Stemming the tide: Obesity prevention and treatment in primary care pediatrics

1. Stemming the tide: Obesity prevention and treatment in primary care pediatrics Eliana M. Perrin, MD, MPH Associate Professor of Pediatrics Department of Pediatrics Division of General Pediatrics and Adolescent Medicine University of North Carolina at Chapel Hill

2. Road Map for Today • My background • My focus: obesity prevention in primary care practice • Earlier project results that form the building blocks for current projects • Current projects • Conclusions and future research directions

3. My background Swarthmore- liberal arts Rochester- biopsychosocial Stanford- academic medicine and weight related disorders UNC- RWJ and faculty and the switch to obesity as a public health problem

4. Six degrees of separation from Indiana

5. How about just two! I love the Tar Heels Hansbrough played for the Tar Heels Now he plays for the Pacers

6. But I digress…. • Right now I spend most of my work time on research • K23 award • R01 award • 2 R03s and AHRQ contract under review • Rest of time I work in primary care pediatrics • Lots of mentorship of medical students, residents, fellows, and junior faculty

7. SCOOPT Lab

8. Possible research focus areas in childhood obesity DOCTOR’S OFFICE CORPORATIONS/POLICY BUILT ENVIRONMENT COMMUNITY/CULTURAL SCHOOLS BIOLOGY/GENETICS

9. National buy in

11. Primary care prevention involves at least a pediatric provider and a patient (parent and child or family) My research attempts to understand both perspectives and provide interventions that impact both.

12. Primary Care Providers’ Plight • “Healthy People 2010” charged primary care providers with task of curbing the epidemic. • Diagnosis of overweight or trends toward overweight considered one of the 1st steps. • Multiple studies show physicians under-diagnose overweight and obesity in both adults and children. (McArtor RE, et al, Intern’l J of Obesity 1992; Denen ME, Hennessey JV, Markert RJ., J of Gen Int Med. 1993; Eck LH, et al Intern’l J of Obesity 1994; Stafford RS, et al Arch Family Med, 2000, Benson, et al, Pediatrics, 2009)

13. Primary Care Providers’ Plight • Much expected to do with limited time: BP, DBP (toilet training, temper tantrums, discipline, school, ADHD), vision and hearing, immunizations, hct/hgb, lead screening, TB screening, cholesterol, sexuality and STD prevention, injury prevention, violence prevention, sleep positioning, and sleep disturbances, to say nothing of the physical exam, chronic problems, etc. Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements.Pediatrics. Oct 2006;118(4):e964-978. • Even obesity screening is complicated…

14. Screening for overweight always involves determining weight for height

15. First complicated aspect of screening… BMI=weight/height2= kg/m2 • In adults: • Definitions for overweight and obesity are static and easy • However, in children: • BMI is a dynamic process that varies as child grows. • BMI values need to be plotted on standardized charts. • A reasonable proxy for weight status. (Dietz WH & Robinson TN, J Pediatrics,1998; Dietz WH & Bellizzi MC, American J Clin Nutr,1999)

16. Second complicated aspect: terminology changes ≥95th % “Obese” previously “overweight” 85th to < 95th % “Overweight” previously “at risk” 5th-85th % Healthy Weight < 5th % Underweight • (2007, Expert Committee on Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity, Pediatrics)

19. Overweight Age 4, 93rd BMI=17.6 Age 4, 87th BMI=17.1 Age 5, 94th BMI=17.7

20. Obese Age 12, >99th BMI=29.8 Age 6, >99th BMI=23

21. “Visual impression”- how good is it?

22. “Visual impression”- how good is it? BMI ~98th Obese BMI ~12th Healthy BMI ~93rd Overweight

23. . . . . . . . . . . . . . . . . . .

24. BMI vs. Height and Weight Study (Journal of Pediatrics, 2004) CONCLUSIONS: • BMI charting compared to height and weight charting • More effective at demonstrating obesity. • Prompted greater concern. • Rarely being used. IMPLICATIONS: • Pediatricians need to detect concerning weight trends. • Further efforts needed to adopt BMI charting.

25. Self-Efficacy Survey Study (Ambulatory Pediatrics, 2005) CONCLUSIONS: • Pediatricians don’t feel effective in treatment/prevention of obesity. • Environmental barriers (like fast food or lack of parks) are most frequently encountered. • Low self-efficacy is associated with practice-based barriers (like lack of EMR to calculate BMI). • Pediatricians want resources including better counseling tools and better ways of communicating weight status to parents. IMPLICATIONS: • Interventions in office-based setting  increase self-efficacy  increase counseling?

26. Pediatrician Weight Self-Perception Study (Obesity Research, 2005) CONCLUSIONS: • Nearly half of overweight pediatricians did not classify themselves as such and misperception of overweight was worse than in non-doctor US samples. • Those identifying themselves as “thin” & those identifying themselves as “overweight” reported more difficulty counseling regardless of actual weight status. IMPLICATIONS: • Physicians’ own weight self-perceptions may be one barrier to appropriate screening and counseling.

27. Pediatrician self-efficacy with a counseling toolkit (Patient Education & Counseling, 2008) • CONCLUSIONS: • Pre-/post- • Confidence to interpret BMI, identify concerning dietary and PA behaviors and counsel during well child checks improved. • Ease of counseling about healthy eating, PA, and healthy weight improved from less than 10% reporting ease of counseling to nearly 40%. • IMPLICATION: • If a very simple toolkit improves self-efficacy and ease, perhaps similar toolkits might help boost counseling rates.

28. Barriers & facilitators of using BMI Pediatrician focus group study (Flower, Perrin, et al, Ambulatory Pediatrics, 2007) CONCLUSIONS: • There are many systems’ barriers to using BMI but it can be a useful diagnostic and even counseling tool. IMPLICATIONS: • Practice-level changes such as incorporating BMI into office systems and EMRs may be needed to support pediatric primary care providers in using BMI routinely. • More research on whether parents understand the concept of BMI or it serves as a communication tool.

29. Do parents understand color-coded BMI charts better than standard charts? What is the relationship of literacy and/or numeracy to that understanding? Oettinger MD, Finkle JP, Esserman D, Whitehead L, Spain TK, Pattishall SR, Rothman RL, Perrin EM. “Color-coding improves parental understanding of body mass index charting.” Acad Pediatr. 2009; 9(5):330-8.

30. Stop-light color coded (à la asthma action plan) vs. standard BMI

31. Methods • N=163 parents (children aged 2-8 yrs) • Two academic pediatric clinics • Parents given: • Demographics, color blindness test, WRAT-3R, S-TOFHLA • “Understanding BMI” questionnaire • Parallel questions -- compare understanding of standard vs. color-coded BMI charting • “Control” questions-- independent of color-coding.

32. Comparison of correctness on parallel questions for B&W vs. color-coded questions (N=163)

33. Performance by numeracy level Mean Correct on Questionnaire Numeracy level (WRAT)

34. Summary: Understanding BMI and Numeracy • Many parents reported understanding BMI (60%) but only 33% could explain it correctly. • Parents had greater odds of answering BMI chart questions correctly using color-coded vs. standard charts. • Lower numeracy parents benefited more from color charts than did higher numeracy parents, who performed well using both charts. • “NNT”= 2 to 6 (K-5 numeracy) = 3 to 23 (middle school numeracy) = 5 to 13 (high school numeracy)

35. Use of a Pediatrician Toolkit (Perrin EM, et al, Academic Pediatrics, 2010) CONCLUSIONS: Post toolkit use in an academic clinic: Children had healthier behaviors Parents developed greater accuracy in children’s weight status IMPLICATIONS: Further RCT research needs to be done, but it looks like our toolkit helps change parental perception!

36. These studies have been the building blocks for my current and future research…

37. Now my research is focused on the parent perspective and primary prevention • What do parents find sensitive and motivating? What is their advice for doctors? -K 23 grant in progress • What health effects are there of obesity at young ages and as predictors for the future that parents might find motivating? -Asheley has presented • How can pediatricians best help prevent obesity from the beginning? -R01 grant in progress

38. Context: Parents don’t see the problem of overweight Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. Maternal perceptions of overweight preschool children. Pediatrics 2000;106:1380-6. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood obesity: do parents recognize this health risk? Obes Res 2003;11:1362-8. Goodman E, Hinden BR, Khandelwal S. Accuracy of teen and parental reports of obesity and body mass index. Pediatrics 2000;106:52-8. Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, Whitaker RC. Why don't low-income mothers worry about their preschoolers being overweight? Pediatrics 2001;107:1138-46. Maynard LM, Galuska DA, Blanck HM, Serdula MK. Maternal perceptions of weight status of children. Pediatrics 2003;111:1226-31. Crawford PB, Gosliner W, Anderson C et al. Counseling Latina mothers of preschool children about weight issues: suggestions for a new framework. J Am Diet Assoc 2004;104:387-94. Jeffery AN, Voss LD, Metcalf BS, Alba S, Wilkin TJ. Parents' awareness of overweight in themselves and their children: cross sectional study within a cohort (EarlyBird 21). BMJ 2005;330:23-4. Lampard AM, Byrne SM, Zubric SR, Davis EA, Parents’ concern about their children’s weight., Int J of Pediatr Obesity 2008; 3 (2): 84-92.

39. In my CLINCAL experience, this is how this plays out If child is healthy weight, parent thinks child is skinny parents try to get the child to GAIN weight If the child is overweight, parents think the child is at a healthy weight no motivation to change dietary or PA behaviors Both groups of parents need education about weight status healthy recommendations

41. Can we teach parents about their children’s weight status in a way that is sensitive and motivating? Theory is…. Understanding health consequences Communication of BMI Understanding the child is an unhealthy weight Intention to change behaviors Behavior change Healthier weight trajectory How to do this quickly, effectively, and sensitively???

42. Interviews with parents Semi-structured interviews • 24 parents of children (12 AA and 12 white) • 4 each of healthy weight, overweight, obese • 1.5 hours; 25 pages of transcript each • Coded themes with Atlas ti software Broad concept of ideal visit and what would be sensitive and motivating Reactions to: • “Ideal” video • Color-coded charts and other tools

43. Interviews with parents study: Demographics

44. Interviews with parents study: Demographics

47. Interviews with parents study Body Mass IndexPrevious knowledge and chart preference 12/24 parents indicated they had not heard of the term body mass index. 7/12 indicated they had heard of the term BMI, but incorrectly defined the term when asked. 23/24 parents preferred the color coded BMI chart over the standard chart.

48. Advice From Parents • Give me charts to help explain recommendations • Give me the color-coded chart • Give it to me straight, but be sensitive in your language • Get to know me & make tailored and realistic recommendations • Listen and know me as a person before making recommendations • Tell me more about health than weight

49. Give me charts Yesterday, I went to the doctor with my youngest son who is the middle boy and they weighed him. … And I was concerned that he weighs very, very little. … And I did ask the doctor what about his weight …I don't know what to do. Does he need vitamins? ‘Oh, no. He looks good. He is healthy. He is not bones, bones, bones like he is not eating well.’ For him it was normal. And I still didn't quite understand him because he didn't show me a paper okay…. Like he is at this age, he should weigh this much, he should be tall this size, you know like that. I wasn’t very happy because I wanted to hear something else… He could show me a paper saying this is the age of certain kids, and this is what they weigh….

50. Charts help explain recommendations The doctor came in and he didn’t say nothing to me about him being overweight or anything like that. He just said we need to talk about a nutrition plan and get him on this and that, and, well, I’m looking at him like I don’t understand why you are telling me this….I think laying it out what you are going to talk about before you decide to talk about it is something that I think is going to help me to not feel like I need to be defensive….