in the beginning centre for healthy...
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Centre for Healthy Weights-BC
A holistic approach to weight management for children and teens:
Sharing our experience
Dietetic InternsJanuary 10, 2013
Arlene Cristall, MSc., RDProgram Coordinator
2003- 2004
Funding for a pilot project from BCCH Telethon Innovations Fund
2006
ActNow BC funding for prototype model and Resource Centre at BCCH
2011
Healthy Families BC
In the Beginning
The Centre for Healthy Weights: Shapedown BC
VISION:
To provide a holistic approach to families with children andteens who are seeking help inweight management
The Centre for Healthy Weights: Shapedown BC
MANDATE:
To implement an evidence-based Pediatric Weight Management Program at BC Children’s Hospital
To act as a Provincial Resource to support and advocate for standardized resources and information throughout the province.
The Centre for Healthy Weights: Shapedown BC
Objective:
To facilitate changes in individual and family functioning that lead to sustainable, enjoyable, and healthy lifestyle habits and attitudes.
Centre for Healthy Weights
Program
Provincial Resource
Centre
Research and Evaluation
Partnerships
Consistent Coordinated Collaborative
Components
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Do NO Harm
Focus on Health not Weight !
Centre for Healthy Weights :Shapedown BC
Provincial ResourceCentre
Program
Centre for Healthy Weights- BC5 Pillars
Mu
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Fam
ily-
cen
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Lif
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le A
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Beh
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Evi
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ased
Multidisciplinary The Core Team
Registered Dietitian
Mental Health Professional
Physician
The Fitness/Activity Specialist
Support and education for groups
To facilitate ongoing linkages and access for children, adolescents and their families to fitness activities in their communities.
Family Centered Individualized to meet the needs of the child/teen
and family
Recognizes family capacity/ underlying contributors
Culturally, ethnically, socioeconomically respectful
Lifestyle Approach Non- diet approach Positive body image, self-acceptance Respectful guidance Acknowledges barriers Environmental compatibility
Behavioural
SMART goal setting
Skills and tools to change behaviour
Motivational Interviewing/Readiness
Screening tools for anxiety, depression, eating disorders; family function
Evidenced -Based 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children On-going support post intervention Evaluation/Responsive team/resources/programs
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Program Components
Program
Referral Assessment Feedback Intervention
Centre for Healthy Weights- BC
Physician referral
6-17 years
95% BMI for age
85% BMI for age with co-morbidities
Parental participation
English speaking
Referral Criteria
Medical EligibilityChildren and Adolescents with BMI > 85% through 95% are eligible if they have the following complications:HypertensionDysglycemia/Type two diabetes DyslipidemiaObstructive sleep apneaNonalcoholic fatty liver diseasePolycystic ovary syndromeFocal segmental glomerulosclerosisOrthopedic complicationsExercise intoleranceFamily risk factors:
Parental obesity (one parent with a BMI greater than 30)Family history of early coronary artery disease (before age 40-myocardial infarction, sudden death or CABG)Family history of metabolic syndrome
Program Components
Program
Referral Assessment Feedback Intervention
The Centre for Healthy Weights:Intake Assessment (4 hours)
Medical
Psycho-social
Nutrition and Lifestyle
Medical Assessment
History
Physical Exam
Bloodwork
Referrals
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WHY?
To determine:
• Cause
• Contributing Factors
• Complications
• Risk stratification
• Medical Eligibility
Psychosocial Assessment
Self-esteem/body image dissatisfaction
Mood disorder/Disordered eating
Family functioning
School functioning
Social functioning
Readiness
Questionnaires: BYI & CBCL
Lifestyle Assessment5 Key Points
1. Family meals / regularly scheduled
2. Sugar sweetened beverages
3. Screen time/Activity
4. Eating out
5. Parental Role Modelling
1. How often do you eat Family Meals together?
Although 80% of families value mealtime together
only 33% achieve this on a daily basis!
Why eat together?Eating Together =Eating Better
Children who eat meals with their families: Tend to eat more fruits and vegetables and less
fried foods
Drink less pop
Eat more fibre, calcium, folate, iron , vitamins B6, B12, C and E
Eat a lower glycemic load
Eat less sat and trans fat
Are more likely to try new foods and enjoy a greater variety of foods
Added Benefits- Children who eat meals with their families…
Have improved communication with their parents
Have fewer behaviour problems Have better school performance Have greater vocabulary Are less like to smoke, use drugs, drink
alcohol or have disordered eating Develop a sense of belonging, feel
more secure and stable
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Benefits of family meals to PARENTS are:
Mealtime provides a way to teach values and traditions
You save money by eating out less often
You eat healthier
You model healthy eating to your children
Regularly scheduled meals/snacks
Assure the child that they can eat again
Help to manage hunger
Better caloric distribution throughout the day
Assure intake of recommended daily nutrients
Help the parent to manage a child’s intake without controlling it
In the 1950s, kids had three cups of milk for every cup of soda. Today that ratio is reversed, meaning they get all the calories and none of the
nutrients.
2. How often do you drink juice, pop, gatorades, iced tea, bubbletea, slurpees, others?
More than half of all US children(74% of boys, 65% of girls) drink soft drinks DAILY
Over 80% of soft drinks (soda + juices) consumed are sugar-sweetened, not diet
Children who drink at least 1 soft drink daily consume about 200 cal/day more than those who don’t (totals 10 pounds a year!)
For children aged 7-11, odds of becoming overweight increased 1.6X for each additional can of sugar-sweetened drink consumed per day
The reality is…
What has changed in 50 years?
Accessibility:Soft drink machines, energy drinks, coffee
beverages, marketing (antioxidant drinks); HFC
Portion size:
How many teaspoons of sugar ?
900ml40 tsps
591 ml18 tsps
591ml14tsps
710 ml11 tsps
250 ml7 tsps
710 ml16 tsps
473 ml7 tsps
1.8 L54 tsps
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And we haven’t even talked about:
Caffeine effect
Displacing milk intake
Dehydration /inadequate water intake
Tooth enamel erosion from acidity
More than 90% of kids begin watching TV
before the age of two, despite
recommendations that screen time should
be zero for children under 2, and limited to 1 hour for kids 2-5.
3. How many hours/day do you spend on computer/ video games and/or television?
today, it is 5 months.
In 1971, the average age at which children began to watch TV was 4 years
Screen time and Physical Activity
Kids are accumulating 6 hours of screen time on weekdays and over 7 hours on weekend days.
TV viewing during mealtime is associated with
fruits and vegetables
pizza
snack foods
pop
twice as much caffeine
We know that …
Screentime uses up time for physical activity
More calories consumed while TV is on (dinner and snacking)
TV in bedroom has been associated with more viewing
Food, drink advertisements on TV affect food choices made by children
4. How often do you eat out, order in, pick up food?
Children who purchased their lunch at school were more likely to be overweight than children who brought their lunch from home.
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How food portion sizes have changed in 20 years
9 Pound Burger
for $23.95 140 calories 3-inch diameter
350 calories6-inch diameter
20 Years Ago Today
500 calories1 cup spaghetti with sauce and 3 small meatballs
1,025 calories2 cups of pasta with sauce and 3 large meatballs
610 calories6.9 ounces
20 Years Ago Today
210 calories2.4 ounces
270 calories5 cups
630 calories11 cups
590 calories
20 Years Ago Today
333 calories
500 calories
850 calories
Besides portion size, the quality of the food is questionable.
The major components of those calories are … FAT SODIUM SUGAR REFINED CARBOHYDRATES
AND LOW IN … CALCIUM/VITAMIN D FIBRE VITAMINS A & C
And the associated micronutrients
5. As a parent, do you eat well and are you active on a regular basis?
Dieting/ food restriction
Excessive exercising
OR
Poor eating/ activity behaviours
Low family activity time
EITHER EXTREME is not an option.
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Food Behaviours
Keeping “treats” out of reach (physically, chronologically) enhances desire- children are far more likely to binge when they have access to “forbidden” foods.
Don’t keep food around that needs to be restricted!
Kids will emulate what their parents do- one study showed that preschoolers tended to like or reject the same fruits and vegetables that their parents did.
Daughters seem to be more susceptible to their mother’s habits
Dieting = Food Restriction
“diet” cooking –Plain, steamed, repetitive
“overly-calculated” - # gms carbs, fat, protein
“no-fat” model = HUNGER!
“diet” beverages only
What is the message here?
Activity Behaviours
“ I go running for 20 miles every day!”
“I enrolled him in soccer, hockey, swimming, baseball, tennis, basketball, karate (add 10 more) and he always quits!”
OR
“I bought him a bike and he won’t use it”
“I am too busy to do things with him”
Program Components
Program
Referral Assessment Feedback Intervention
Feedback Session (1hour)
Care plan and appropriate intervention discussed with family
Strengths of family are built on and short term goals established
MEDICAL
Strengths: BP normal, fasting blood sugar normal, no physical barriers to being active.
Challenges:BMI =30.7, elevated fasting insulin, elevated liver enzymes, elevated cholesterol
READINESS
Strengths: Rating 5-7
Challenges:
SCHOOL/PEERS
Strengths: Good student, extra supports in place, many friends, best friend to talk to
Challenges: Numerous school transitions
PSYCHOLOGICALStrengths: friendlySelf-report: no significant symptoms of anxiety or depressionParent-report: no concerns with behaviour or emotional well-being
Challenges: self-report: lower than average self-esteem
FAMILYStrengths: close family relationships, mother is concerned about child’s well beingSupportive extended family
Challenges: Some sibling conflict with brotherHealthy habits away from home.
LIFESTYLEStrengths: Interests:drawing, painting, dance,family meals,limited screentime, some fruits and vegetables
Challenges:Uneven patterns, snacks vs.meals(after school)/quantity of food, activity levels, high milk intake>3c./day, access to junk food
WEIGHT
Biopsychosocial Feedback Tool
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Program Components
Program
Referral Assessment Feedback Intervention
Intervention Structure
10 weeks total• 1 session/week at BCCH site• 1 session/week at YMCA• 3 additional sessions for teens only
addressing emotional eating
2 hours long 10 - 12 families per group Children age clustered
What we do in group
Topics focus on Youth, Parent, and Family Functioning Co-facilitated by dietitian & psychologist Separate child/teen & parent session Joint session 30 minutes of activity with YMCA instructor Nutritious snack
Topics Nutrition education Active Living Smart Goal setting Parent skills training Communication skills training Self-esteem
PARENTS TEENS CHILDREN
Giving Teens responsibility
Feeling good about yourself- body image
Dealing with teasing
Helping to promote positive self-esteem in your child
Effective limit setting Effectively managing emotions (ie. Positive self-talk, challenging maladaptive thought patterns)
Managing worry and stress
Guiding and communicating with your teen
Handling difficult situations-problem solving
Feeling good about yourself- promoting positive self-esteem
Menu Planning Accepting body build-improving self-esteem
Feelings about weight
Healthy but not depriving diet-healthy recipes/ healthy cooking methods
Understanding causes of weight
Speaking up
Importance of family meals
Recognizing needs, speaking up
Targeted Themes
SV
Nutrition InformationEating 3 meals per day (establish patterns)
Eating in response to hunger
Eating until just satisfied not full
Eating more servings of fruits and vegetables
Eating more servings of light dairy products
Eating more servings of light protein foods
Eating more servings of whole grains (lighter choices)Reducing number of servings of processed foods
Exercise Philosophy
Decreasing screen time
Exercising for at least 200 (increase to 500)
minutes per week
Alternating different kinds of exercise (endurance, flexibility & strength)
Enjoying exercisebiking, walking, swimming, walking the dog, hiking, rollerblading, ice skating, dancing, etc.
Doing activity while watching TVjumping jacks, skip rope, stretch, dance, sit-ups, exercise bike, run/march in place, etc.
SV
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Generational Line
Balance between nurturing and limit setting: Love & Limits
SMART Goal Setting
S
M
A
R
T
PECIFICe.g., I am going to walk 30 minutes a day compared to I am going to be healthier
EASURABLEe.g., I am going to walk three times a week for 30 minutes instead of I am going to start walking more
TTAINABLESet goals that will push you slightly but be careful goals are not too far out of your reach
EALISTICMake small, doable changes
IMELYe.g., “In the next week, I will …”
GOAL TUES WED THURS FRI SAT SUN MON TOTAL Did I meet my goal?
1 My Activity
_________minutes per week
YESNO
Family Physical ActivityDid you attend the YMCA or do activity as a family? (check)
2 Screen Time
__________minutes per week
YESNO
3 Nutrition YESNO
4 I took time each day to keep this record (check)
YESNO
If all family members meet at least 3 out of the 4 goals, I will receive the following reward (If you are a child, please discuss reward with parents):___________________________________________________
Signed by Child: ____________________________________
Parent/Caregiver: ____________________________________
Two accomplishments this week were:1)
2)A challenge this week was:
1)
Active Living and Healthy Eating Chart
Name: ______________________ Date:____________________
Instructions: write the number of minutes that you completed (or check box) for each goal under the day of the week.
Learning to receive good things that have nothing to do with food
Sleeping in late on Sunday
A night out by yourself or with a friend
A paperback book
Renting a video for yourself
Taking a bubble bath
Going to the gym when you would otherwise be doing chores
Going for a walk with a friend
Going to the beach or mountains
Taking a bike ride
Have a friend spend the night
Taking a long bath
Buying a CD
Renting a movie Going to a movie or sports event
Buying a new book
Sleeping in
Child
Parent
REWARDS
Treatment Goals
To facilitate changes in individual and family functioning that lead to sustainable, enjoyable, and healthy lifestyle habits and attitudes
Individualized according to pubertal development (pre, mid, post)
Rule of ThumbWeight maintenance
½ Ib./week OR1Ib./week to healthy
BMI
Weight Maintenance: A Successful Goal
160
140
120
100
80
cm
302010
190
170
150
908070605040kg
cm
kg
2 4 6 10 12 14 16 20Age (yrs)
188 2 4 6 10 12 14 16 20Age (yrs)
188
343230282624222018161412
BMI (kg/m2)Height (cm) and weight (kg)
50
85
95
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Case Study
At intake:56.85 kg 142.1 cm
BMI = 28.15(99.1%ile)
Waist/Hip = .97
Female9 years 2 mos
Risk Factors
Mom’s BMI = 34.4 ENT history-surgeries related to tonsils
and adenoids/nasal obstruction has limited capacity for physical activity; also eating patterns of quickly eating and difficulty chewing
TV in bedroom/excessive screentimeWorries and sadness related to bullying
At intake:56.85 kg 142.1 cm
BMI = 28.15(99.1%ile)
Waist/Hip = .97
1 yr post58.2 kg153.3 cm
BMI =24.76(96.4 %ile)Waist/Hip = .88
Female9 years 2 mos
Over the short-term, Shapedown BC is effective in addressing:
1. Medical outcomes• Change in trajectory of weight gain from intake to
program completion• Reduction in BMI z-score and waist circumference
2. Psychological Outcomes• Improvement in Beck Youth Inventory scores: Self
concept and anxiety scores showed a significant improvement from intake to program completion
3. Physical activity• Improvement in reported mod-vigorous physical activity• Decrease in reported sedentary activity
Program Evaluation
Int. J. Environ. Res. Public Health 2011, 8, 4662-4678
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Centre for Healthy Weights :Shapedown BC
Provincial ResourceCentre
Program
PartnershipsResearch and Evaluation
Data overview 2006-2012 874 referrals
45% of mothers’ BMI> 30
44% of fathers’ BMI >30
29% of mothers’ BMI = 25-30
45% of fathers’ BMI = 25-30
Referral by Age/Sex(Oct 2006-Feb 2012)Age Group M F Total
<1 Years 1 1
1-5 Years 16 16 32
6-8 Years 74 71 145
9-11 Years 181 133 314
12-13 Years 100 86 186
14-17 Years 85 108 193
18+ Years 1 2 3
TOTAL 458 416 874
Referral by Health Region (Oct 2006-Feb 2012)
Region Count Percentage
Vancouver Coastal Health 439 50.2%
Fraser Health 400 45.8%
Other Health Authorities 35 4.0%
All Health Regions 874 100.0%
Research ScheduleIntakeSession
1st session of group Last session of group 3 months post group 12 months post group
Height x x x x x
Weight x x x x x
Hip:Waist x x x x x
Psychosocial /Lifestyle Measures
x x x x
Blood Requisition :Fasting GlucoseFasting Insulin
x x x x
Blood Requisition :Total CholesterolHDL, LDLTG, ALT, AST
x x
Fitness Test(6 minute walk)
x x x
High prevalence of metabolic syndrome at intake
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Over the short-term, Shapedown BC is effective in addressing: 1. Medical outcomes
• Change in trajectory of weight gain from intake to program completion
• Reduction in BMI z-score and waist circumference2. Psychological Outcomes
• Improvement in Beck Youth Inventory scores: Self concept and anxiety scores showed a significant improvement from intake to program completion
3. Physical activity• Improvement in reported mod-vigorous physical activity• Decrease in reported sedentary activity
Summary
Int. J. Environ. Res. Public Health 2011, 8, 4662-4678
Research
Currently 10 research partners:
No burden to families/staffing No interference with program delivery Potential for improving outcomes/maintenance
What we have learned
Program-level:
Site location is critical - community
Connection back to “home”resources
Length of program intervention
Development of maintenance phase
Use of partners -Cooking programs, gardens, schools, corporates, Y, Parks and Rec etc.
Constant evolution – responsive to participants’ needs.
What we learnedProfessional-level:
Reason for referral; weight is impairingfunctioning Raising issue of HEALTH – overall well-
being, SAFE- confidential/ comfortMotivation and Readiness/ Motivational
InterviewingRole-modeling the behaviour we expect
to seeFacilitate : Animation, Listening, Relationship
What we learned
Participant-level:
Validation: weight management is not easy
Needs to be fun: recipes, snacks, game-based activity
FlexibilityNon-judgmental stanceAvoid powerpoints
Nutrition and Lifestyle changes are key
Requires great sensitivity to the social, cultural and ethnic context that food and activity hold within a family unit
Present guidance to change that is compatible with the child’s/family’s readiness level and realistic to family’s capacity
Understand the no-diet approach to weight management and distinguish between this and the diet/weight loss focus approach
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“What Was Most Valuable About SHAPEDOWN?”
The Kids Said…
The parts where you learn about
your feelings and how to deal with
them
The information about healthy
eating habits and the good advice given on how to
read labels
Learning how to deal with
emotional stuff and
communication skills
Everything was valuable –i.e the
group setting and the information
learned
Learning to prioritize my
life
My family all started to help me and in a good way Learning all
about healthy food
Planning your life
How to talk to your parents
“What Was Most Valuable About SHAPEDOWN?”The Parents Said…
Thank you. An excellent
beginning!”
I had limited knowledge of my
daughter’s feelings, this
program helped open up those
feelings.”
This program was soooo great, and I am so thankful that we were chosen for
it. It has made a huge difference in
our lives and for my daughter.
I wish there was an advanced Shapedown to continue on with the instructors. They were excellent and taught us
so much about ourselves and our kids.
This was a very worthwhile
experience. Thanks for everything.”
The supportive, understanding
approach by the instructors was
great.
Thanks for your commitment to
helping us and our children
Contact InformationPROGRAM TEAM
Dr. Mary Hinchliffe, Medical DirectorDr. Janice Blocka, Physician
Arlene Cristall, RD/Program CoordinatorLeah Perrier, Registered Dietitian
Noony Paletta Santos, Registered DietitianDr.Sandy Klar, PsychologistDr. JP Chanoine - Research
CENTRE FOR HEALTHY WEIGHTS - BCBC Children’s Hospital
Room V2-210 Clinical Support Building948 West 28th Avenue
Vancouver, BC V5Z 4H4Phone: (604) 875-2345 ext. 5984; Fax: (604) 875-2388
www.bcchildrens.ca/healthyweights