2018 MOC Part II Self Assessment: Obesity Prevention in Primary - - PowerPoint PPT Presentation

2018 MOC Part II

Self – Assessment: Obesity Prevention in Primary Care: Amy Sternstein, MD, FAAP May 5, 2018

CME Disclosure

No relevant financial relationship to

• disclose. No off-label products will be

discussed in this presentation.

Purpose

• The Obesity Prevention in Primary Care Self-Assessment contains 50

questions that address childhood obesity. Childhood obesity continues to be recognized as a public health priority and primary prevention is a critical component of a sustainable solution. Pediatricians, as primary care health providers play a key role in prevention as a reliable source of health advice as well as experts in developmentally appropriate approaches to prevention. A critical window of opportunity exists through out the prenatal period into the first 5 years of life. This selection of articles support new research and strategies to enhance prevention efforts within the pediatric clinic setting. Healthy weights can be achieved by assisting families in health promotion by building a fundamental foundation of good nutrition, activity and sleep habits early in life.

Credit

• Completion of these 50 questions will give

participants 20 MOC Part II credits

• Qualifies for American Board of Pediatrics

5 year MOC cycle

MOC Part II, CME & Remote Attendees

MOC Part II - Eligible physicians can earn 20 points.

• Answer sheets for the MOC Part II self-assessment were provided to
• you. If you do not have an answer sheet, please be sure to get one

now

• Your ABP Diplomate No. AND Date of Birth is required to be listed on

your answer sheet.

• In-person attendees must submit their answer sheets to Candice

Hamilton at the end of today’s session. Answers will be shared with Ohio AAP for your MOC II credit.

• A CME evaluation will be e-mailed to you.
• Your CME certificate will be e-mailed directly to you upon completion
• f the CME evaluation to submit to your accrediting board.
• MOC Part II points will be entered into your ABP profile within 10

days.

Continued - Part II, CME

& Remote Attendees

CME – Eligible participants can receive 2 hours of credit

• For those seeking only CME credit, make sure you provided your

e-mail address when you signed in to receive the CME evaluation.

• Your CME certificate will be e-mailed directly to you upon completion
• f the CME evaluation to submit to your accrediting board.

Overview of Topics

• Primary Care’s Role in Obesity Prevention
• Significance of Early Intervention
• Importance of Tracking Wt/Ht and BMI
• Prenatal/Maternal Influences
• Emphasis on the Parenting Role with Active Child

Engagement

• Impact of Developmental Age Appropriate PA and

Nutrition Counseling

Stage 4

Stage 1 - Prevent Obesity & use BMI within Primary Care

Stage 2 - Assess Patient within Primary Care with Support- RD

Stage 3 – A program (3-6 months) tertiary care for weight management

Original Article on Obesity Prevention and Management

The Expert Committee on Childhood Obesity, Pediatric Supplement Dec. 2007

• 1. Educate and empower families

about lifelong nutrition and physical activity through anticipatory guidance.

• 2. Early recognition of excessive

weight gain relative to linear growth and BMI documentation starting at 2 years of age

AAP Recommends Obesity Prevention within Primary Care - Stage 1

WHY Bother? Because OVERWEIGHT PERSISTS

• More rapid increases in weight for length in the first 6 months

increase risk of overweight at 3 years

Taveras et al, Pediatrics. 2009; 123: No4.1177-1183

• Children with BMI >85% at ages 2-4.5 years 5 TIMES MORE

LIKELY to be overweight at age 12

Nader et al doi:10.1542/peds2005-2801 ( Dec 2006)

• Overweight or obese at 10 years = 80% risk of obesity as adult vs.

normal risk of 10%

Whitaker et al. NEJM: 1997;337:869-873

CAMPBELL, F., G. CONTI, J. J. HECKMAN, S. H. MOON, R. PINTO,

• E. PUNGELLO, AND Y. PAN.

"EARLY CHILDHOOD INVESTMENTS SUBSTANTIALLY BOOST ADULT HEALTH." SCIENCE, 2014, 1478-485.

1972-77: 111 Impoverished Children Randomized 57 Children

• Preschool 0-5 years
• 8 hrs/ day
• 2 meals, 1 snack
• Supervised play
• Cognitive & Social

stimulation:

• Language
• Emotional regulation
• Cognitive skills
• Access to Primary

Pediatric Care 54 Children Controls No intervention

• Survey: children, parents, teachers
• Demographics
• Health evaluation
• Lab tests
• Personality & Behavior
• Cognition & Achievement

Follow-up years: 12, 15, 21, 30 and mid-30s

Campbell et al., 2014

Early Intervention & Adult Health The Carolina Abecedarian Study

Early BMI rise predicted

• besity

at age 30 years Almost no treated child was above the 85th percentile BMI in first 2 years Significantly lower BMI at age 8 years

Campbell et al., 2014

Early Childhood & Adult Health

Physical Health at 40

• BP Lower

– Systolic: 17.5 mm Hg – Diastolic: 13.5 mm Hg

• Lipids

– HDL: 11 mg/dL higher – Abn Lipids: 31% less (males)

• Obesity

– Lower abd and severe obesity

• Metabolic syndrome

– Controls ¼; Treated none

• Cardiovascular risk score

– 2 fold lower

Males > Females

Campbell et al., 2014

It’s all about connections

• The brain doubles in size in just one year
• By year 3 it is almost adult-size
• Stimulation strengthens connections
• Unstimulated, those connections disappear

ANSWER QUESTIONS #1-3

Campbell et al., 2014

#1

The first stage of intervention in the ABC study was found to have a significant difference on adult health

• utcomes. Which of the following interventions was

NOT provided for the high risk children in the study?

A. Cognitive and Social stimulation B. Trained caregivers for 8 hours/ day from 0-5 years of age C. Supervised play D. Nutrition counseling for families

#2

The nutritional and health care component of the ABC program included:

• A. Children having nutrition education in preschool

classroom setting

• B. Children having poor access to well care visits
• C. Two meals and a snack that were provided in

addition to offering Health Maintenance Supervision

• D. Only serving fruits and vegetables in the preschool

setting

#3

The ABC study demonstrated greater improvement in males than females for all of the long term

• utcome measures. Which of the following was

NOT a demonstrated improvement in the ABC study?

• A. Lower BP in adult years
• B. Improved Cholesterol profiles in adult years
• C. Lower incidence of metabolic syndrome in adult

years

• D. Obesity risk was cut by 50% for study participants

TAVERAS, E. M., S. L. RIFAS- SHIMAN, M. B. BELFORT, K. P. KLEINMAN, E. OKEN, AND M. W.

• GILLMAN. "WEIGHT STATUS IN

THE FIRST 6 MONTHS OF LIFE AND OBESITY AT 3 YEARS OF AGE." PEDIATRICS, 2009, 1177-183

• 559 children- within cohort study of pregnancy
• utcomes- measured weight / length ( WFL) at

birth, 6 months and 3 years

• Evaluate prenatal growth impact vs. post natal
• Children with higher 6 month WFL had mothers

with higher BMI and infants not breast fed

• Results- Rapid increase in WFL in the first 6 months

were associated with increased risk of obesity at 3 years

• Confounding factors maternal body habitus,

smoking, pregnancy wt gain

Taveras et al., 2009

Weight for Length and BMI

Trajectory, more so than exact #

• r Percentile

ANSWER QUESTIONS #4-5

Campbell et al., 2014 Taveras et al., 2009

#4

Within this prospective cohort study,

• besity within the first 6 months was

most notably associated with?

• A. Socioeconomic status
• B. Pre-pregnancy BMI
• C. Rapid increases in weight per length
• D. Maternal smoking

#5

The best way to predict adiposity in children less than 2 years of age?

• A. Increasing weight measurement alone
• B. Increasing weight for length

measurement

• C. Rate of maternal weight gain
• D. Birth weight and prenatal factors

GILES, LC, MJ WHITROW, MJ DAVIES, CE DAVIES, AR RUMBOLD, AND VM MOORE. "GROWTH TRAJECTORIES IN EARLY CHILDHOOD, THEIR RELATIONSHIP WITH ANTENATAL AND POSTNATAL FACTORS, AND DEVELOPMENT OF OBESITY BY AGE 9 YEARS: RESULTS FROM AN AUSTRALIAN BIRTH COHORT STUDY." INT J OBES RELAT METAB DISORD INTERNATIONAL JOURNAL OF OBESITY, 2015, 1049-056.

• 1 in 4 UK, US, and Australian children are overweight or
• bese

– Birth weight and accelerated postnatal growth are risk factors but not well understood – Maternal antenatal and post natal risk factors can play a role

• Study looked at growth patterns of children ages 0-3

years and identified presumed antenatal and postnatal risk factors for obesity

• Characterizing Growth Trajectories allows us to connect

birth weight and growth patterns

Giles et al., 2015

Four Growth Trajectories Defined

– z-BMI= Age and sex adjusted BMI. – z-BMI close to zero= close to the birth weight mean – Characterized by birth weight and postnatal growth in first 6 months of life

• Low: Start close to zero, then

decelerate and stabilize

• Intermediate: Less deceleration than

low but still stabilize

• High: One s.d. above the mean BW,

stable growth

• Accelerating: High BW and rapid

acceleration to 2 years, then slows

Giles et al., 2015

• Maternal factors were studied and risk was assessed

– Antenatal:

• Maternal Age, Height, Weight, BMI (early pregnancy)
• Parity, smoking, weight gain in pregnancy, HTN, DM

– Postnatal:

• Breastfeeding/formula feeding status at 6 and 12 weeks recorded
• Timing of solid food introduction
• Of the Maternal factors the most important factor that

differentiated between growth trajectories was maternal BMI in early pregnancy, not maternal weight gain!

– More kids in the accelerated and high growth trajectories

Giles et al., 2015

• Low trajectory group associated with reduced height and

weight at 9 years

– Slightly below the mean compared to intermediate

• High and Accelerating trajectories were associated with

increased overweight and obesity at 9 years

– High: fourfold increase in odds of overweight or obesity by 9 years – Accelerated: 15 fold increase in the odds of overweight or obesity by 9 years

• Maternal obesity in early pregnancy was associated with

a fourfold risk of membership of the accelerating trajectory group

Giles et al., 2015

Main Outcomes, Giles

• Excess maternal weight and weight gain
• Premature birth +/- not conclusive
• Maternal stress
• Gestational diabetes (even controlled)
• Smoking during pregnancy (results in low

birth weight but later obesity) Impact of Prenatal Influences

ANSWER QUESTIONS #6-7

Giles et al., 2015

Giles et al., 2015

#6

The article describes four distinct growth trajectories noted in early childhood. Which

• f the trajectories is correlated with

increased odds of overweight/obesity by the age of 9?

• A. High and Accelerated Growth trajectories
• B. High Growth trajectory only
• C. High and intermediate growth trajectories
• D. Low Growth trajectory only

#7

Of the antenatal and postnatal exposures considered, the most important factor that differentiated growth trajectories and showed a four-fold higher risk of the accelerated trajectory was:

• A. Maternal Diabetes
• B. Maternal tobacco use
• C. Hypertension in pregnancy
• D. Elevated maternal BMI in early pregnancy

BIRCH, L. L., AND A. E. DOUB. "LEARNING TO EAT: BIRTH TO AGE 2 Y." AMERICAN JOURNAL OF CLINICAL NUTRITION, 2014.

• Infants and toddlers’ experiences and learning within the caregiver-

child feeding relationship shape the development of eating behavior

• Rapid brain growth and developmental milestones in first 2 years
• Parent feeding practices play a critical role in food preferences and

eating behaviors

– What, when, and how parents feed

• Parents have the opportunity to establish healthy dietary patterns

but the persistence of traditional feeding practices is problematic.

– Transition to table food diet is typically complete by 2 years – These were protective in times of food scarcity

• Feeding to Soothe: Now an overabundance of food, promote excessive energy intake
• Pressuring children to eat: promotes dislike of foods and preference for energy dense and sweet, food

less likely to be eaten

• Feeding frequently or in large portions-decrease variety, eat fewer vegetables
• Offering preferred foods- evidence shows infants and preschoolers will eat more when given larger

portions of preferred foods

– These practices compromise development of self-regulation Birch & Doub, 2014

Learning to eat: birth to age 2 yr.

Familiarization

• Familiar is preferred, unfamiliar will be avoided or disliked
• Milk is most familiar. When weaning, all things measured by this

– Formula flavors – Breastmilk provides a variety of flavors

• Infants reactions to foods introduced at weaning shapes the development of likes and

dislikes for table food – Early exposure and repetition – With increasing age neophobia to novel foods and flavors increases until middle childhood

• Understanding this helps see that this is a normal response not just “picky

eating”

• Infants also have unlearned preferences for sweet and salty and rejection of bitter and

sour – Can be modified with repetition – Easy to establish unhealthy patterns if one forgets the importance of familiarization Birch & Doub, 2014

Learning to eat: birth to age 2 yr.

• Associative Learning

– Association of the food or flavor with the affect generated

• Associations with emotional tone during feeding can shape food likes and

dislikes

– Pairing of novel flavors with familiar ones can influence development of food preferences

• Unfamiliar flavor becomes associated with the preferred flavor, increasing

liking of the new flavor, even by itself

– Tasting the food is necessary to alter preference and intake

• Yet children hesitate to taste. Flavor-flavor conditioning increases child’s

willingness to taste novel food. Birch & Doub, 2014

Learning to eat: birth to age 2 yr.

• Observational Learning

– Social influence provides tool for promoting tasting and intake of novel foods

• Children show tendency to taste unfamiliar food more readily when they
• bserve adults eating them than when offered alone to the child

Birch & Doub, 2014

Learning to eat: birth to age 2 yr.

HOW DO WE INSPIRE PARENTS TO BUILD A GOOD NUTRITION FOUNDATION?

Focus on Lifelong Habits….Not Weight

• Enhancing patient-provider relations

through parent-child engagement

• Innovative, sustainable approach to build

healthy habits

Mealtime is Playtime

• Sight
• Smell
• Taste
• Texture
• Sound
• Qualities
• Fine motor skills
• Exploration
• Independence

Sensory Education & Exploration

Instead of asking children if they like what they’ve tasted, ask them to taste the food and tell you what they think:

• Taste
• Texture
• Aroma
• Appearance
• Sound
• Temperature

The Benefits of Sensory Education

• Eliminates the thumbs-up/thumbs-down dismissal of food.
• Helps develop awareness about different properties of food.
• Allows for incremental exposure to difficult foods.
• Keeps kids open to multiple tastings.
• Takes the focus off fruits and vegetables (less pressure=more

success).

• Fun!

ANSWER QUESTIONS #8-16

Birch & Doub et al., 2014

#8

The article discusses how parenting and feeding approaches may:

• A. Impede the development of self-regulation

and the acceptance of a variety of foods and flavors necessary for a healthy diet

• B. Improve fruit and vegetable intake
• C. Promote restrictive practices in feeding
• D. Encourage the child to have the same likes

and dislikes as the parent

#9

The article states that the parent-child feeding relationships shapes the development of eating behavior. At what age is the transition typically completed from breast milk or formula to table foods only?

• A. 18 months
• B. 12 months
• C. 2 Years
• D. 3 Years

#10

Three important factors in the development of feeding practices include parents' decisions regarding:

• A. When and where children eat
• B. What children eat
• C. Why, for how long, and what children eat
• D. What, when, and how children eat

#11

Traditional feeding practices that developed in the context of food scarcity over centuries that are still practiced today include all of the following EXCEPT:

• A. Feeding to soothe
• B. Pressuring children to eat what is given to them
• C. Feeding frequently and offering large portions
• D. Offering preferred foods
• E. Eating small amounts to conserve food over

time

#12

Pressure of children to eat 'healthy foods' has been associated with all of the following EXCEPT:

• A. A trial and error method that results in

learning to taste new foods

• B. Dislike for the healthy foods
• C. Greater consumption of energy-dense sweet

snacks

• D. Decreased likelihood of the healthy food to be

eaten

#13

Which of the following is true regarding the familiarization process?

A. The neophobic response in the toddler years is concerning in the development of picky eaters B. There is no link between early food preferences and food preference later in life C. Infants’ reactions to foods introduced at weaning shapes the development of likes and dislikes for table foods

• D. timing of the familiarization process is not important in

the development of food and flavor preferences

#14

Which of the following is true regarding associative learning and feeding?

• A. Associations with emotional tone of social interactions

during feeding can shape food likes and dislikes

• B. Pressure to eat can be beneficial in getting children to

learn to like new foods

• C. Pairing of novel flavors with familiar flavors does not

have an effect on the development of food preferences

• D. Flavor-flavor learning decreases children’s willingness

to taste a novel food

#15

Which of the following is true regarding

• bservational learning and feeding?
• A. Feeding behaviors do not change when

children are eating in the presence of adults

• B. Modeling has little to no effect on the

feeding behavior of children

• C. Children show a tendency to taste unfamiliar

foods when they observe adults eating them

• D. Social effects of eating primarily change

mood but not food consumption

#16

What contribution does breastfeeding have in the introduction and familiarization of food to infants?

A. breastfeeding provides repeated exposure to a variety

• f flavors which increases the acceptance of initially

rejected flavors B. breast milk is sweet, which makes it difficult to introduce vegetable flavors to infants beginning pureed foods C. breastfeeding increases the bond between mother and infant, making the infant trust the mother more regarding the introduction of new foods

• D. breastfeeding or formula feeding has no effect on the

familiarization of new tastes or foods to infants

ANZMAN, S L, B Y ROLLINS, AND L L

• BIRCH. REVIEW ARTICLE "PARENTAL

INFLUENCE ON CHILDREN'S EARLY EATING ENVIRONMENTS AND OBESITY RISK: IMPLICATIONS FOR PREVENTION." INT J OBES RELAT METAB DISORD INTERNATIONAL JOURNAL OF OBESITY, 2010, 1116-124.

Parental Influence on Children’s Eating Environments and Obesity Risk: Implications for Preventions

Key Points

• Parents have a high degree of control over their

child’s eating environment

• Parents’ own food preferences, intake patterns

and eating behaviors greatly influence their children

• Observational learning greatly affects children’s

intake

• Pressure, coercion, food restriction and strict

meal time without hunger are counterproductive

Anzman et al., 2010

Observational Studies Support

• Early periods in eating transition and

development show promise for targets in obesity prevention

• Most notably post-natal suckling to solids but

also baby food to table food

• Repeated exposure to a variety of solid foods

increasing acceptance of fruits and vegetables in childhood

Anzman et al., 2010

ANSWER QUESTIONS #17-19

Anzman et al., 2010

#17

Traditional feeding practices to promote healthy eating support the positive influence of:

• A. Observational learning
• B. Coercion techniques
• C. Food restriction
• D. Strict meal schedule even in the absence
• f hunger

#18

Observational studies support the hypothesis that childhood obesity can be prevented by:

• A. Inattention to gestational weight gain
• B. Parents serving only the foods that they like
• C. Targeting the periods of developmental

milestones like post-natal suckling to solid food transition

• D. Limited exposure to a variety of foods

#19

Research reveals that infants who are repeatedly exposed to a variety of solid foods during infancy showed:

• A. Restrictive taste preferences
• B. Less acceptance to fruits and vegetables in

childhood

• C. More acceptance to fruits and vegetables in

childhood

• D. More food allergies

MONTAÑO, Z., JD SMITH, TJ DISHION, DS SHAW, AND MN

• WILSON. "LONGITUDINAL

RELATIONS BETWEEN OBSERVED PARENTING BEHAVIORS AND DIETARY QUALITY OF MEALS FROM AGES 2 TO 5." APPETITE, 2015, 324-29.

Longitudinal relations between observed parenting behaviors and dietary quality

• f meal from ages 2-5
• 731 culturally diverse, low income WIC families

with children ages 2, randomized, controlled trial- half reg WIC, half intervention group

• Intervention=Yearly home visits- ages 2, 3 , 4 or 5

assessment of positive behavior support defined as skillful behavior management and structuring

• f daily activities
• Positive behavior support from parents helped

predict dietary quality- video taped prep & meal

Montaño et al., 2015

ANSWER QUESTION #20

Montaño et al., 2010

#20

Predictive measures of a child's dietary quality are related to:

• A. Positive interactive support of parents
• B. Duration of meals
• C. Clear expectations prior to the meal

D.Controlling the child’s intake

BERGE, J. M., S. G. ROWLEY, A. TROFHOLZ, C. HANSON, M. RUETER, R. F. MACLEHOSE, AND

• D. NEUMARK-SZTAINER.

"CHILDHOOD OBESITY AND INTERPERSONAL DYNAMICS DURING FAMILY MEALS." PEDIATRICS, 2014, 923-32.

Childhood Obesity and Interpersonal Dynamics During Family Meals.

• Cross sectional study 120 children (mean age 9 yrs)

and parents (mean age 35 yrs)

• Low income within minority communities in

Minneapolis/St Paul

• Testing main hypothesis of Family Systems Theory
• 2 home visits Day 1 and Day 10
• 8 day direct observational study w/ video of family

meals, interviews, three 24 hr dietary recall

• During family meals- measured types of food, length
• f meal, interpersonal communication and parental

food control evaluated

Berge et al., 2014

Family Systems Theory

• Multiple levels of family influence
• parent – child
• child – sibling
• Interpersonal communication matters in the context of

food related dynamics

• Impact of positive communication= group enjoyment,

quality relationships can lessen incidence of

• verwt/obesity vs. negative factors=hostility, stress,

intrusiveness, level of distractions & inconsistent discipline

Berge et al., 2014

• Less overweight/obesity children within

positive family meal environment

• Characteristics than can influence success

include:

• Length of meal – 20 minutes
• Presence and engagement of family

members

• Positive interpersonal communication
• Minimal distractions

Conclusions

Berge et al., 2014

ANSWER QUESTIONS #21-23

Berge et al., 2014

Berge et al., 2014

#21

What is the main hypothesis of this study based on the Family Systems Theory?

• A. Positive interpersonal food related dynamics

are good for families but have no impact on weight

• B. Positive interpersonal food related dynamics

can lessen incidence of overweight/obesity

• C. Positive interpersonal food related dynamics

work best with strict parental control

#22

The characteristics that influence the success of family meals include all the following EXCEPT?

• A. People present at the meal
• B. Television viewing during the meal
• C. Electronics used during the meal
• D. Length of the meal
• E. “Cleaning the plate”

#23

Family meals can be structured in hopes of preventing obesity by all of the following EXCEPT?

• A. Keep the meal short i.e. 20 minutes
• B. Include multiple family members with at least one

parent

• C. Foster communication without electronic distractions
• D. Maintain a positive attitude encouraging group

enjoyment

• E. Requiring all participants to eat their vegetables served

Discussion

• Questions or Comments?
• How do you foresee integrating this into your

daily practice? Strengths and Challenges of doing so?

• Biological Break

GREGORY, J. E., S. J. PAXTON, AND A.

• M. BROZOVIC. "PRESSURE TO EAT AND

RESTRICTION ARE ASSOCIATED WITH CHILD EATING BEHAVIOURS AND MATERNAL CONCERN ABOUT CHILD WEIGHT, BUT NOT CHILD BODY MASS INDEX, IN 2- TO 4-YEAR-OLD CHILDREN." APPETITE: 550-56.

• Feeding strategies that parents use to control the

quantity and content of their children’s food intake may influence the child’s eating behavior

• Parents are more likely to use higher levels of control
• ver child feeding when they are concerned about their

child’s weight

– Disrupts a child’s ability to self-regulate their eating – May exacerbate problem eating behavior

• Pressure to eat more leads to reduced food consumption
• Restriction of snack foods leads to increased preference for the food

– However, modeled healthy eating has been found to increase intake of foods being modeled

Gregory et al., 2010

Two Main Aims

• 1. Explore maternal feeding practices and concern about

child weight (overweight or underweight)

– Directive measures-pressure to eat and restriction – Non-directive measures-monitoring intake of unhealthy foods and modeling

• 2. Test whether this concern impacted child eating

behaviors and/or BMI

Measures

• Participants were mothers of children aged 2-4; given

questionnaires at home

• Demographics
• Concern about child weight
• Feeding practices
• Child eating behavior

Gregory et al., 2010

• Key Findings

– Pressure to eat was significantly positively associated with maternal concern about child underweight – Pressure to eat was associated with higher child fussiness – Restriction was significantly positively associated with maternal concern about child overweight – Mothers were not influenced by the child’s actual weight status, but their concern instead

• Pressure to eat and restriction were associated with concern

about child weight and eating behaviors but not with the child’s BMI directly

Gregory et al., 2010

ANSWER QUESTIONS #24-27

Gregory et al., 2010 Gregory et al., 2010

#24

Parents attempts to restrict unhealthy foods and promote healthy foods can result in:

• A. Disruption of the child’s ability to self-regulate

their eating and can exacerbate the problematic eating behavior

• B. Limitation of unhealthy foods and exclusion of

those foods from the child’s diet

• C. Improved vegetable consumption
• D. Acceptable role modeling of feeding behavior for

children

#25

The study discussed two primary aims. These were:

• A. To explore maternal feeding practices and concerns

about child’s weight, and test whether this concern impacted child eating behaviors and/or BMI

• B. To explore food restriction and maternal factors

related to food intake, and BMI of children as a result

• C. To explore relationships in maternal feeding as a child

with choices made as an adult and their impact on BMI

• D. To focus on restriction of food and it’s effects on BMI

alone

#26

There is a direct association between maternal concern for their child being underweight and:

• A. The child’s actual weight status
• B. Higher levels of food fussiness
• C. Failure to thrive in the child
• D. Decreased use of pressure to eat

#27

Overall study findings concluded that generally:

• A. Parents use feeding practices to control their child’s

actual weight status

• B. Parents use of pressure to eat and restriction were

directly related to the child’s actual weight

• C. Pressure to eat and restriction were associated with

concern about child weight and eating behaviors but not with the child’s BMI

• D. The child’s BMI could be positively impacted by

parental use of pressure to eat or restriction practices

"LOOK AT NUTRIENT DENSITY WHEN TALKING ABOUT HEALTHY DIET." AAP NEWS, 2015, 31. AAP COMMITTEE ON NUTRITION.

Look at nutrient density when talking about healthy diet

• “Commentary” from the AAP Policy Statement on

Snacks, Sweetened Beverages, Added Sugars, and Schools

• Policy Statement focuses on competitive school foods

considering 5 attributes

– Selected from the 5 food groups (vegetables, fruits, grains, low- fat dairy, quality protein) – Promote a broad variety of food experiences – Avoid highly processed foods; use fresh when possible – Use the minimum amount of added sugar necessary to promote palatability and consumption – Adheres to USDA nutrition standards and portion sizes

AAP News, 2015

• Commentary discusses errors of the past and new approaches

– Elimination of foods that are deemed a high health risk – Low cholesterol, low fat, low sugar fads were ineffective and leave people confused

• Focus instead on nutrient density

– Foods are a blend of nutrients – It’s impractical to omit “bad” foods from the diet – “Forbidden” ingredients used in moderation improve the taste and enhance desirability of high-nutrient foods

• Emphasis on nutrient-dense foods allow “all foods to fit” in a

dietary pattern when portion and proportion are appropriate

– Focus instead on gradual improvements without asking for abrupt change in dietary habit

• Change to sweetened whole grain cereal with fiber from a sugary breakfast

cereal

AAP News, 2015

ANSWER QUESTIONS #28-29

AAP News, 2015

#28

The primary benefit of taking a nutrient-dense approach is:

• A. The ability to drastically change the diet quickly
• B. To focus on getting exactly the number of required

nutrients from each food group each day

• C. Its ability to encourage gradual improvement in

dietary choices without abruptly changing all dietary habits

• D. To better understand the food categories and

necessary nutrients

#29

Emphasis on nutrient-dense foods and drinks allows an 'all foods fit' approach as long as:

• A. Portion and proportion are appropriate
• B. Portion sizes have calories exactly measured
• C. Excess sugar can be removed from the diet

altogether

• D. Fatty foods are limited as much as possible

GINSBURG, K. R. "THE IMPORTANCE OF PLAY IN PROMOTING HEALTHY CHILD DEVELOPMENT AND MAINTAINING STRONG PARENT- CHILD BONDS." PEDIATRICS, 2007, 182-91.

The importance of play in promoting healthy child development and maintaining strong parent-child bonds.

• Play has been recognized by the United Nations High

Commission for Human Rights as the right of every child

• Children are being raised in hurried and pressured style

– may limit the protective benefits they would gain from child- driven play – Early focus on academic readiness

Ginsburg, 2007

The Benefits of Play

• Play is important for healthy brain development

– Practice adult roles – Work in groups – Negotiate – Resolve conflicts – Learn self-advocacy skills

• Play should be primarily child-led

– Adult led can cause kids to lose creativity, leadership, and group skills – Unstructured play builds healthy active bodies

• Increased physical activity levels with unstructured play

The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Ginsburg, 2007

The Benefits of Play

• Play and the Parent Relationship

– Developmental trajectory is “critically mediated” by appropriate affective relationships with loving caregivers that relate to their children through play – Parents can see the world through the child’s eyes

• Reduced Child driven play has potential repercussions

The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Ginsburg, 2007

What factors have changed the routine of childhood?

• More families with single household head or 2 working parents
• Fewer multi-generational households, resulting in more child-care
• Parents have become increasingly efficient in managing work and home

schedules – Strive to give children every possible opportunity and “make the most of their time” – “Professionalization of parenthood”

• The college admissions process

– Parents feel compelled to help their child build a strong resume – Students feel the need to do more and take more difficult classes

• Decreased play time at school to support academics
• Decrease play time at home due to passive activity
• Safety

The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Ginsburg, 2007

Why is it a problem?

• Some children can excel in this faster paced lifestyle

– Even these children need time to decompress

• This hurried lifestyle can be a source of stress and anxiety, and may

contribute to depression

– Parents need to balance allowing the child to achieve his/her potential without pushing beyond child’s comfort limits

• Increased pressures of adolescence have left some young people less

equipped to manage the transition to college

– Linked to highly critical parents that pressure to excel – American College Health Assoc. reports:

• 61% college students had feelings of hopelessness during previous year
• 45% were so depressed they had trouble functioning
• 9% had suicidal ideation
• Perfection at all costs mentality

– Increased cheating in college – Despite grade inflation, students more stressed about scores

The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Ginsburg, 2007

What is a pediatrician to do?

• Promote free play as a healthy essential part of childhood
• Emphasize that active child-centered play is a way of producing

healthy bodies

• Discuss the benefits of “true toys” like blocks and dolls that promote

the use of imagination

• Educate families regarding increased resiliency developed through

free play and unscheduled time

• Support parental nurturing and support through parents that share

in this spontaneous play

• Supporting children having an academic schedule that is appropriately

challenging and extracurricular exposures that offer appropriate balance.

• Encouraging parents to allow children to explore a variety of interests in a

balanced way without feeling pressured to excel in each area.

The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Ginsburg, 2007

Never Forget the Crucial Role of Play Essential skills:

• Social
• Emotional
• Cognitive
• Physical
• Creative
• Communication

ANSWER QUESTIONS #30-34

Ginsburg, 2007

#30

It is through play that children engage and interact in the world around them. When play is child-driven, it allows all of the following EXCEPT:

• A. Self advocacy skills
• B. The ability to practice adult roles
• C. Development of negotiation skills
• D. Conflict resolution skills
• E. The ability to maintain focus on a single rule

#31

What type of play has been shown to increase physical activity levels in children?

• A. Adult driven play
• B. structured play
• C. unstructured play
• D. focused play

#32

When considering play and the parent relationship, which of the following is true?

• A. A child’s developmental trajectory is critically

mediated by affective relationships with caregivers as they relate to children through play.

• B. Play allows a parent to lead the child through

important activities and concepts

• C. Through play, parents can see what they need to

change in their child’s perspective

• D. Play can show a parent how socially adaptable the

child can be, when play is parent-led

#33

This article relates that there is a problem with the loss of free-play time. What link does the author make to mental health in later years?

• A. Children that grew up with adequate free time, are rarely

depressed.

• B. For some children, the commonly practiced hurried

lifestyle is a source of stress and anxiety, and may even contribute to depression.

• C. There is a well-studied, strong link to mental health

problems in early adult life related to lack of free play as a child.

• D. Children that grew up with the promotion of free play

tend to be “wanderers”, without clear goals.

#34

The pediatrician can support the importance of protecting play in childhood in all of the following ways EXCEPT:

A. Recommending that children have ample, unscheduled, independent, non-screen time to be creative, reflect, and decompress. B. Counseling parents to choose early childhood programs with a focus

• n academic excellence.

C. Educating families regarding the protective assets and increased resiliency developed through free play. D. Supporting children having an academic schedule that is appropriately challenging and extracurricular exposures that offer appropriate balance. E. Encouraging parents to allow children to explore a variety of interests in a balanced way without feeling pressured to excel in each area.

EPSTEIN, L. H., J. N. ROEMMICH, J. L. ROBINSON, R. A. PALUCH, D. D. WINIEWICZ,

• J. H. FUERCH, AND T. N. ROBINSON. "A

RANDOMIZED TRIAL OF THE EFFECTS OF REDUCING TELEVISION VIEWING AND COMPUTER USE ON BODY MASS INDEX IN YOUNG CHILDREN." ARCH PEDIATR ADOLESC MED ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE, 2008, 239.

A Common Challenge

• Television viewing is related to obesity in children
• School based interventions show reducing TV viewing in 3rd

and 4th grade slows BMI increase

• Television viewing is related to consumption of fast food and

advertised foods and beverages

• Viewing cartoons with embedded food commercials increase

the choice of the advertised food in preschoolers

• TV commercials prompt eating
• TV viewing may impair satiety cues by interfering with

gustatory and olfactory cues

• Reducing TV time decreased energy and fat intake in lean

adolescents

• TV viewing and sedentary behavior competes with physical

activity

Epstein et al., 2008

Current Evidence

• Aim

– Primary: Determine the effects of reducing TV viewing and computer use on BMI – Secondary: Assess the effects of TV viewing on energy intake and expenditure

• Subjects

– Children ages 4-7 at or above 75% for BMI

• Methods

– TV Allowance device was attached to all TVs, game systems, computers, etc

• Controls and monitors use and time of use

– Each family member given a 4 digit code – Baseline use obtained over 3 week period – Study staff set a weekly time budget

• Budgets reduced by 10% per month until 50% reduced
• When budget was reached the device could not be turned on for remainder of week

Epstein et al., 2008

Epstein et al., 2008

• Incentives

– Intervention group received $0.25 for each half hour under budget, up to $2 per week

• Parents instructed to praise, star charts made-study staff praised

child on home visit

• At the end of the study, families provided with sustainability

information and resources

– Control

• Children had free access to TV
• Kids received $2 per week regardless of any behavior change
• Families received a newsletter providing tips and solutions

Epstein et al., 2008

Epstein et al., 2008

• Results

– Reduction in TV viewing and computer use was associated with decreases in zBMI

• Greater effect on children of lower socioeconomic status

– Reduction from baseline in targeted sedentary behavior (TV and computer use) – Reduction in energy intake for both groups over time

• Benefits

– TV and computer use can be modified using behavioral engineering

• Parental control of budget but the child chooses how to spend the budget
• Difference in the child’s perception of control that may relate to effectiveness

– Changes on the Home Environment may have effects on child BMI

Epstein et al., 2008

Epstein et al., 2008

ANSWER QUESTIONS #35-38

Epstein et al., 2008

#35

Current evidence has shown that TV time has been associated with all of the following EXCEPT:

• A. A reduction in TV time slowed the increase in BMI

in 3rd and 4th graders

• B. reducing TV time was related to decreased energy

and fat intake in lean adolescents

• C. TV time does not compete with physical activity or

energy expenditure

• D. TV viewing is related to consumption of fast food

#36

In this study the behavioral modification

• f a TV allowance aimed to:
• A. Decrease TV viewing time by 10% each week

until a 50% reduction was achieved

• B. Decrease TV viewing each day by 50% with

rewards offered

• C. Decrease overall TV viewing for the week by

10%

• D. Decrease overall family TV viewing time

#37

The benefit of using behavioral engineering technology as a means of modification of TV watching time is:

• A. It requires effort on the child’s part to keep track of

time

• B. Parents can achieve behavioral modification in TV

time without having to engage in alternative activities

• C. There is a difference in the child’s perception of

control that may relate to intervention effectiveness

• D. It can control all situations where a child may be

watching TV

#38

Television viewing while eating has been associated with all of the following EXCEPT:

• A. Viewing cartoons with food commercials can increase

choice of advertised item in preschoolers

• B. TV viewing may prompt eating by the association of

these behaviors with eating

• C. TV viewing while eating may impair the developments
• f satiety by interfering with habituation to gustatory

and olfactory cues

• D. TV viewing has been associated with decreased overall

food intake at a single meal

RESNICOW, K., F. MCMASTER, A. BOCIAN, D. HARRIS, Y. ZHOU, L. SNETSELAAR, R. SCHWARTZ, E. MYERS, J. GOTLIEB, J. FOSTER, D. HOLLINGER, K. SMITH, S. WOOLFORD, D. MUELLER, AND R. C.

• WASSERMAN. "MOTIVATIONAL

INTERVIEWING AND DIETARY COUNSELING FOR OBESITY IN PRIMARY CARE: AN RCT." PEDIATRICS, 2015, 649-57.

Resnicow et al., 2015

• 42 practices from AAP Office Settings Network with
• verweight patients ( n= 645 ages 2-8 yrs) in

randomly assigned 3 groups- 1) Usual care – no MI training 2) Provider with 4 MI counseling sessions 3) Provider with 4 MI and 6 MI from RD

• At 2 year follow up – lower adjusted BMI percentile

1) 1.8 percentile change to 90.8 2) 3.8 percentile change to 88.1 3) 4.9 percentile change to 87.1

Resnicow et al., 2015

Motivational Interviewing

• Patient centered
• Reflective listening
• Autonomy support
• Shared decision- making
• Eliciting change talk-

www.kognito.com/changetalk

• Conclusion that MI used by provider or in

combination with RD more effective in lowering BMI

Resnicow et al., 2015

ANSWER QUESTIONS #39-40

Resnicow et al., 2015

#39

Motivational Interviewing is a patient centered communication style using all of the following EXCEPT:

• A. Reflective listening
• B. Autonomy support
• C. Shared decision making
• D. Elicit change talk
• E. Physician directed plans

#40

Comparing methods of brief MI in a primary care setting revealed:

• A. Primary care providers alone were not effective in

lowering BMI

• B. Registered Dietitians (RD) alone are more effective

than primary care providers in lowering BMI

• C. MI used in a primary care setting by either provider
• r in combination with an RD can effectively lower

BMI

• D. MI is ineffective and time consuming

DANIELS, S. R., AND S. G.

• HASSINK. "THE ROLE OF THE

PEDIATRICIAN IN PRIMARY PREVENTION OF OBESITY." PEDIATRICS, 2015.

Daniels & Hassink, 2015

• This clinical report updates and replaces AAP

endorsed 2007 Expert Committee recommendations

• Childhood Obesity is still public health priority
• Combined responsibility of pediatricians,

public and private sector- government policy/ programs, school, community based programs

Daniels & Hassink, 2015

Pediatric Prevention Strategies

• Counsel on family based interactive

interventions because education alone is less effective

• Tailor to the child’s developmental stage
• Consideration of socioeconomic status
• Cultural and psychological characteristics
• f the family

Daniels & Hassink, 2015

Daniels & Hassink, 2015

Counseling Tips

• Provide suggestions for improved

parenting skills with behavior modification techniques

• Counsel on managing the food and activity

environment

• Use MI- family centered counseling not

provider driven guidance

• Emphasize parents as role models

Daniels & Hassink, 2015

Behavior Targets During Counseling

• Historically, target behaviors were derived from

knowledge gained from obesity treatments.

• Now, focus on longitudinally studies, randomized

and observational studies and consider basic science research

• Target Behaviors include:

– Breast feeding- self regulation – Limit sweetened beverages and screen time – Promotion of balanced meals & snacks – Age appropriate portions – Adequate sleep – Active play

Daniels & Hassink, 2015

Obesity Risk Factors

• Family history of obesity
• Parental weight status
• Prenatal environment- gestational diabetes

and maternal smoking

• Influence of maternal diet on the child’s taste

preference

• Rapid rise in rate of weight for length and

BMI

• Never breast fed
• Poor nutrition, sedentary behavior and lack
• f sleep

• Food preferences, activity and sedentary levels are

formed during early childhood and closely mirror that

• f parents.

“ Weight fate can be set by age 5 years.”

NEJM Cunningham Jan 2014

• Prevention is possible and crucial during early

childhood

IOM 2011

Importance of Early Risk Assessment

ANSWER QUESTIONS #41-50

Daniels & Hassink, 2015

#41

Prevention of obesity is the responsibility

• f all of the following EXCEPT:
• A. Pediatrician and their patient’s parents
• B. Community - public and private sectors
• C. Government programs
• D. Schools
• E. The overweight child

#42

The role of the pediatrician in practice is to provide advice by all of the following EXCEPT:

• A. Behavior Modification techniques
• B. Improvement of parenting skills
• C. Environmental control approaches
• D. Physician directed goals

#43

Historically, the tools and behavior targets derived for prevention in primary care are from:

• A. Observational studies
• B. Randomized controlled studies
• C. Knowledge of obesity treatments
• D. Basic science research

#44

Prevention counseling should be tailored to all of the following EXCEPT:

• A. Child’s developmental stage
• B. Socioeconomic status of the family
• C. Cultural and psychological characteristics of the

family

• D. What the medical community deems to be

important

#45

The main reasons to address obesity prevention prenatally through age 2 years is:

• A. Maternal weight at the time of pregnancy

determines outcome

• B. Fetal environment, maternal weight, maternal

diet and early taste preferences contribute to

• utcome
• C. Exclusive breastfeeding has been proven to

lower obesity rates

• D. Maternal diet alone determines outcome

#46

At risk patients are identified by all of the following EXCEPT:

• A. Family history and parental weight status
• B. Weight for length under 24 months and

BMI over 24 months

• C. Rate of weight gain
• D. Poor nutrition and sedentary behavior
• E. Exact birth weight

#47

Health promotion - hence obesity prevention efforts should aim for all of the following EXCEPT:

• A. Removing sweetened beverages
• B. Promote vegetables, fruit, whole grains, low fat dairy,

lean meat and fish and legumes

• C. Promote active play for 1 hour per day
• D. Recommend no screen time < 2 years of age and limit

screen time to < 2 hours for 2 years and older

• E. Strict exclusion of all unhealthy foods

#48

One advantage of involving primary care providers in the prevention strategy for obesity is:

• A. They follow patients and families longitudinally

and can tailor prevention interventions

• B. They have an authoritative role in the care of the

patient

• C. Parents exclusively follow the primary care

physician’s advice when it comes to their child

• D. What they have to say applies to all families

#49

Known prenatal risk factors for obesity include all of the following EXCEPT:

• A. Parental obesity
• B. Maternal gestational diabetes
• C. Family history of obesity
• D. Maternal stress

#50

Known child risk factors for obesity include all of the following EXCEPT:

• A. Never being breastfed
• B. Rapid infant weight gain
• C. Maternal neglect
• D. Short sleep duration

WHAT IS PMP?

• Comprehensive program for early

intervention

– Ounce of Prevention – Parenting at Mealtime and Playtime – Pound of Cure

• 3 main outcomes

– practice and provider quality improvement – data collection – obesity prevention via early intervention

PMP Project Team

Co-Medical Directors

Amy Sternstein, MD, FAAP Elizabeth Zmuda, DO, FAAP, FACOP

Quality Improvement Consultant

Samantha Anzeljc, PhD

Program Manager

Renee Dickman, MS

Early Identification and Intervention

• Practice strategy:
• 3 Main Targets:

– Parent-child dialogue – Motor skills development – Dietary habits/ healthy weight Consider – Parent-Child engagement – Parenting style – Early brain development – Social-emotional skills

Assess “RISK”

At Each Well-Child Visit

Dietary Guidance Play Promotion Motor Skills Language

Targeted Counseling

Determine RISK

• Family history
• Medical history
• Targeted review of systems
• Targeted physical exam
• Blood pressure
• Labs
• Lifestyle habits: diet & activity

PMP Mobile App pmp.ohioaap.org

• Physician-endorsed materials

for parents to access on-demand

• Resources for parents organized

by age

• Text reminders sent monthly

and/or for age milestones

• Videos on feeding, play,

nutrition and more

• Access the app by searching

“Parenting at Meal and Playtime” in the Apple App Store or on Google Play

App Highlights….

Use the PMP Mobile App flyer and/or magnet to promote it to your patients and their families! Feel free to print and post in exam rooms, reception areas or on bulletin boards, or as a handout to give to families at their well child visits.

T r u s t e d P a r e n t i n g A d v i c e a t Y

• u

r F i n g e r t i p s !

W

• u

l d y

• u

l i k e s

• m

e t i p s

• n

f u n p l a y ? D

• y
• u

h a v e a p i c k y e a t e r ? D

• y
• u

w a n t t

• e

n j

• y

, n

• t

d r e a d , m e a l t i m e w i t h y

• u

r c h i l d ? N

• t

s u r e w h e n t

• s

w i t c h f r

• m

f

• r

m u l a / b r e a s t f e e d i n g t

• s
• l

i d f

• d

? A r e y

• u

c

• n

f u s e d a b

• u

t w h a t t

• f

e e d y

• u

r c h i l d b a s e d

• n

t h e i r a g e ?

The Ohio AAP, in partnership with the Ohio Department of Health, is excited to share the Parenting at Mealtime and Playtime Mobile App. Developed in consultation with physicians, pediatric experts and dietitians, the app is designed to provide parents and caregivers with easy access to trusted, age-appropriate advice outside of their doctor’s

• ffic

e f or children ages birth to 5 years. This visually-appealing app is organized by age and includes helpful photos, content and videos. Y

• u will be able to access:
• Meaningful tips about your child’s nutrition and activity
• Information specific

to y our child’s age

• Reminders for well child visits and age-specific

tip s Access the app by searching “Parenting at Meal and Playtime” in the Apple App Store or on Google Play. After you download, click the “Information” logo in the upper right, and follow the directions to register an account. To receive notific a tio ns, click the “Information” logo again, select “Settings,” and then enable “Notific a tio

• ns. ” Finally, tap “Notific

a tio ns” and select your child/children’s birth year(s) and month(s).

Networking Discussion

• How do you see working with each other (other

community providers) and using PMP collaboratively?

– Networking with other providers: WHO, HOW – Using PMP resources and messaging – Overcome challenges – Share successes

• Questions & Comments

USING PMP IN YOUR PRACTICE:

Access the PMP materials and resources electronically:

• Handouts and Notebook: http://ohioaap.org/PMPSpirals
• Primary Care Pocket Guide:

http://ohioaap.org/PMPPocketGuide

• Mobile App: https://pmp.ohioaap.org

For more information on the Parenting at Mealtime and Playtime program, contact PMP Program Manager, Renee Dickman at rdickman@ohioaap.org or call Ohio AAP at 614-846-6258.

Parenting at Mealtime and Playtime This concludes the session THANK YOU!