rx: physical activity use of a portable gym system in overweight adolescents dominique r. williams,...

RX: Physical ActivityUse Of A Portable Gym System In Overweight

AdolescentsDominique R. Williams, MD, FAAP

Medical Director, Children’s Hospital of the King’s Daughters, Healthy You for LifeAssistant 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.

Identify barriers to physical activity

Review the use of therapeutic contact

Discuss study findings and clinical implications

Describe CHKD Healthy You for Life

Learning Objectives

Dominique R. Williams, MD, FAAP, Medical DirectorBarbara “Babs” Benson, RN, Program Manager

Jessica Rodriguez, Community Outreach Coordinator

Patricia Belford-Cohen, LCSWKira Davies, DPT, SCS

Joseph GillLynn Kistler, MS, RD

Jill Layne, LCSW

Regina BurkardMary Jo Haney, RD, CSPKim Kranz, PT, DScPT, OCS, SCSEllen Pelton, MS

Health Center at Oakbrooke - ChesapeakeHealth 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 percentileConsultation with

PhysicianPhysical Therapist and

Exercise SpecialistRegistered DietitianLicensed 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

Social Workers

• Individual and/or family counseling

• Coordinate care with other providers

Physical TherapistsExercise 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

Multidisciplinary Approach

Obesity

Initiatives

Support

Finances

Health

Access

Caregivers

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

Patient-centered Resist arguing,

persuasion, confrontation

Understand motivation Listen to the family Empower the patient

and affirm attempts to change

Tools

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 StylesFollowing 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

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

Maintenance/Relapse

Action maintained over 6 months (maintenance) or return to old habits (relapse)

The goal is to move from one stage to the nextPatients and their families may move back and forth

There may be differences in readiness – food, fitness, feelings

Adapted from National Obesity Forum, Patient Motivation - Readiness for Change, http://www.nationalobesityforum.org.uk

Preparation or Action Stage

BMI>95th

Child >8yo

Child’s weight is a health problem Their

weight is above

average

Being overweigh

t is a health

problem

Rhee et al. Pediatrics 2005; 116:e94 - e101

Parental Readiness for Change

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.

Marketing Corpulence

Source: Center for Science in the Public Interest (2003); Foley Freisleben LLC (2012); Kalb (2010)

She’s a brick house…36-24-36

Social & Cultural Norms

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

SpecificMeasurableAchievableRewardingTimely

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 trialsMay affect attrition, adherence more than BMI, weight

Have a plan for protected health information and HIPAAClearly define usefulness, timeliness, and “rules”

Emphasize the Medical Home

Adult MedicineWadden et al. Two year randomized trial of

obesity treatment in primary care setting. N Eng J Med 2011; 365: 1969-79.

Pediatric MedicineTaveras 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

• 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

Portable Gym System

Moving Forward

Conclusions

Differences in attrition

Differences in physical

activity

BMI velocity

Cardiovascular fitness

Next Steps

Consider short-term use

Foster increase

confidence

Randomize sample

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 DirectorDominique R. Williams, MD(757) 668-9177Dominique.Williams@chkd.org

Community Outreach CoordinatorJessica Rodriguez (757) 668-7860Jessica.Rodriguez@chkd.org

www.chkd.org/HealthyYou

Program ManagerBabs Benson, RN(757) 668-7035Barbara.Benson@chkd.org

FAX: (757) 668-7809

Healthy You for Life

Thank You