Psychosocial Factors in Pediatric Obesity: Counseling Overweight Youth and Families in your OfficeCarl P. McKnight, Psy.D.Specialized Foster Care Program Los Angeles County Department of Mental HealthOctober 3, 2007
Prevalence • 11% of children and adolescents are currently obese (National Health and Nutrition Examination Survey, 2001) • 22% of children and adolescents are obese, overweight, or at risk to be overweight (Troiano & Flegal, 1998)
Percent Overweight Children U.S. & Orange County Percent Overweight (>95% weight/height) Year Data from the CDC & Prevention, NCHS, NHANES, HHNES, NHES, Report on the Conditions of Children in Orange County, 2002
Percent Overweight 10-12 year olds in Orange County by Ethnicity Percent overweight (>95% BMI) Year Data from the, Report on the Conditions of Children in Orange County, 2002
Percent Overweight 5-9 year olds in Orange County by Ethnicity Percent overweight (>95% BMI) Year Data from the, Report on the Conditions of Children in Orange County, 2002
Childhood Overweight 2003 BMI (Body Mass Index) is Now Defining Tool • BMI Calculated as • Weight / Height Squared • Used to judge appropriateness • of weight for height • Replaces weight for height • charts and % ideal body wt • For a child, BMI > 95% is obese • BMI 85-95% is “at risk” • BMI data from retrospective analysis: • 1. Reflect increasing fatness • 2. Predict adult risk
BMIAdult to Child Predictive Value (NEJM 337:869) Obese AdultsObese Children 15%obese at age6 months 40%obese at age7 years 70% obese at age 12 years 80%obese asadolescents
Epidemic Overweight • 1/4 California children ages 9-17 now overweight (i.e. BMI > 95%) • Fattestkids getting fatter - now twice as many children > 100 lbs overweight as in 1980 • African American, Latino and low socioeconomic children more severely affected (1/3 overweight)
Latinos and Pediatric Obesity • Mexican-American children ages 6-11 are more likely to be overweight (22%) than non- Hispanic children. • Mexican-American adolescents ages12-19 are also more likely to be overwieght (23% of total population).
Latinos and Pediatic Obesity • The higher rates in Latino children start at 6-7 years of age, continue throughout adolescence, and extend into adulthood • Type II diabetes is 2 to 3 times higher in Latino children than in non-Hispanic Whites.
Latinos and Pediatric Obesity • 60% of Latino children and adolescents with Type II diabetes have 1st or 2nd degree relatives with T2DM . • T2DM very common in Mexican-American youths from low income families and is often undiagnosed.
ConsequencesChildhood Obesity It begins… • More than just adult obesity • Adult type diabetes (insulin resistance) • Tall stature • Early puberty • High blood pressure, heart disease • Orthopedic stress and injury (70% of SCFE) • Hyperlipidemia • Sleep apnea & breathing problems • Polycystic ovarian disease • Cancer of endometrium, breast, colon • Gallstones (33% of child cases are obese) • Steatohepatitis (50% of childhood cases) • Emotional and lifecourse disturbances
DM2 in Kids • The Orange County Register May 19, 2003 • Karina Oyarce • 13-years-old Latina in 7th grade • Diagnosed with DM2 in January 2003 • Weighs 200 lbs
Cardiovascular Complications of Obesity • Cardiovascular Disease • Atherosclerosis • Hypertension
Obesity, Hypertension, and Dyslipdemia • Obese children are at a 3 fold higher risk for hypertension than non obese • The risk of hypertension increases with increasing BMI • Dyslipidemia • Overweight Children 2 ½ more likely to have elevated cholesterol • Total cholesterol (TC) >200 • LDL > 130 • HDL<35
Pulmonary Consequences of Childhood Obesity • Decrease in pulmonary function of >15% in >80% of obese children vs. 40% of non-obese children • Obstructive Sleep Apnea: • Abnormal sleep patterns in 94% of obese children • Severe sleep apnea results in hypoventilation, right ventricular hypertrophy & heart failure, possible pulmonary embolisms
Summary Childhood Obesity Risk FactorsUSA Today Survey 1. Too much milk in infancy 2. Too much soda 3. Too much juice 4. Use / overuse of ketchup (or ranch dressing) 5. Eating in front of the TV 6. Watching more than 2 hours per day of TV 7. Eating from snack machines 8. Eating in the car 9. Skipping breakfast 10. Not participating in PE
Variables Contributing to the Development of Obesity • NATURE verses NURTURE • Familial Variables/Genetics • general consensus regarding genetic link in developing obesity (Myer & Stukard, 1993) • Familial Variables/Shared Environment • For infants/young children, parents play a central role in providing food and activity choices in the household • Can influence regulation of hunger and satiety cues
Variables Contributing to the Development of Obesity • Toxic Environment in America • decreased access to physical activity • increased sedentary activities • increased access to high-fat and high calorie foods
Psychological Assessment • Psychosocial Correlates • “Being overweight during childhood and adolescence is potentially associated with a number of negative psychosocial outcomes” (Jelalian & Mehlenbeck, 2003, p. 530). • Social problems & deficits • Depression • BMI positively correlated with depressive symptoms in girls (Erickson, Robinson, Haydel, & Killen, 2000)
Five Warning Signs of Depression • 1) Sad anxious or “empty” mood • “Have you felt sad/ worried or just not like yourself lately?” • 2) Declining school performance • “Have you noticed that school is harder for you than it used to be, or that you are not doing as well as you used to?” • 3) Loss of pleasure/interest in social and/or sports activities • “Do you find that you do not enjoy activities as much as you used to?” • 4) Sleeping too little or too much. • “Are you finding that you are sleeping a lot more or a lot less than you used to?” • 5) Changes in weight or appetite • “Has your appetite changed lately?”
Psychological Assessment • Self-esteem • low views of physical and general self worth (Braet, Mervielde, & Vandereycken, 1997) • self esteem decreases between school age and adolescence (Strauss, 2000). • diminished self-efficacy with respect to physical activity (Trost, Kerr, Ward, & Pate, 2001) • Quality of life (JAMA, 2003) • obese children’s rated quality of life is as low as pediatric cancer patients
Psychological Assessment • Eating Disorders • Obesity is a major risk factor for the development of eating disorders (Fairburn, Welch, Doll, Davies, & O’Conner, 1997). • Eating Disorder NOS (Binge Eating Disorder) • recurrent episodes of binge eating in the absence of inappropriate compensatory behaviors characteristic of Bulimia Nervosa (DSM-IV; American Psychiatric Association). • Important to rule out Prader-Willi syndrome
Psychological Assessment • Recommendations for taking histories • Assess the following areas: • social functioning • self-concept • mood • eating disorders
Psychological Treatment • Overview. Most interventions with obese children are delivered in a group setting and contain: • 1) Dietary Restriction • 2) Physical Activity Prescription • 3) Behavioral Modification • 4) Parental Involvement
Psychological Treatment • Dietary Interventions • “Traffic Light Diet” (Epstein, Wing , & Valoski, 1985) • RED: limit high fat foods • Y ELLOW: moderate amounts of yellow/starchy food • GREEN: freely eat fruits and vegetables • Physical Activity Interventions • increasing lifestyle physical activity as well as decreasing sedentary behaviors (Epstein, Paluch, Gordy, & Dorn, 2000). • Physical activity that can be incorporated into daily routine • Start with 30 minutes of exercise a week, add 30 minutes each week, with goal of 180 minutes per week.
Psychological Treatment • Behavioral Interventions • self-monitoring dietary intake and physical activity • stimulus control • change the environment to ensure success ( have no sodas in the home) • contingency management (positive reinforcement) • providing rewards for decreases in BMI and sedentary behaviors as well as improvements in diet and exercise.
Setting Goals • Explore the problem • what has or has not worked in past • Determine meaning of problem • feelings,barriers, costs, benefits to change • Identify goals that are realistic • Determine a plan of action • simple, specific, part of routine • Evaluate outcome • modify strategies
Identify goals • Select one or two priority areas that needs to change (ex, long term goal of losing weight) • Decide behavior goals related to above (short term goals) • small change in eating behaviors • small change in exercise • gradually increase expectations with rewards at each step
Practical Recommendations • General Considerations (Jelalian & Mehlenbeck, 2003) • Assess child’s or adolescent’s motivation for weight loss • does child have concerns about weight? • does child get teased? • can child keep up with peers during physical activities with peers? • If motivation mainly from parent, then family interventions are needed • If child is motivated, then can teach how to learn healthier behaviors
Practical Recommendations • Family-Based Interventions • engage entire family • promote idea that healthy habits may benefit all family members • encourage parents to assume responsibility for foods available inside the home • promote activities unrelated to eating to mark special events • do not use food as a reward • encourage parents to monitor frequency of “screen time.”
Practical Recommendations • Kaiser’s Brief Negotiation: Communication Guidelines to Promote Behavior Change • Very helpful tool to briefly assess motivation to change
Stages of Change Model Five stages of change • Precontemplation • Contemplation • Preparation • Action • Maintenance
Precontemplation Stage Not Intending to Change • Doesn’t believe behavior has negative consequences • May be resistant to change • Health professionals may be resistant to intervening with this stage • Cons >> Pros • Self-confidence
Contemplation Stage Intending to Change • Knows the negative consequences • Doesn’t know how to get started • Cons > Pros • Externally motivated • Self-confidence
Preparation Stage Making small/inconsistent changes • Know a little about how to get started • Don’t know how to stay with it; need a plan • Cons = Pros • Externally motivated • Typically the people who participate in “action” programs • Self-confidence
Action Stage Doing the behavior regularly but for < 6 mos. • Greatest risk for relapse • Most use of the processes of change • Cons < Pros • Externally (and internally) motivated • Most likely to participate in “action” programs • Self-confidence
Maintenance Stage Sustaining the change • Continue to do the behavior no matter what • The processes of change are now skills • Cons < < Pros • Internally motivated; part of value system • Self-confidence
Processes of Change Behavioral Strategies (later stages) Making a Commitment Enlisting Social Support Substituting Alternatives Rewarding Yourself Reminding Yourself Information Strategies (earlier stages) Increasing Knowledge Comprehending Benefits Warning of Risks Caring About Consequences Increasing Healthy Opportunities