CMA Foundation Childhood Obesity Multicultural Communications Webinar

Childhood Obesity – Strengthening the Capacity of Healthcare Providers to Work in Multicultural Communities in the Clinical Setting

The PartnershipIn 2010, the Federal Office of Minority

Health, provided funding support to the California Office of Multicultural Health to initiate a partnership with the CMA Foundation to increase awareness among healthcare professionals about the impact and importance of race, ethnicity and culture on pediatric overweight and obesity.

This collaboration lead to the update of the Child and Adolescent Obesity Provider Toolkit in 2011 and the development of a series of webinars to provide additional support to healthcare professionals addressing these issues in 2012.

Sophia Yen, MD, MPH Assistant Professor Division of Adolescent Medicine Department of Pediatrics Lucile Packard Children's Hospital Stanford University School of Medicine

Raynald Samoa, MD Assistant Professor City of Hope Department of Diabetes, Endocrinology and Metabolism

Webinar Faculty

Ricky Y. Choi, MD, MPH, Department Head of Pediatrics Asian Health Services Community Health Center

Disclosure Statement• We have no relevant financial relationships

with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this activity.

• We do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Webinar Objectives

Using a case presentation format, participants will be able to:

• Identify how culture and ethnicity can influence Asian-American and Pacific-Island patients' decision making related to overweight and obesity.

• Identify in which target areas (diet, physical activity) APIs are at greater risk for overweight and obesity.

• Describe effective patient/provider communication techniques to help families understand behaviors they can take to help their child reach healthy weight/lifestyle/behaviors, particularly focusing on increasing healthy food choices.

Complexities of “Asian”• Afghanistan

• Armenia

• Azerbaijan

• Bahrain

• Bangladesh

• Bhutan

• Brunei

• Burma

• Cambodia

• China

• Cyprus

• Georgia

•Sri Lanka•Syria•Taiwan•Tajikistan•Thailand•Turkey•Turkmenistan•United Arab Emirates

•Uzbekistan•Vietnam•Yemen

•Hong Kong•India•Indonesia•Iran•Iraq• Israel•Japan•Jordan•Kazakhstan•Korea, North•Korea, South•Kuwait•Kyrgyzstan

•Laos•Lebanon•Macau•Malaysia•Maldives•Mongolia•Nepal•Oman•Pakistan•Palestine•Philippines•Qatar•Saudi Arabia•Singapore

Diversity of Pacific Islander• Micronesia• Tonga• Fiji• Papua New Guinea• Wallis and Fatuna• Cook Islands• Niue• Hawaii• Samoa• Maori• Aborigines• New Caledonia• Guam• Northern Marianna • Tahiti• Tokelau

• 14 yo Chinese American male presents to clinic with mother for well child check. Noted to have BMI of 28. He gained 10 lb over the summer when he traveled to visit relatives in China. He lives with his parents and grandparents. He is getting As/Bs in school. At home prefers to spend free time playing video games over outdoor activities.

Case

• While mother is concerned about his weight, grandparents are dismissive.

• Grandmother does most of the cooking while parents work late.

• Dietary history: He usually eats noodles for breakfast. Meals at home are family style. He prefers salty meat and eats 2 small bowls of rice at each meal, ramen noodles 2x a week.

Case

Why is This Important• In the “State of Asian American, Native Hawaiian and Pacific

Islander Health in California Report,” Pacific Islander children had the highest rates of 5th graders in the unhealthy zone for body composition of all ethnic groups in the state

• In Hawaii, Samoan children had the highest prevalence of overweight, and 29% of all 4 & 5 year olds in Hawaii (multiethnic cohort) were either overweight or obese.

• In a study conducted at a large community health center in New York City, 40% of Chinese US born boys, aged 6–11 years, were identified as overweight or obese.

• The LA County Department of Public Health looked at Fitnessgram and found that 49% of Samoans in 5th, 7th, & 9th grades were obese.

Definitions of the EpidemicIn 2001, the Surgeon General declared

“overweight and obesity” a national epidemic.• Originally Different definitions, but now the same

BMI Adults /Children

>85th%-94th% overweight

>95th% obese

Weight (kilograms)BMI =

[Height (meters)]2

or lbs x703

in2

Body Mass Index (BMI)

CDC BMI charts not based on APIs

• APIs had same % body fat as Caucasian at BMI 3-6 points higher– South Asians are thinner but have greater

body fat and higher insulin sensitivity for any given BMI

• 33% of obese APIs (%BF >25 % for boys, >30 % for girls) not identified using WHO criteria

BMI by Ethnicity

Per 1996 Medical Expenditure Panel Survey:

• APIA teens more likely to be overweight than Hispanics, blacks and white (non-Hispanic) teens– APIA teens had 4.35 X the odds of being

overweight compared to whites/blacks

Consequences of Childhood Obesity

• Low self-esteem • Asthma• Sleep apnea• Heart disease• Type 2 diabetes• Fatty liver• 70% chance of being obese adults

What Contributes to Obesity among Children?

• Genetic factors• Behavioral factors

– Food intake– Physical activity

• Environmental factors– Homes– Childcare or schools– Community

IN OUT

IN

OUT

Which Foods Predispose to Weight Gain?

• Fast food– High in saturated fat & sugar– Low in protein

• 2003 CHIS showed:– 26% of 2-5 y/o APIAs ate 2 or

more servings of “high-sugar foods” per day

– vs. 23% of African Americans

Many Asian Teens Eat Fast Food 4+/wk

2009 CHIS showed:

• 17% of Asian teens vs 10% of whites

Eating out adds calories

• fast-food restaurant increased calories by – 126 calories in 2-11 y/o– 309 calories in 12-19 y/o

• full-service restaurant – 160 calories in 2-11 y/o– 267 calories in 2-11 y/o

Which has more calories?

Juice Soda

Answer?

Juice 14 cal/oz vs Soda 12 cal/oz

Juice has more calories!

Foods That Cause Weight Gain

• Drinks with Calories– Juice, soda, sports drinks, 1%/2%/whole milk– Whole milk is OK until 2 years old – AFTER 2 years old, kids should drink non-fat milk– Water is best

• Large portion size– All-you-can-eat– More than in “homeland”

• Rice, Fatty meat

Physical Inactivity

• Watching TV

• Playing video games

• Browsing the Internet

0 <1 2 3 4-5 6-20

19% of Asians 3-5 y/o Watch More TV Than Recommended

2005 CHIS, 12-18 y/o Asians

% Asian Teens that are Overweight/Obese

Teen Boys Worse Than Girls

2001-03 CHIS

• 14 yo Chinese American male presents to clinic with mother for well child check. Noted to have BMI of 28. He gained 10 lb over the summer when he traveled to visit relatives in China. He lives with his parents and grandparents. He is getting As/Bs in school. At home prefers to spend free time playing video games over outdoor activities.

Case

• While mother is concerned about his weight, grandparents are dismissive.

• Grandmother does most of the cooking while parents work late.

• Dietary history: He usually eats noodles for breakfast. Meals at home are family style. He prefers salty meat and eats 2 small bowls of rice at each meal, ramen noodles 2x a week.

Case

Components for change

Motivation Resources

Culture

Change

• Most Asian Americans are new immigrants– 66% born outside of the United States

• Many parents experienced scarcity in childhood– Scarcity mindset: “finish every grain of rice”, meat

• While some live in isolation, others live in multigenerational homes and close knit communities– Parents receive input/pressure on child rearing

Cultural Context

Cultural Context

• Different sources of unhealthy foods/extra calories: salty meat, other high calorie drinks (boba milk tea), instant ramen noodles, white rice, snacks from grandparents

• Traditional food may not be so healthy– Carbohydrates– Pork, shrimp, beef– Fried foods - Lumpia, Tempura

• Recognize food is an intimate connection to culture and community

• “Plate method” difficult to translate into family style meals

• Obesity not just a problem in the US.• Families may have limited knowledge of

some fruits and vegetable that are available in the US.

Cultural Context

Improving Patient Communication to

Improve Health Outcomes

This makes it critical to identify how we improve communication with our ethnically diverse patients to improve health outcomes.

Provider Guidelines

Recommendations1) Breast Feeding• % obesity in

NON BF BF4.5% 2.8%

• Longer is better % obesity 2 mos

3.8%3-5 mos 2.3%6-12 mos 1.7%>12 mos 0.8%

2) Healthy Meals- Careful dietary history including ethnic snacks (high calorie drinks)- Identify the person who prepares food for the child. Educate THAT person.- Suggest culturally acceptable food alternatives: Brown rice (vs white rice), ethnic vegetables, avoid fried food-More fish and chicken, less beef/pork - Eat >5 servings of vegetables/fruits per day

Recommendations

RecommendationsHealthy Meals (cont)

- Encourage family to try new fruits and vegetables- Avoid fast food

- Stress appropriate serving size

3) Brawn helps brain – being fit is key

4) Emphasize importance of setting life long healthy diet and activity patterns

5) Recognize the other competing priorities (stresses of acculturation) and plug them into community activities

6) Screen Time

Limit screen time to < 2 hrs/day.

Don’t eat in front of a screen.

Recommendations

Recommendations

7) Strengths: Involve the whole family– Family meals– Be physically active together– Plan active family fun

Conclusions• Overweight and obesity is an important

concern in the API community• API children are less physically active, watch

more screen time, eat more fast food, and eat fewer fruits and vegetables.

• Ethnic/Cultural accommodations are important in promoting a healthy lifestyle

Questions?

Multicultural Resources in the ToolkitEthnoMed – http://ethnomed.org

Healthy Roads Media - www.healthyroadsmedia.org

MiPiramide – www.mypyramid.gov/sp-index.html

Hawaii Pediatric Weight Management Toolkit-www.pfoh.org or by contacting Chock at gchock@aap.net.

Consumer Health Materials in Spanish – http://nnlm.gov/outreach/consumer/chspanish.html

Think Culturally (Office of Minority Health) – www.thinkculturalhealth.hhs.gov

The Provider’s Guide to Quality & Culture – http://erc.msh.org/mainpage.cfm?

file=5.4.5.htm&module=provider&language=English

Community Resources for Healthy Eating Have your staff identify resources available in your community to help you help your patients. These may include the YMCA, health plans, school based programs, faith based organizations, local hospitals, parks and recreation programs and community centers.

– Have the list easily available in your office.

Web based Resource ListAcademy of Nutrition & Dietetics

www.eatright.orgKids Health from Nemours

http://kidshealth.org

American Assoc. of Diabetes Educatorswww.diabeteseducator.org

USDA Food & Nutrition Services www.fns.usda.gov

California Dietetic Associationwww.dietician.org

YMCA of the USAwww.ymca.net

United States Department of Agriculturewww.choosemyplate.gov

NCES Health and Nutrition Educationwww.ncescatalog.com