Public Health Feature - July 2010
Tex Med. 2010;106(7):49-53.
By Crystal Conde
When people examine the childhood obesity epidemic, they often focus on statistics. But there are faces behind those numbers. Lyahnesha Thomas is one of those faces. The eighth-grade student attends Forbes Middle School in Georgetown and has struggled with her weight since early childhood, according to her mother, Urika Mendoza.
"Lyahnesha is very quiet and doesn't hang out with a lot of peers her age. Her self-esteem is low, she doesn't want to go out, and I suspect her weight gain contributes to that," Ms. Mendoza said.
When Lyahnesha's weight escalated to a point that concerned her mother, Ms. Mendoza took her to a physician who examined her and recommended a weight-loss regimen. But insurance wouldn't cover the medical treatment her physician advised.
Desperate to find her daughter some help, Ms. Mendoza called the Forbes Middle School nurse, who referred her to the Get Fit, Get Healthy, Get Moving (G3) program, which helps overweight children set and accomplish fitness and nutrition goals, leading to healthier lifestyles.
The year-long program encourages participants to eat five daily servings of fruits and vegetables and to exercise 30 minutes a day. Williamson County children aged 6 to 15 with a body mass index (BMI) above 24, or the 85th percentile, can qualify for the free program with referral from a school nurse or physician.
Ms. Mendoza says that since the program started in January, Lyahnesha has lost 15 pounds and is excited to attend bimonthly Saturday classes at the Clay Madsen Recreation Center in Round Rock. Lyahnesha and other children like her engage in activities like yoga, dancing, and water aerobics.
"Since the program, Lyahnesha exercises more and goes on walks regularly," Ms. Mendoza said. "She helps me make her lunches for school, and I prepare a healthy breakfast for her each day."
The program has improved Lyahnesha's outlook, too. Ms. Mendoza says her daughter is starting to go out more, has expressed an interest in wearing makeup, and is looking forward to her eighth-grade graduation.
"We're still working on Lyahnesha's vegetable consumption, but she's at least willing to try them now," Ms. Mendoza said. "She's eating a lot more fruit, and she keeps a record of her daily food intake for the program."
A Community Approach
G3 is one of a number of community-based programs that combat one of the biggest modern-day threats to child health. Health professionals are intervening in clinical and community settings to make a difference in children's lives.
Jennifer Helmcamp, MD, worked with the Williamson County and Cities Health District (WCCHD), Scott & White Healthcare-Round Rock, and the Clay Madsen Recreation Center to launch G3 in January. She says she hopes the program can draw in children like Lyahnesha.
"One reason we want referrals from school nurses is that we're hoping to include more children who may be underinsured or uninsured. We know not all children have access to a pediatrician. The program is free, so we want all children, regardless of insurance status, to have an outlet to prevent obesity," Dr. Helmcamp said.
She says G3 involves two six-month phases. During the first six months, parents attend bimonthly Saturday classes with their children and learn about communication skills, how to read nutrition labels, obesity-related health complications, healthy cooking, and more. The classes, Dr. Helmcamp says, expose children to activities like hip-hop dancing and water aerobics.
Families also meet with a nutritionist to develop a healthy lifestyle plan. The G3 staff refers children who need additional services to the Children With Special Health Care Needs (CSHCN) program, as well as primary care physicians. Implemented by the Texas Department of State Health Services (DSHS), CSHCN serves children with special health care needs and people of any age who have cystic fibrosis.
Ms. Mendoza says she appreciates the program's emphasis on lifestyle change.
"G3 is not a diet plan. Parents learn how to read food labels and get ideas for how to incorporate more nutritious foods into meals," she said.
Dr. Helmcamp says taking focus away from weight loss and stressing the importance of behavioral change is a key component of G3.
"We want the children to get moving and have fun. We don't want to focus on weight, but on changing lifestyle behaviors, so these kids will lead healthier lives," she said.
During the second six-month phase of the program, a WCCHD nutritionist and health educators call the kids to follow up on their healthy lifestyle choices. At the end of each phase, parents and children attend an event to celebrate the participants' progress.
Funding for the program comes from a St. David's Community Foundation innovation grant and a Community Access to Child Health implementation grant from the American Academy of Pediatrics. Clay Madsen Recreation Center supplies the venue for the bimonthly meetings and offers free round-trip transportation for participants who need a ride.
In addition, some Scott & White pediatricians donate their time by speaking to participating children's parents about health topics at the Saturday meetings.
Melissa Cole, MS, WCCHD project coordinator, says WCCHD is seeking more funding and partners to continue expanding the program.
Dr. Helmcamp encourages physicians throughout Texas to collaborate with stakeholders in their communities to make a difference in the fight against obesity.
"Collaboration makes all the difference in a program like G3," she said. "Pediatricians often don't have the time or resources to devote more attention to overweight and obese patients. Programs like G3 make it so that physicians don't have to go it alone."
Keeping Them Afloat
Housed within the Dell Children's Medical Center in Austin, the Texas Center for the Prevention and Treatment of Childhood Obesity features a multidisciplinary pediatric weight management clinic and the Healthy Living Happy Living program. The clinic opened to patients in April and provides medical evaluation, dietitian consultation, psychosocial support, mental health services, and physical therapy to develop comprehensive treatment plans for overweight and obese children and adolescents.
The center's medical director, Stephen Pont, MD, MPH, says the multidisciplinary clinic targets children who have a BMI greater than the 99th percentile or those who have a BMI greater than the 95th percentile and a significant comorbidity.
The obesity center has an educational component, as well, and reaches out to current and future health care professionals.
"In addition to the clinical care provided to patients of our multidisciplinary clinic, we want to develop tools that primary care physicians can use to help them manage obesity in their practices and really have an impact," he said.
Besides education, the center lobbies for evidence-based best practices to shape obesity policies at the local, state, and national levels.
"The obesity epidemic is like a flood. Physicians and their patients need help to stay afloat. There's no way we can solve the problem alone," Dr. Pont said.
Kimberly Avila Edwards, MD, a member of TMA's Council on Public Health and medical director of Healthy Living Happy Living, says children treated in the clinic may be referred to the Healthy Living Happy Living program. Children also learn about the program from their physicians and school nurses, she says.
Healthy Living Happy Living is the center's 10-week family-based intervention offered free of charge to overweight and obese children between ages 6 and 11. Also taught in Spanish, it gives families the resources they need to make healthy life changes.
Children and their parents meet once a week for two-and-a-half hours at Dell Children's Medical Center to exercise, learn about nutrition, and address the mental health and behavior change challenges that overweight and obese children face. Dietitians also speak to parents about how to eat healthy on a budget and take them on tours of farmers markets.
Funded by multiple local philanthropic partners and the Children's Medical Center Foundation, Healthy Living Happy Living began its first session last January.
"We've recognized the need to integrate physicians into the Healthy Living Happy Living program," Dr. Avila Edwards said. "We've seen the tremendous need for mental health intervention in these children. In a group of 20 participants, for example, we'll identify two to six who need individual mental health care."
Jane Gray, PhD, the center's director of child psychology, says children are tested for depression before they participate in Healthy Living Happy Living. Those in need of mental health care primarily receive follow-up at the Texas Child Study Center, a collaboration between Dell Children's Medical Center and the College of Education at The University of Texas at Austin.
Drs. Gray and Avila Edwards say that by the end of the 10-week program, they typically see an improvement in parents' stress levels and a decrease in depression among the children who struggle with it. Dr. Pont adds that throughout the course of the program, 80 percent of participants have improved their BMI percentiles.
When it comes to having a positive impact on the childhood obesity epidemic, Dr. Avila Edwards says it's important that clinical treatment and community-based programs complement each other.
"A community effort can't exist without clinical treatment. Community interventions that focus specifically on overweight or obese children may not recognize mental health and physiological problems children are dealing with. At the same time, focusing just on the clinical setting won't necessarily result in recognizing all the determinants of why a child is obese," she said.
El Paso's Success
Deanna Hoelscher, PhD, RD, LD, CNS, director of The Michael & Susan Dell Center for Advancement of Healthy Living, says comprehensive interventions that reach children at a multitude of settings reduce obesity. She oversaw the Dell center's School Physical Activity and Nutrition (SPAN) surveillance study during 2000-02 and 2004-05.
The study examined regional changes in the prevalence of obesity based on statewide policies and programs among children in grades 4, 8, and 11 in Texas health services regions during 2000-02 and 2004-05 and in nine selected counties during 2004-05. SPAN results showed the most significant decrease in the prevalence of obesity occurred among El Paso fourth graders - from 25.8 percent to 18.8 percent.
DSHS funded the SPAN project. Dr. Hoelscher expects new SPAN data for the 2009-10 school year to be available in the fall.
Dr. Hoelscher says the 7-percent overall drop in obesity rates among El Paso fourth-grade students is due in large part to a "perfect storm" of community-based obesity prevention programs operating during the SPAN study. The Paso del Norte Health Foundation funded a Coordinated Approach to Child Health program to increase El Paso elementary students' physical activity level and reduce their dietary fat consumption. The foundation also developed adult nutrition and physical activity programs and a radio and television advertising campaign.
"All the messages of the programs were consistent to reinforce healthy eating and physical activity," Dr. Hoelscher said.
She emphasizes that local, community-based programs need reinforcement from public health and medical systems to be successful.
"The lessons children learn in medically based obesity treatment programs need to be reinforced at school, at home, and in the community. Healthy choices need to be easier by giving children access to healthy foods and safe places to be active," Dr. Hoelscher said.
She says physicians can take some initiative in curtailing child obesity rates with help from the Texas Pediatric Society's pediatric obesity toolkit for physicians. The resource aids physicians in diagnosing and treating obese children.
In addition, Melissa Garretson, MD, a Fort Worth pediatric emergency physician and chair of TMA's Council on Health Promotion, recommends the American Medical Association's Healthier Life StepsTM program, which allows physicians to tailor resources to fit each patient's health needs.
"Healthier Life Steps gives doctors an easy way to do health maintenance counseling. Physicians can download the resources for patients and have staff work with them to develop goals," she said.
The program guides physicians in working to change patients' diets and physical activity levels and includes materials for physicians and a comprehensive toolkit for patients. (See "Resources Help Physicians Change Patients' Behaviors.")
Dr. Garretson says a community-based solution to the child obesity epidemic is essential because children don't buy the food they eat, pick the neighborhoods they live in, or choose the activities in which they participate.
"The data show that if all you do is intervention with a child without changing behaviors, you won't have any long-term, lasting effects," Dr. Garretson said. "Communities need to focus on efforts to set up parks, walking trails, and farmers markets, and to improve the nutritional value in school lunches and breakfasts."
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde.
Resources Help Physicians Change Patients' Behaviors
TMA brings physicians the American Medical Association Healthier Life Steps TM program, which guides physicians in working to change patients' diets, physical activity levels, alcohol consumption, and tobacco use. The Physicians' Guide instructs doctors in implementing strategies to assess patients' readiness to change and in counseling patients on making changes in their lifestyles.
The toolkit portion of the program fosters one-on-one, in-office communication between physicians and their patients. It provides a self-assessment questionnaire, action plans, progress-tracking calendars, and a poster to encourage necessary behavior changes.
Healthier Life Steps materials are free for physicians and patients, courtesy of TMA and AMA. Physicians may earn up to 1 hour of AMA PRA Category 1 CME Credit TM by completing the continuing medical education requirements in the Physicians' Guide.
For more information, e-mail TMA Outreach Coordinator or call (800) 880-1300, ext. 1470.
The Texas Pediatric Society (TPS) in 2003 formed its Obesity Task Force to help physicians manage their obese patients' health. The task force created Pediatric Obesity: A Clinical Toolkit for Healthcare Providers , and TPS distributed 15,000 copies to physicians.
The toolkit serves as a diagnosis and treatment overview for physicians and includes an evaluation form; posters in English and Spanish; patient handouts in English and Spanish that provide nutrition, behavioral, and lifestyle guidelines; English and Spanish healthy lifestyle "prescription" forms; and a body mass index (BMI) wheel designed to calculate BMI percentile by age and gender.
TPS released the second edition of the obesity toolkit last year. That version features new elements, such as information on motivational interviewing to assess and empower patients' likelihood for positive health change, as well as recommendations of an expert committee formed in 2007 by the Department of Health and Human Services Health Resources and Services Administration.
The recommendations guide health care professionals on the prevention, assessment, and treatment of child and adolescent overweight and obesity, and feature information on motivational interviewing and the steps that can be taken in the prenatal period and infancy years to prevent overweight and obesity. The revised version contains a chapter on the prenatal and perinatal influences on childhood obesity.
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TMAF Seeks Student Grant Proposals
The TMA Foundation (TMAF) invites proposals from TMA medical student chapters for a grant to fully or partially fund a project that focuses on one or more of the key health behaviors featured in the American Medical Association Healthier Life StepsTM program.
Student chapters may apply for up to $3,000 from the foundation'sMedical Student Community Leadership Grants program and must seek matching funding from other sources in the form of cash contributions, school funding, volunteer time, or in-kind donations for the program under consideration.
The program reinforces two of the five public health priorities set by the TMA Council on Public Health:
- Promote a healthy population through educating patients, exchanging information on disease prevention, and forming collaborative alliances with patients as well as community, business, government, and academia.
- Identify pressing public health issues in Texas and prepare physicians to address these issues through education, advocacy, and public awareness, especially in the areas of prevention, bioterrorism, violence, addictions, injuries, and special populations.
The grants will support health-related, short-term (one year) start-up or enhancements to ongoing educational or community service projects that enhance Texans' well being, reflect TMA's health improvement objectives, and reinforce the trusted leadership of physicians. Priority will be given to projects for which funding is not traditionally provided by medical school or local community sponsors.
E-mail proposals to Sean Dunham no later than 5 pm on July 30.
The TMA Foundation Board of Trustees will review and act on the proposals at its Oct. 15 meeting, and the winner will be notified by Oct. 31.
For additional information, contact TMA Foundation Executive Director Lisa Stark Walsh, MA, at 401 W. 15th St. #810, Austin, TX 78701; at (800) 880-1300, ext. 1666, or (512) 370-1666; or e-mail Lisa Stark Walsh.
The AMA Medical Student Section also offers $500 grants for service projects.
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