Successful Wellness by Eating

1
Successful Wellness by Eating Exercising
Together (SWEET)

• Eric I. Schwartz, MD, MBA
• Chief Medical Officer
• Henry J. Austin Health Center
• Trenton, NJ

2
Overview

• Obesity in the community
• Evidenced-based strategies
• Nutrition
• Behavior
• Fitness
• SWEET Program
• Design of program
• Outcomes
• Next Steps

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Overweight Obesity in the Community

• 30.4 of US adolescents are overweight (BMI85th
  percentile), It increases to 40.4 in African
  American and 43.8 in Mexican-American
  adolescents
• 2,393 sixth graders in NJ in 2002, 20 obese and
  18 overweight2
• Socio Economic Impact
• High SES 10 obesity
• Low SES 27 obesity
• Clinically - DM, HTN, sleep apnea, arthritis,
  lipid abnormalities, depression, gallstones
• 1. Ogden C.L., Flegal K.M., Carroll M.D., Johnson 
  C.L.,  Prevalence and trends in overweight among
  US children and adolescents, 19992000.   JAMA
  (2002) 288 pp 1728-1732.
• 2. Source Childhood Weight status, NJ Dept of
  Health Senior Services, Sept 2004, vol 1

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Nutrition

• No high quality RCTs in literature (sm numbers,
  short f/u)
• Traffic Light Diet break foods into
• Red (high fat or simple sugars -4 servings/wk)
• Yellow (ex. rice, pasta, plain breakfast cereal
  in moderation)
• Green (low calorie, high fiber) no restrictions
• Low fat/low calorie vs. low glycemic index
• Smaller portions with regular meal snack
  pattern
• Replace sweetened beverages with water,
  sugar-free drinks
• Involve the family
• Epstein LH, et al. Childhood Obesity. Ped Clin NA
  198532363-9.
• Kirk S, et al. Pediatric Obesity
  EpidemicTreatment Options J of ADA.
  2005544-51.
• Cooperman N, Jacobson MS. Adol Med 20031411-21.

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Glycemic Index (GI)

• Glycemic (sugar)response after consumption of
  food. Carbohydrates increase blood glucose and
  plasma insulin release and can lead increase risk
  of insulin resistance DM
• Typical GI diet limits to 130 gms of carb and 70
  gms of fat
• Low GI (lt50) fruit, low fat milk
• Mod GI (50-70) sweet potato, corn, whole grain
  pasta
• High GI (gt70) White bread, baked potato, french
  fries
• Ludwig DS. The glycemic indexphysiological
  mechanisms related to obesity, diabetesand CV
  disease. JAMA 20022872414-2423.

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Behavior Modification

• 4 Components
• Goal setting (education alone wont work)
• Self monitoring (awareness of cues)
• Stimulus control
• Incentives (within context of supportive family
  environment)
• Behavioral contract in 2 tiered phases if meet
  initial goals (simple behavior, food choices)
  move to next tier
• Role playing for difficult scenerios
• Motivational Interviewing pros/cons of behavior
  change so can customize and buy into a course
  of change

Source Kirk S, et al. Journal of ADA
200544-51. and Wisotsky W, Swencionis C.
Adolescent Med 20031437-48. DiLillo V, etal.
Incorporating motivational interviewing into
behavioral obesity treatment. Cognit Behavor
Pract 200410120-130.
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Fitness/Activity

• Increasing activity and decreasing sedentary time
  are two distinct interventions
• 2 hours of TV/day (American Academy of Peds)
• Accumulate activity time rest/play in
  intermittent bouts
• Elementary school age 30-60 min most days
• Adolescents 20 min/3 times a week
• Source Kavey RE, et al. American Heart
  Association guidelines for primary prevention of
  atherosclerotic CV disease beginning in
  childhood. Circulation 20031071562-1566.

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Assessing Readiness

• Direct programs at motivated children and
  families
• Aim for weight maintenance rather than weight
  loss
• Readiness (family lists pros/cons of wt change)
• Precontemplation (not considering behavior
  change)
• Contemplation (thinking about behavior change)
• Preparation (planning to change)
• Action (initiating behavior change)
• Interview questions can be found _at_ Bright
  Futures in Practice physical Activity
  www.brightfutures.org/physicalactivity
• Wiscotsky W, Swencionis C. Cognitive behavior
  approaches in management of obesity. Adol Med
  20031437-43.

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SWEET Program

• Successful Wellness by Eating Exercising
  Together (SWEET)
• Staffed by Dietitian, Child Psychologist,
  Physician, and Outreach/Data Coordinator
• Funded by RWJ Foundation NJ Health Initiatives
  (2004-2007)
• 8-week program for children and their families
• Nutrition education and 1 meal/week
• Behavior modification (logs, incentives,
  role-playing)
• Fitness opportunity Wacky Gym 3x/week and
  maintenance

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SWEET (II)

• Recruitment through
• School nurses
• Physician referral
• DYFS
• Word of Mouth
• Typical group will have 8-12 children and family
  members

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Outcomes

• Groups 1-5 (Oct 04-Nov 05)
• 41 children in total participated
• only 25 (61) completed entire program
• BMI decreased on avg 0.4
• Changes made
• Screen for readiness
• Changed staff (RD, Outreach Coordinator)
• Changed site from YWCA to school-based site

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Outcomes (II)

• Groups 6-10 (Jan 06-March 07)
• Group 8, 4-wk summer session 7 children - non
  compliance, little impact
• Otherwise, 35 children participated
• 31 (94) completed program
• 29 (83) decreased BMI
• Avg. BMI loss -0.72
• 9 children (26) decreased BMI by gt1

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Group 6 Data
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Group 7 Data
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Group 9 Data
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Group 10 Data
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Maintenance Group (March 07)

• Occurs monthly
• In March, 14 children participated
• From groups 7,9,10
• 13 of 14 (93) decreased BMI from initial visit
• Avg. BMI change - 1.35

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Maintenance Group (Wt)
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Maintenance Group Height
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Maintenance Group BMI Change
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Success Stories of our S.W.E.E.T. participants

• JM Started program with elevated BP, was refused
  to participate in sports went through program
  normalized BP, went on to play football. Mom made
  several changes including providing a fruit
  vegetable at every family dinner.
• KH Lost weight, lowered BMI (83.5 on 3/29/06
  76.5 on 8/9/06) lost tummy weight completely
  continues 1 year later to participate in Wacky
  Gym and Maintenance Phase Reunions.
• NS Lost significant weight (169.8 on 3/29/06
  158.0 on 8/9/06) despite being one of the oldest
  participants (senior in high school) did
  exceptionally well returned to two Maintenance
  Phase Reunions.
• AD Mom reported when child first entered program
  she never ate fruit/vegetables until she came to
  S.W.E.E.T. she now incorporates vegetables in
  family dinners and now is encouraged to try new
  foods.

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What we learned

• Screening for readiness before accept into
  program
• Study each groups dynamics and address strengths
  and weaknesses (ex. mentors, buddies)
• Self-esteem of participants not a major issue
• Importance of cultural competency
  (bilingual/bicultural translator), diet, and
  activity

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Next Steps

• Standardize curriculum
• Introduce program into after-school curriculum
• Advocate for reimbursement from Managed-care
  companies
• Study various components for program (diet,
  behavior intervention) in a randomized-controlled
  fashion.
• Advocate for required measurement reporting of
  BMI

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CNNSix States get an A

• PA, CA, SC, Illinois, Tenn, Oklahoma
• Set nutrition standards in schools
• Require measurement reporting of BMI
• Recess physical education classes
• Add weight wellness to school curriculum
• Support obesity research
• Support insurance coverage for obesity
• University Of Baltimore Obesity Initiative, Jan
  31, 2007

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Questions?