rx: physical activity use of a portable gym system in overweight adolescents dominique r. williams,...
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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)
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) [email protected]
Community Outreach CoordinatorJessica Rodriguez (757) [email protected]
www.chkd.org/HealthyYou
Program ManagerBabs Benson, RN(757) [email protected]
FAX: (757) 668-7809
Healthy You for Life
Thank You