaviors

Lifestyle-related lab values

BMI z scores

ALT

A1C FPG

TGs LDL


• Participants included in the evaluation if their first visit was between January 1, 2015 and September 30, 2017

• Questionnaire and health outcome data were included if the date of measurement was between January 1, 2015 and March 31, 2018.

• All data was from HealthLink (EPIC)

METHODS


DEMOGRAPHIC CHARACTERISTICS OF PHLC PARTICIPANTS

1-4 y.o51.6 % 48.4%

Spanish66.4% Other

1.5%

9.5%

5-8 y.o 9-12 y.o 13-19 y.o

37.7%26.8% 26.0%

Asian/Pacific IslanderBack/African AmericanHispanic/Latino

White

Other

Unknown

Hispanic88.5%

English32.2%


RESULTS


PHLC OUTCOMES: PROGRAM PARTICIPATION

National studies dropout rates

of 32%

PHLCdropout rates

of 25%


Parents removed soda and juice from the home

Children consumed more vegetables with each visit

Fruit consumption increased with adolescents improving the most

Participants ages 5-12 saw the most improvement for several nutritional behaviors

Families reported they watched less TV/Screens with meals

Improving levels of physical activity was both harder to achieve and took longer to affect than improvements in nutrition

PHLC OUTCOMES: LIFESTYLE BEHAVIORS


Percentage of households with

Soda

PHLC OUTCOMES: LIFESTYLE BEHAVIORS

1-4 5-8 9-12 13-19Ages

Percentage of households with

Juice

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjzmI7F5PviAhWJhVQKHTqaCkoQjRx6BAgBEAU&url=https://www.flaticon.com/free-icon/soda_175797&psig=AOvVaw3KFtEAbpGB9mCokxai00WP&ust=1561248021732783


All Ages

N (%) of participants

HbA1c 117 (10.4%)FBG 96 (9.0%)ALT 195 (17.0%)Triglycerides 364 (31.7%)LDL 358 (31.2%)

PHLC OUTCOMES: LIFESTYLE-RELATED LAB VALUES

*Data pull limitations

Participants with abnormal labs at referral


26Improved

74%20

Improved 80%

HEMOGLOBIN A1C

* Mean average of 0.2%

Outcomes among participants with an abnormal result at baseline

Normal 76%

Decreased 24%

FASTING BLOOD GLUCOSE (FBG)


* Mean average of 9 mg/dL

Normal 75%

Decreased 25%



25 Improved 75%

Normal 60%

Decreased 40%

ALANINE AMINOTRANSFERASE (ALT)

* Mean average decrease of 35 U/L



27Improved

73%33

Improved 67%

TRIGLYCERIDES (TG)


Normal 31%

Decreased 69%

LOW DENSITY LIPOPROTEINS (LDL)


Normal 51%

Decreased 49%

* Mean average decrease of 59 mg/dL * Mean average decrease of 20 mg/dL


So…What about weight?


% of participants(All Ages)

Normal 17 (1.9%)

BMI >85th-94th percentile 114 (12.7%)

BMI >95th percentile 770 (88.5%)

BMI AT REFERRAL


23 Improved 77%

Decreased 65%

Stabilized 35%

BODY MASS INDEX (BMI) Z-SCORE

* Mean average BMI-z score change -0.3

Outcomes among participants with abnormal BMI at baseline


Empower Families with habit conversations

31

Commit+

Practice

Be consistent

Model

Do it Daily


KEY TAKEAWAYS

32

Focus on health and habitsinstead of weight

Re-direct conversations with our patients/families to habit focused to prevent unintended consequences of weight talk in our children

Change the conversation of Who’s Healthier

[email protected]

Focus on Health and Habits, Not Weight · 2019-07-11 · avoidance of health care services, decreased physical activity, and increased weight gain, which worsen obesity and create

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