Session # G1c October 17 , 2015

1. Session # G1c October 17, 2015 Childhood Obesity Prevention and Treatment: Behavioral Health and Medical Providers Partnering in Research and Practice Jerica Berge, Ph.D., Associate Professor, University of Minnesota Keeley J. Pratt, Ph.D., Assistant Professor, The Ohio State University

2. Faculty Disclosure The presenters of this session • have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe the prevalence of childhood obesity and obesity disparities and discuss how family medicine/primary care clinics are a natural environment for childhood obesity prevention and treatment interventions. • Describe interdisciplinary childhood obesity intervention research approaches and clinical care models currently being carried out in family medicine/primary care clinics. • Discuss clinical recommendations and best practices for working with families who have an overweight or obese child in family medicine/primary care clinics.

4. Bibliography / References Berge, J.M., Meyer, C., MacLehose, R., Crichlow, R., Neumark-Sztainer, D. (in press). All in the family: Associations between parents’ and siblings’ weight and weight-related behaviors and adolescents’ weight and weight-related behaviors. Obesity. 2. Berge, J.M., Everts, J. (2011). Family-based interventions targeting childhood obesity: A meta-analysis. Childhood Obesity, 7(2), 110-121. 3. Sherwood, N.E., French, S.A., Veblen-Mortenson, S., Crain, A.L., Berge, J., Kunin-Batson, A., Mitchell, N., Senso, M. (2013). NET-Works: linking families, communities and primary care to prevent obesity in preschool-age children. Contemporary Clinical Trials, 36(2): 544-554. 4. Berge, J.M., Law, D.D., Johnson, J., Wells, M.G. (2010). Effectiveness of a psychoeducational parenting group on child, parent and family behavior: a pilot study in a family practice clinic with an underserved population. Families, Systems and Health, 28, 224-235. 5. Stovitz, S., Berge, J.M., Wetzsteon, R.J., Sherwood, N., Hannan, P.J., Himes, J. (2014). Stage 1 treatment of pediatric overweight and obesity: A pilot and feasibility randomized controlled trial. Childhood Obesity, 10(1):50-57.

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Overview of Presentation • Agenda • Introduction to presenters, topic, and prevalence • Family Systems Theory and it’s application to Childhood Obesity • Research and Clinical Applications for family-based obesity intervention • Prevention • Treatment • Questions

7. Introduction to the topic and prevalence

8. Prevalence of Childhood Overweight/Obesity • Worldwide • Approx. 1.6 billion adults (age 15+) are overweight • At least 20 million children under the age of 5 years are overweight • Nationally: USA (ages 2-19) • 31.8% Overweight ≥ 85th percentile • 16.9% Obese ≥ 95th percentile • 12.3% Severely Obese ≥ 97th percentile • Highest among Hispanics (22.4) and non-Hispanic Black youth (20.2) • 2-5 years old least obese group vs 6-11 and 12-19 age groups (Crawford, 2008; IOM, 2005; Federal Interagency Forum on Child and Family Statistics, 2007; National Survey of Children’s Health, 2007; Ogden et al., 2012)

9. BMI Trends in Families • BMI between youth and parents is highly correlated (especially mothers) • 1 parent and 2 parent obesity risks • BMI between partners/spouses is highly correlated • Mixed findings before, during, and after marital disruption (divorce/separation) and child BMI (Arkes, 2012; Bralic, Vrdoijak, & Kovacic, 2005; Safer et al., 2001; Yannakoulia et al., 2008)

10. Diverse Settings • Obesity may be treated in several contexts depending on the severity and availability of specialty care • Inpatient • Outpatient • Specialty Clinic/Tertiary Care • School, church, or other community-based interventions

11. Stages of Treatment – Childhood Obesity • Stage 1: Prevention Plus (Primary Care) • Family visits with MD or health professional for lifestyle/behavioral treatment • Stage 2: Structured Weight Management (Primary or Specialty Care) • More structure and support with individual or group follow-ups with a dietician and exercise therapist • Included self-monitoring, goal setting and rewards, and monthly individualized treatment • Stage 3: Comprehensive and multidisciplinary approach (Specialty Care) • Structured behavioral program with diet and physical activity goals • Weekly group sessions for 8-12 weeks plus follow-up • Stage 4: Tertiary Care for Severely Obese Youth (Specialty Care) • Medication • Very low-calorie diets • Surgical approaches *Differences based on age. (NICHQ, 2007; Barlow, 2007; AAP, 2007; NHLBI, 2007)

12. Davison & Birch, 2001, Ecological Model of Predictors of Child Overweight

13. Differences in Age • The Expert Committee Recommendations (Barlow, 2007) directs healthcare providers to focus their approach based on the developmental and chronological age of the youth: • Youth ages 2–5: focus the discussion on parenting behavior • Youth ages 6–11: equally target caregiver(s) and youth • Adolescents: discuss health behaviors directly with the adolescent, and parents/caregivers should be encouraged to make the home environment as healthy as possible and provide support to their teen

14. Family Systems Theory and Application to Childhood Obesity

15. Family Systems Theory (FST) • Families are complex systems where multiple reciprocal interactions occur simultaneously between members • Members of a family are connected, and must be viewed as a whole • Families resist change, and strive to stay in homeostasis • Family subsystems (i.e. parent-child) can influence the whole family’s functioning (Bertalanffy, 1952)

16. Parental Domain: 1. Parenting Style 2. Parenting Practices (e.g., modeling of health behaviors and conversations about health behaviors) 3. Parental Perceptions 4. Personal Behaviors Obesity & Other Weight-Related Outcomes Among Children & Adolescents: 1. Weight Status 2. Dietary Intake 3. Physical Activity 4. Unhealthy Weight Control Behaviors Family Functioning Domain: 1. Family Functioning 2. Emotional Closeness and Connectedness 3. Family Weight Teasing 4. Availability & Accessibility of Healthful Food 5. Resources for Physical Activity 6. Family Meal Frequency • Sibling Domain: • Weight Teasing • Modeling healthful behaviors Family Systems Approach to Childhood Obesity (Berge, 2009)

17. FST continued • Families set the rules and boundaries for the way information is communicated in the system, and the expectations for behaviors and relationships in families • Rules and rituals are established within families and subsystems • Interactions and dynamics between family members should be considered in the context of the family environment (Bertalanffy, 1952; Skelton, Buehler, and Irby 2012)

18. FST continued • In the case of childhood obesity, family dynamics, rules, and interactions could preclude or encourage healthy behavior change and habits • Families should be adaptable and responsive to change • Families who organize around weight-related behaviors vs those who don't (Bertalanffy, 1952; Skelton, Buehler, and Irby 2012)

19. Given that childhood obesity is a complex problem and MFT’s have a family systems theory lens… • MFT’s are well-situated to lead the way in research and clinical interventions with families around childhood obesity!!

20. Childhood Obesity & Family • Involving the family system promotes more sustainable diet and physical activity behavioral changes in the youth • Including parents as active participants in habit change and weight loss was effective for weight control among children at 5-year follow-up • Positive outcomes have included: • Reductions in BMI (z-score) • Increases in QOL • Decreases in depression • Reductions in sedentary behavior (Barlow, 2007; Denzeret al., 2004; Epstein et al., 1990, 1994; Pratt et al., 2013; Robertson et al., 2011)

21. Systematic Reviews of RCTs • Parent-only vs parent-child (family-focused) approaches for weight loss in obese and overweight children • 4 RCTs meet inclusion criteria • No significant differences in BMI z-score from baseline to end of treatment or follow-up • Family-based models for childhood-obesity intervention: a systematic review of RCTs • 15 RCTs of family-based lifestyle intervention for youth (2-19) were included • Family-based behavioral interventions achieved better results than family systems theory for treatment effectiveness • 20 family-based RCT treatment interventions focused on lifestyle with children (2-12 yrs.) and families (some multiple family members) • Significant effects for family-based treatment; opposite-sex parent/child dyads experienced more weight loss (Jull & Chen, 2013; Sung-Chan, Sung, Zhao, & Brownson, 2013; Berge & Everts, 2011)

22. Systematic Review of RCTs cont. • Family-focused physical activity, diet and obesity interventions in African-American girls • 27 obesity prevention or treatment studies with family • Most targeted parent–child dyads • Effects on weight-related behaviors and outcomes were generally promising but often non-significant • Data did not detail whether or how best to involve family members in obesity prevention and treatment interventions with African–American girls (Barr-Anderson, Adams-Wynn, DiSantis, & Kumanyika, 2013)

23. Parenting Practices - Dietary • Restricting and monitoring associated with child: • Eating in absence of hunger • Eating more sweet/savory snacks w/out supervision • Responsiveness and nurturance associated with child: • Greater intake of fruits and vegetables • Permissive and uninvolved associated with child: • Lower fruit and vegetable intake • Greater likelihood of child being overweight/obese (Berge, 2009; Hurley, Cross, & Hughes, 2011; Patrick, Hennessy, McSpadden, & Oh, 2013)

24. Parenting Practices – Physical Activity, Screen Time • Restricting and monitoring associated with: • Eating in absence of hunger • Lower screen-time use • Permissive and uninvolved associated with: • Greater engagement in moderate-vigorous activity (Hennessy et al., 2010; Jago, Davidson, Brockman, et al., 2011; Jago, Davidson, Thompson, et al., 2011)

25. Parenting Style • The more girls feel that their parents care about them the more likely they were to have a normal BMI • Mothers: authoritative parenting style predicted lower BMI in adolescent sons and daughters • Fathers: permissive parenting styles were more likely to have preschoolers with a higher BMI (Crossman et al., 2006; Moens, Braet, Bosmans, & Rosseel, 2009;Berge, Wall, Loth, & Neumark-Sztainer, 2010; Wake et al., 2007)

26. Parenting Practices & Parenting Style • Parenting behaviors don’t happen in isolation • Combination of parenting practices (e.g., modeling & encouraging healthful patterns) and parenting style • Two parents: What if parents have different parenting practices and parenting style in relation to childhood obesity? • Incongruence between parenting behaviors was associated with higher BMI z-score in adolescents (Berge, Wall, Bauer, Neumark-Sztainer, 2010)

27. Family Meals Benefits • Positive association between maternal and paternal authoritative parenting style and frequency of family meals for adolescent girls (only maternal for boys) • Family meal frequency was associated with: • Increased fruits/vegetables • Less fast food intake for fathers • Fewer dieting and binge eating behaviors for mothers (Berge, Wall, Neumark-Sztainer, Larson, & Story, 2011 Berge et al., 2012)

28. Family Meals Structure & Interpersonal Relationships • Structural characteristics and interpersonal dynamics of family meals and its protection for youth • structural (e.g., length of the meal, types of foods served) • interpersonal characteristics (e.g., communication, emotion/affect management) • Meals were approx. 20 min long, included multiple family members, served family style (70%), and occurred in the kitchen (62%) • Significant associations between positive interpersonal dynamics at family meals and • lower adolescent BMI • higher vegetable intake (Berge, Jin, Hannan, & Neumark-Sztainer, 2013)

29. Family Functioning • Higher family functioning was associated with: • Lower BMI in adolescents • Higher healthful dietary intake (i.e., fruit and vegetables, breakfast, family meals) • Less sedentary behavior (i.e., screen time) • More physical activity (only for boys) (Berge, Wall, Larson, Loth, Neumark-Sztainer, 2013)

30. Family Weight Talk • Parent “weight conversations” (e.g., talk about child’s weight, shape or size) • Adolescents had higher BMI and more disordered eating behaviors • Parent “healthy eating and physical activity conversations” (e.g., eat healthy so you can have strong bones and run faster) • Adolescents had lower BMI and fewer disordered eating behaviors (Berge, MacLehose, Loth, Eisenberg, Bucchianari, Neumark-Sztainer, 2013)

31. Research and Clinical Applications for Family-based Obesity Intervention

32. Family-based Childhood Obesity Interventions • Specific – where parents target specific child behaviors (and parenting practices) related to eating and exercise • General – aim at changing the broader family context or family functioning • Family cohesion (family expressiveness, family functioning) • Parenting style (Kitzman & Beech, 2006)

33. Prevention

34. Prevention • NET-Works Study: • Multi-level, multi-setting interventions are needed to address the complex childhood obesity problem (Ecological Model) • NIH and other expert committees have recommended using primary care as an entry point for family-based interventions • Need for reducing obesity disparities in racial/ethnic groups • U01 NIH Center grant; 7-years

35. NET-Works Specific Aims • Evaluate three-year parent-targeted multi-level (i.e., home, community, primary care) intervention for preschool children • Primary outcome change in child BMI z-score • Randomized two-group design (N = 500)

36. NET-Works Intervention Components • Primary care message • Family Medicine doctors • Family Connector (9 home visits per year) • Home visiting • Parenting class (12 weeks x 2 semesters) • Family Life Educators • Community food retail and recreation • Connecting to pre-existing resources such as farmers markets, green space/community gyms, libraries

37. Sample N=500 families (10 community clinics) Somali Hispanic Hmong African American White Randomized two-group design (N = 500) • Standard Care Control Group (safety message); n=250 • Experimental Group; n=250 3 year duration in order to increase the likelihood of seeing significant BMI changes

38. Parenting around Mealtime and Playtime (PMP) • Sponsored by the Ohio American Academy of Pediatrics and the Cardinal Health Foundation • Parenting at Mealtime and Playtime Learning Collaborative assists pediatric practices in providing anticipatory guidance to and assessing obesity-related health risk in infants and young children to instill a foundation of healthy lifestyle behaviors at an early age.   • Resources and strategies to help clinicians educate and counsel parents during well child visits about developing sound nutrition and strong fundamental motor skills for their children birth through 5 years of age. • Play and Filial therapy foundations instilled in PMP handouts to enhance the parent/guardian-child relationship http://ohioaap.org/projects/PMP

39. Treatment

40. T-1 QOL and BMI Changes in an Integrated Pediatric Obesity Treatment Program • To describe the changes from youth baseline variables in QOL, caregiver and teen depression status, and child/teen BMI z-score from baseline through two follow-up visits • Longitudinal panel descriptive • Analyzed the relationships over time using linear mixed models with time as a covariate, considering a model with random intercepts and slopes, and having the unstructured covariance structure • Patient trajectories are shown together with the estimated mean function (bold curve) obtained using a kernel smoother (a nonparametric function estimation procedure) with bandwidth chosen via the GCV procedure implemented in PACE package in Matlab (Pratt, Lazorick, Lamson, Ivanescu, & Collier, 2013; Fitzmaurice, Laird, & Ware, 2004; Yao, Muller & Wang, 2005 )

41. T-1

42. T-1 Figure 1. Quality of Life for all youth (age 8-18) participants (n=266) The average QOL intercept was 74.28 (t (260) = 78.9, p < .001), and slope was .034 (t (61) = 4.9, p < .001). The mean QOL increased by .034 points, from the average QOL at the first visit, for each additional day all youth participants continue in the study.

43. T-1 Figure 2: Body Mass Index z-score for all youth The average BMI z-score intercept was 2.49 (t (264.0) = 120.1, p < .001), the slope was -0.00011 (t (66.3) = -2.54, p = .013). Compared to the average BMI z-score at the first visit, the mean BMI z-score decreased by .00011 for each additional day the participants continue in the study.

44. T-1 Figure 3: Patient Healthcare Questionnaire (nine item) for all teen (age 13-18) participants The average PHQ9 intercept was 5.35 (t (121) = 14.2, p < .001), and the slope was -.01 (t (56) = -4.2, p < .001). Compared to the average PHQ of 5.35 for teens at the first visit, the mean PHQ decreased by .01 points for each additional day the participants continue in the study.

45. T-1 Discussion • Overall, across three visits, our results indicated youth’s BMI z-score decreased slightly, their QOL significantly increased, and teen depression level improved. • Interestingly, youth had significant improvements in their QOL, despite their BMI z-score and the majority of our sample being either obese or severely obese • Researchers have reported that QOL is inversely related to weight; suggesting that the most overweight youth have the most significantly impaired QOL • Limitations: treatment seeking sample, no significant predictors of follow-up, only dyads assessed

46. T-2 The Self-Reported Strengths and Concerns of Obese Youth and Caregivers Purpose: To investigate how youth's self-reported strengths and concerns compare to their caregivers, and to determine if youth's self-reported strengths and concerns differ between race and gender subgroups (i.e., black and white, male and female) • Same qualitative phenomenological method • Youth and caregivers were independently asked to list their top three strengths and top three concerns. • “Please write in the space provided the top three concerns in your life right now or things you are worried about. Please write down the top three strengths in your life right now or things that are going well.” • (Pratt, Lamson, Radley, 2014)

47. T-2 Results • n = sample size (number of participants) • Top Themes = clustered classification codes • Top Classifications = codes assigned to direct quotations • Representative Quotations = direct quotations given by participants that are representative of the parallel assigned code • *Only the highest frequencies were included in each table

50. Caregiver Strengths