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


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.


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-

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Lif

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Beh

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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


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


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


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

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