Transcript Portable gym system in overweight adolescents in pediatric

RX: Physical Activity
Use Of A Portable Gym System
In Overweight Adolescents
Dominique R. Williams, MD, FAAP
Medical Director, Children’s Hospital of the King’s Daughters, Healthy You for Life
Assistant Professor, Department of Pediatrics, Eastern Virginia Medical School
Norfolk, Virginia
I do not have any financial disclosures; neither
do I intend to discuss off-label use of
medications or devices.
Learning Objectives
 Identify barriers to physical activity
 Review the use of therapeutic contact
 Discuss study findings and clinical implications
 Describe CHKD Healthy You for Life
Dominique R. Williams, MD, FAAP, Medical Director
Barbara “Babs” Benson, RN, Program Manager
Jessica Rodriguez, Community Outreach Coordinator
Patricia Belford-Cohen, LCSW
Kira Davies, DPT, SCS
Joseph Gill
Lynn Kistler, MS, RD
Jill Layne, LCSW
Regina Burkard
Mary Jo Haney, RD, CSP
Kim Kranz, PT, DScPT, OCS, SCS
Ellen Pelton, MS
Health Center at Oakbrooke - Chesapeake
Health and Surgery Center at Oyster Point– Newport News
Health Center at Neurodevelopmental Center (NDC) - Norfolk
CHKD Healthy You for Life
Prevention Plus
• Office setting
• Healthy
lifestyle
• Healthy eating
• Activity habits
Structured
Weight
Management
• Requires
referrals
• Monitored
behavior
• Planned diet
and physical
activity
Multi-Disciplinary
Intervention
• Frequent office
visits
• Team approach
• Structured
• Parental
participation
Tertiary Care
• Attempted MDI
• Severely
obese
• Medications,
VLCD
• Bariatric
Surgery
CHKD Healthy You for Life
Clinic
 Open to children 3-16 years old
 BMI >85th percentile
 Consultation with
 Physician
 Physical Therapist and Exercise
Specialist
 Registered Dietitian
 Licensed Clinical Social Worker
Health Classes
 Available once clinic assessment
completed
 Open to children 8-16 years old
 8 week academic class
 6-week membership to YMCA,
contingent upon class attendance
Multidisciplinary Approach
 Social Workers
• Individual and/or family
counseling
• Coordinate care with other
providers
Physical Therapists
Exercise Specialists
• Functional movement
assessment
• Fitness plan based on
needs, interests
Registered Dietitians
• Assess risk for food
insecurity
• Advice based on labs,
medical conditions
• Monitor nutrition goals
Initiatives
Caregivers
Support
Obesity
Access
Finances
Health
deBono et al (2012); Eisenmann et al (2011); Faith et al (2002); Schmalz DL (2010);
Hartline-Grafton (2011); Gooze et al (2012).
Motivational Interviewing
Principles
Tools
 Patient-centered
 Resist arguing, persuasion,
confrontation
 Understand motivation
 Listen to the family
 Empower the patient and
affirm attempts to change
 Establish rapport
 Set an agenda
 Ask open ended questions,
provide menu of solutions
 Use reflective listening
 Develop discrepancies,
elicit change talk
Schwartz RP. (2010). Pediatric Annals 39:3, doi: 10.3928/00904481-20100223-06.
Communication Styles
Following
 Listening; gathering information; obtaining a history
 Includes asking permission, open-ended questions
Directing
 Patients are told what to do and how to do it
 Includes menu building, action reflections
Guiding
 Patient led and tutored to find their way to solutions
 Best suited for health behavior change discussions
Schwartz (2010)
Approaching the Family
Ask permission to discuss weight, lifestyle
Advise about risks, benefits, improvements
Assess readiness for change, barriers
Assist with and Agree on plan, goals
Arrange follow up
Source: Canadian Obesity Network, Jay et al (2010); Quinn et al (2009); Stewart et al (2011); Vallis et al (2013)
Advise About
Risks & Benefits
Joint Pains
Sleep Disturbances
Low Self-Esteem
Poor Body Image
Difficulty Establishing Peer Groups
Short Term Effects
School Absences
Inattentiveness and Hyperactivity
Fatigue and Daytime Somnolence
Teasing and Bullying
Mood or Adjustment Disorders
School Related Effects
Insulin Resistance or Diabetes
Obstructive Sleep Apnea
Menstrual Irregularities
High Blood Pressure
Lipid Abnormalities
Fatty Liver Disease
Long Term Effects
Assess for Readiness for Change
&
Presence of Barriers
Readiness for Change
The goal is to move from one stage to the next
Patients and their families may move back and forth
There may be differences in readiness – food, fitness, feelings
Transtheoretical Model and Stages of Change
Pre-Contemplation
Unaware, denies or minimizes the problem
Contemplation
Aware of the problem, ambivalent about change
Preparation
Has decided to make change, plans to do so soon
or is gathering information
Action
Plan is in progress, attitude and behavior
changes have begun
Action maintained over 6 months (maintenance)
or return to old habits (relapse)
Maintenance/Relapse
Adapted from National Obesity Forum, Patient Motivation - Readiness for Change, http://www.nationalobesityforum.org.uk
Parental Readiness for Change
Child’s
weight is a
health
problem
Child >8yo
BMI>95th
Rhee et al. Pediatrics 2005; 116:e94 - e101
Preparation
or Action
Stage
Their weight
is above
average
Being
overweight is
a health
problem
Skelton and Beech. (2011). Obes Review, 12, e273-281.
MONEY
MIND
MECHANICAL
METABOLIC
Barriers
MONEY
MIND
Stankor I, Olds T, and Cargo M. (2012). Overweight and obese adolescents: What turns them off physical activity?
International Journal of Behavioral Nutrition and Physical Activity, 9:53. doi: 10.1186/1479-5868-9-53.
Source: Center for Science in the Public Interest (2003); Foley Freisleben LLC (2012); Kalb (2010)
Marketing Corpulence
Social & Cultural Norms
She’s a brick house…36-24-36
MECHANICAL
Stankor I, Olds T, and Cargo M. (2012). Overweight and obese adolescents: What turns them off physical activity?
International Journal of Behavioral Nutrition and Physical Activity, 9:53. doi: 10.1186/1479-5868-9-53.
METABOLIC
Assist with Making a Plan &
Agree on Goals
Specific
Measurable
Achievable
Rewarding
Timely
SMART Goals
Small Changes Theory
Lutes and Steinbaugh (2010)
Arrange Follow Up
Electronic Communication &
Therapeutic Contact
Electronic Communication
 Short message services (SMS)
 Email
 Apps for smartphones, tablets
Therapeutic Contact
 Telephone call
 Handwritten note
 Office visits
 Electronic communication
Emerging evidence base with randomized trials
May affect attrition, adherence more than BMI, weight
Have a plan for protected health information and HIPAA
Clearly define usefulness, timeliness, and “rules”
Emphasize the Medical Home
Adult Medicine
 Wadden et al. Two year randomized trial of obesity
treatment in primary care setting. N Eng J Med 2011; 365:
1969-79.
Pediatric Medicine
 Taveras et al. Randomized control trial to improve
primary care to prevent and manage childhood obesity:
the High Five for Kids Study. Arch Pediatr Adolesc Med
2011; 165(8): 714-22.
 Kwapiszewski and Wallace. A pilot program to identify
and reverse childhood obesity in a primary care clinic.
Clin Pediatr 2011; 50(7): 630-5.
Multidisciplinary
Community Partnerships
Healthy City Initiatives: Portsmouth, Norfolk, Eastern Shore
Specialty Services: Nutrition, Social Work, Physical Therapy,
Personal Training, Exercise Specialist
Insurance Programs: VA Premier, Optima, Anthem
Community Programs: YMCA, GOTR, Mentors
Portable Gym System
• Convenience sample of 100 patients, ages 10-17 years
• Action stage of readiness for change
• Demonstrated by physical therapist, exercise specialist
• Exclusion Criteria: remediation, developmental delay, previous
suicide attempt, in foster care, medical history, patient decline
receipt of bag
Moving Forward
Conclusions
Next Steps
 Differences in attrition
 Consider short-term use
 Differences in physical activity
 Foster increase confidence
 BMI velocity
 Randomize sample
 Cardiovascular fitness
 Objectively measure PA
Moving Forward
Physical Activity
o Determine age
appropriateness
o Use of bag in previously
physically inactive patients
o Measures of cardiovascular
fitness and endurance
Therapeutic Contact
o Continue to identify factors
that contribute to attrition and
physical activity
o Focus on specific form of
therapeutic contact
Medical Director
Dominique R. Williams, MD
(757) 668-9177
[email protected]
Community Outreach Coordinator
Jessica Rodriguez
(757) 668-7860
[email protected]
Program Manager
Babs Benson, RN
(757) 668-7035
[email protected]
FAX: (757) 668-7809
www.chkd.org/HealthyYou
Healthy You for Life
Thank You