Texas Pediatric Society Obesity Toolkit

The Texas Pediatric Society Obesity Committee develops, maintains, and works to disseminate practical guidelines to aid pediatric practitioners in the prevention, early recognition, and clinical care of children and adolescents who are overweight or obese, with or without associated comorbid conditions. Toward this end, in 2005, the committee developed the first edition of this toolkit to assist clinicians in providing care for both overweight and obese children.  In 2008, we released the second edition of this toolkit in a free online format, which included new additions and updates, many based on the 2007 Expert Committee recommendations published in December 2007 in a supplement to Pediatrics ("Assessment of Child and Adolescent Overweight and Obesity," Pediatrics, December 2007;230 suppl 4:5163-5288). The current online toolkit is constantly reviewed and revised to adhere to current AAP recommendations for the screening, management and prevention of pediatric obesity. 

Members of the Texas Pediatric Society Obesity Committee who contributed to the current online edition include:


Kimberly Avila Edwards, MD
Kelly Coleman, MD
Jennifer Helcamp, MD
James Herrin, MD
Atoosa Kourosh, MD, MPH
LeAnn Kridlebaugh, MD
Arthi Krishnan, MD
John Menchaca, MD
Teresia O'Connor, MD
Kenya Parks, MD
Stephen J. Pont, MD, MPH
Valerie Smith, MD
Miranda Loh, MS4

We would like to extend a special thanks to Sarah Barlow, MD, whose presence and continued expert assistance has added tremendously to the state of Texas. 

Additionally, we would like to thank Diana Arceo, MD, MS, who contributed her expertise and assistance in the translation of patient materials. 

The support, collaboration and fresh ideas of the Obesity Committee as a whole have also greatly enriched the ongoing update process that keeps the toolkit current and user friendly.

Finally, to Mary Greene-Noble, who served as the executive director of the Texas Pediatric Society for 40 years, and to her outstanding staff, including Amy White and Laura Blanke: thank you for your unending support, assistance, and work on this project. 

Please click on the topics below to access information, materials, and resources for each of the following subjects:

Obesity Toolkit

Diagnosis Overview

Body Mass Index

Body Mass Index (BMI) is an indirect way to assess body fat and is calculated by dividing weight by height squared (1). In a clinical setting BMI is a useful tool in assessing children’s weight status, but additional clinical information is useful in making the diagnosis of obesity. For children aged 2 to 20 years, age- and gender-specific references for BMI exist. They were included in the 2000 CDC Growth Charts, which are widely used in clinical practice and are available at www.cdc.gov/growthcharts.

The current recommendation from the American Academy of Pediatrics is to track BMI percentile for children on a yearly basis. The growth curves for children younger than 2 years do not include BMI percentiles, as BMI standards for children in that age group do not exist. Weight-for-height values for these children should be plotted. Intervention and prevention of childhood obesity should begin as early in life as possible. For a more detailed discussion of possible factors and interventions in children's early years, see Perspectives for the Future.

BMI is defined by six categories (Table 1). A child is considered underweight when the BMI < 5th percentile for age and gender. A BMI = 5th percentile and < 85th percentile is considered healthy weight. A child with a BMI > 85th and < 95th percentiles is categorized as overweight; if the BMI = 95th percentile, the child is considered obese. For children younger than 2 years, weight-for-height values above the 95th percentile are classified as overweight. Currently, there are no cutoff points to define obesity in children younger than 2 years. Table 1. BMI Categories for Children 2-18 Years of Age

BMI < 5th percentile Underweight
BMI 5th-84th percentile Healthy Weight
BMI 85th-94th percentile Overweight
BMI ≥ 95th percentile Obese
BMI ≥ 99th percentile* Severe Obesity
Children < 2 years: Weight-for-height > 95th percentile Overweight

*Reported for 5-18 year-olds
BMI Handout

Toolkit Base: 

BMI Categories

The importance of clinically identifying children with severe obesity is increasing, as these children are at particularly high risk for medical and probably psychological complications and may need to be specifically targeted for treatment. Pediatric practitioners can use the 99th percentile BMI cutoff points listed in Table 2. These are not included on the current growth charts.

Table 2. 99th Percentile BMI Cutoff Points According to Age and Gender

Click here for a printable copy of this chart.

99th Percentile BMI Cutoff Point kg/m2    
Age Boys Girls
5 20.1 21.5
6 21.6 23.0
7 23.6 24.6
8 25.6 26.4
9 27.6 28.2
10 29.3 29.9
11 30.7 31.5
12 31.8 33.1
13 32.6 34.6
14 33.2 37.5
15 33.6 37.5
16 33.9 39.1
17 34.4 40.8

Simple formulas can be used to calculate BMI.

English Formula:

 Matric Formula:

Toolkit Base: 

99th Percentile BMI Cutoff Points

Alternatively, an online BMI calculator is available on the CDC website, and BMI wheels have been developed to simplify this calculation for practitioners (order here). It is as important for pediatric practitioners to identify overweight and obese children as it is to recognize patients in whom BMI is increasing. Early intervention is critical for the prevention of childhood obesity. Thus, practitioners are urged to discuss and intervene by proposing nutritional, lifestyle, and behavior modifications for children in whom an upward trend in BMI is noted.

Obese children are at risk for developing numerous obesity-related conditions and medical problems during childhood (Table 3). Additionally, childhood obesity may be an independent risk factor for adult morbidity and mortality, regardless of the persistence of childhood obesity (2). The primary care provider should seek to identify associated comorbidities in each patient. Included in the list of obesity-related conditions are the psychological and social effects on overweight and obese children. These must be investigated thoroughly, as they may often be as damaging as the medical complications.

Type 2 Diabetes Mellitus Particular attention should also be focused on the occurrence of type 2 diabetes mellitus (DM) in children. Type 2 DM is being diagnosed more often in children. Less than a generation ago, type 2 DM was seen almost strictly as an adult disease, with less than 2% of new diabetic cases in children diagnosed as type 2 DM. Today, this number has increased to between 25% and 60% of new-onset childhood diabetics. With obesity being a major risk factor for type 2 DM, pediatric care providers must now view type 2 DM as a pediatric illness (3).

Cardiovascular Hypertension, ↑ [total cholesterol], ↑ [low-density lipoproteins], ↓ [high-density lipoproteins], syndrome X
Respiratory Abnormal respiratory muscle function and central respiratory regulation, diffi­culty with ventilation during surgery, lower arterial oxygenation, sleep apnea, Pickwickian syndrome, more frequent and severe upper respiratory infections, snoring, daytime somnolence, asthma
Orthopedic Coxa vara, slipped capital femoral epiphyses, Blount disease, Legg-Calv é-Perthes disease, degenerative arthritis, foot pain
Dermatologic Intertrigo, furunculosis, acanthosis nigricans
Immunologic Impaired cell-mediated immunity, polymorphonuclear leukocyte killing capacity, lymphocyte generation of migration inhibiting factor, and maturation rates of monocytes into macrophages
Gastro­intestinal Gallstones, hepatic steatosis, steatohepatitis
Neurologic seudotumor cerebri, hyperactivity and behavior problems (secondary to sleep apnea)
Somatotroph ↓ basal and stimulated growth hormone release with normal concentration of insulin-like growth factor-l, accelerated linear growth and bone age
Lactotroph ↑ basal serum prolactin but ↓ prolactin release in response to provocative stimuli
Gonadotroph Early entrance into puberty with normal circulating gonadotropin concentrations
Thyroid Normal serum T4 and reverse T3, normal or ↑ serum T3, ↓TSH-stimulated T4 release
Adrenal Normal serum cortisol but ↑ cortisol production and excretion, early adrenarche, ↑ adrenal androgens and dehydroepiandrosterone, normal serum catecholamines and 24-hour urinary catecholamine excretion
Gonad circulating gonadal androgens in males; ↑ androgens in females with ↓ sex-hormone binding globulin, dysmenorrhea, dysfunctional uterine bleeding, polycystic ovary syndrome
Pancreas fasting plasma insulin, ↑ insulin and glucagon release, ↑ resistance to insulin-mediated glucose transport, type 2 diabetes mellitus, pancreatitis (secondary to gallstones)

Adapted with permission from the AAP Pediatric Nutrition Handbook.4

Toolkit Base: 

Metabolic Syndrome

Pediatric practitioners also need to have an increased awareness for metabolic syndrome. This syndrome comprises a group of risk factors that indicates an increase in the risk for developing type 2 DM and premature cardiovascular disease in adults (5,6). The concept that insulin resistance and associated metabolic abnormalities, including lipid and blood pressure abnormalities and type 2 DM, increase the risk of atherosclerotic cardiovascular disease in adults was first proposed by Reaven in 1988 at the American Diabetes Association’s annual meeting (7). The metabolic syndrome is known by many names, including syndrome X, insulin resistance syndrome, dysmetabolic syndrome, Reaven’s syndrome, and metabolic cardiovascular syndrome.

Several diagnostic criteria have been proposed for metabolic syndrome, with the two most widely used definitions in adults established by the World Health Organization (WHO) (8) and the U.S. National Cholesterol Education Program (NECP) (9). Table 4 outlines these criteria. Although diagnostic criteria exist for adults, the definition of metabolic syndrome in the pediatric population is nonexistent (10). However, metabolic syndrome in adults has been shown to have its roots in childhood (11). Early recognition and intervention by the pediatrician is therefore critical to the treatment of metabolic syndrome.

Table 4. Diagnostic Criteria of Metabolic Syndrome in Adults

US National Cholesterol Education Program (NCEP)* World Health Organization (WHO) †
High fasting plasma glucose ≥110mg/dL Dysglycemia: type 2 diabetes, impaired glucose tolerance, impaired fasting glucose, or insulin resistance
Abdominal obesity: waist circumference >40 inches (men) or >35 inches (women) Obesity in adults, BMI >30 or waist-hip ratio >0.90 (men) or >0.85 (women)
Hypertriglyceridemia: TG ≥150 mg/dL Dyslipidemia: TG ≥ 150 mg/dL, HDL <35 mg/dL (men), HDL <39 mg/dL (women)
HDL <40 mg/dL (men)
HDL <50 mg/dL (women)
Hypertension ≥160/90 mm Hg)
Blood pressure ≥130/85 mm Hg Microalbuminuria: urinary albumin excretion rate ≥20 μg/min or albumin/creatinine ratio ≥20 mg/g

*NCEP: must meet three of five criteria.

†WHO: must meet glucose/insulin criterion and two more.

Toolkit Base: 

Hypertension

Hypertension has increased in the pediatric population, in part because of the increase in childhood obesity. Unlike hypertension in adults, hypertension in children is not defined by an established cutoff point. Like BMI, the definition of childhood hypertension is defined based upon the normative distribution of blood pressure in healthy children. Blood pressure percentiles are based on gender, age, and height. Hypertension is diagnosed after elevated measurements are noted on three separate occasions. Here are blood pressure reference tables for both boys and girls .

The guidelines for the definition of normal and elevated blood pressures in children were updated in 2004 and are included below. The systolic and diastolic blood pressures are of equal importance. If there is a disparity between the two, the higher value determines the blood pressure category. Blood pressure categories are defined as: 1) Normal Blood Pressure: Systolic and diastolic blood pressure < 90th percentile 2) Prehypertention: Systolic and/or diastolic blood pressure ≥ 90th but < 95th percentile, or if the blood pressure exceeds 120/80 mmHg even if < 90th percentile. A systolic pressure of 120 typically occurs at 12 years of age, although a diastolic pressure of 80 typically occurs at 16 years of age. 3) Stage 1 Hypertension: Systolic and/or diastolic blood pressure between the 95th and 99th percentiles plus 5 mm Hg 4) Stage 2 Hypertension: Systolic and/or diastolic blood pressure ≥ 99th percentile plus 5 mm Hg (12).

1) Normal Blood Pressure: Systolic and diastolic blood pressure < 90th percentile

2) Prehypertention: Systolic and/or diastolic blood pressure ≥ 90th but < 95th percentile, or if the blood pressure exceeds 120/80 mmHg even if < 90th percentile. A systolic pressure of 120 typically occurs at 12 years of age, although a diastolic pressure of 80 typically occurs at 16 years of age.

3) Stage 1 Hypertension: Systolic and/or diastolic blood pressure between the 95th and 99th percentiles plus 5 mm Hg

4) Stage 2 Hypertension: Systolic and/or diastolic blood pressure ≥ 99th percentile plus 5 mm Hg (12).

Toolkit Base: 

References

1.   Binns HJ, Ariza AJ. Guidelines help clinicians identify fisk factors for overweight in children. Pediatr Ann. 2004;33(1):19-22.

2.   Kleinman RE. American Academy of Pediatrics. Pediatric Nutrition Handbook. Elk Grove Village, IL: American Academy of Pediatics; 2004:466.

3.   Kleinman RE. American Academy of Pediatrics. Pediatric Nutrition Handbook. Elk Grove Village, IL: American Academy of Pediatrics; 2004:568-569.

4.   Kleinman RE. Pediatric Nutrition Handbook. Elk Grove Village, IL: American Acedmy of Pediatrics; 2004:567.

5.   Laaksonen DE, Lakka HM, Niskanen LK, Kaplan GA, Salonen JT, Lakka TA. Metabolic syndrome and the development of diabetes mellitus: application and validation of recently suggested definitions of the metabolic syndrome in a prospective cohort study. Am J Epidemiol. 2002;156(11):1070-1077.

6.   Lakka HM, Laaksonen DE, Lakka TA, et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA. 2002;288(21):2709-2716.

7.   Reaven GM, Banting lecture 1988. Role of insulin resistance in human disease. Diabetes. 1988;37(12):1595-1607.

8.   Alberti KG, Zimmet PZ. Definition, diagnosis, and classification of diabetes mellitus and its complications: Part 1. Diagnosis and classification of diabetes mellitus. Report of a WHO consultation. Diab Med. 1998;15:539-553.

9.   Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel Ill.) JAMA. 2001;285(19):2486-2497.

10.  Cook S. The metabolic syndrome: antecedent of adult cardiovascular disease in pediatrics. J Pediatr. 2004:145(4):427-430.

11. Steinberger J. Diagnosis of the metabolic syndrome in children. Curr Opin Lipidol. 2003;14(6):555-559.

12.  National High Blood Pressure Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl 4th report):555-576.

Toolkit Base: 

Treatment Overview

Pediatric practitioners should approach the discussion of childhood obesity with sensitivity and a nonjudgmental tone toward parents and patients.  Practitioners must minimize embarrassment, harm to self-esteem, and stigmatization, and, instead, be supportive when discussing the issue with patients. Even though the clinical terms "overweight" and "obese" are recommended for documentation and clinical risk assessment, the use of different words should be considered in the dialogue with patients and families. Words such as "fatness," "excessive fat," and "obesity" may be derogatory, so pediatric practitioners should discuss overweight and obesity by using neutral terms such as "weight," "excess weight," "body mass index," and "healthier weight." Another neutral alternative is "risk for diabetes and heart disease."(1)

Successful treatment of overweight children depends on the cooperation of not only the child but also the child’s family. The importance of a family-based management strategy cannot be overemphasized. Thus, before initiating therapy, it is important to determine the family’s therapeutic readiness. The clinician should assess parental perceptions about their child’s weight. Specific questions to measure the family's knowledge, culture, and readiness for change are included in the Family Readiness Questionnaire.  Behavior modification requires commitment by the family as well as the older patient. Providers can consider using motivational interviewing or other behavioral techniques for families that currently do not express an interest in lifestyle modifications to change their attitude. For families interested in changing dietary, physical activity, and sedentary behaviors, several behavioral intervention techniques are currently used in treatment programs. Cognitive behavioral therapy (described here) and motivational interviewing (described here) have been studied in child and family interventions. Principles of these behavioral methods can be incorporated in the pediatric primary care setting.

If parents do not feel that their child’s weight is a problem or if they feel that it cannot be changed, then therapy should be delayed. Instead, the clinician should focus on parental counseling and education, hoping to improve parental motivation. Issues that should be addressed in such counseling, according to the AAP Pediatric Nutrition Handbook, include the following:

• The risk of persistence of obesity into adulthood increases with the child’s age.

• Obesity is associated with many potential medical complications, some of which may already be evident in family members.

• The cooperation of the entire family (including all caregivers) in any therapeutic regimen is essential.

• Adopting a healthier lifestyle benefits the entire family, regardless of whether any individual family member is obese.

• The major goal is long-term maintenance of reduced body fatness, not just short-term weight reduction.

• Good health habits (diet and exercise) that are started early will likely persist into adulthood (2).

Decreased morbidity and mortality risk should be the principle aim of any treatment regimen for overweight children. Too often, an overweight child and/or his or her parents may be looking only to achieve a certain accepted body weight (3).  If morbidity is not evident, then initial therapy should focus on maintaining weight while height increases. Ideally, the child will reach an appropriate height for his or her weight within a couple of years. Twenty percent of excess weight for height can be corrected in this manner within one or two years.  In cases of severe obesity in which a child is already obese by adult criteria, weight loss is indicated. Click here for appropriate weight loss rates for children by age and BMI percentile to achieve deflection in BMI percentile.  Children with weight loss greater than these recommended rates should be monitored for causes of excessive weight loss (4). The need for pharmacologic or surgical intervention for weight loss is best evaluated by referring these children to pediatric specialty-trained multidisciplinary programs with clinical protocols in place to carefully monitor children and adolescents.

Before recommending dietary, lifestyle, or behavior modifications, the clinician should assess the current behaviors of the child and his or her family. Standardized instruments, such as WAVE and REAP, can be used to assess diet and activity behaviors, although none of the instruments assess all the recommended areas for intervention.

LIFESTYLE MODIFICATIONS

Dietary Modifications

Dietary changes are often viewed in a negative light by children. The clinician should keep this in mind when making recommendations to parents. Parents must understand that the presentation of dietary changes is as important as the dietary changes themselves. To effectively modify a child’s eating habits, the child must not see the changes as punishment. The importance of participation by the entire family is a crucial factor for success. Such participation will eliminate feelings of isolation that the child may experience. All caregivers should be counseled about the important role they play in the development of healthy eating habits, and they should be educated about how children’s eating habits mimic those of their parents. Rather than encouraging dangerous short-term diets promoting rapid weight loss, the clinician and parents should focus on long-term dietary modifications that will lead to a nutritionally balanced diet. For specific recommendations, see the Nutrition Guidelines. Additionally, USDA provides portion size and calorie recommendations.

Sedentary Behavior Modifications

The sedentary nature of today’s society has contributed to the increase in childhood obesity. Much of children’s free time is spent watching television, playing video games, and working on the computer or surfing the Internet. Such activities reduce the amount of time spent on physical, calorie-burning activities, and, with television, the harm is compounded by the widespread prevalence of food advertisements included in today’s programming. It is necessary to limit these sedentary activities and encourage children to participate in more active pastimes.

Physical Activity Modifications

Typically, schools and communities provide many opportunities for children to participate in various team and individual sports. Parental participation should be encouraged and considered integral to successful lifestyle changes. The health care provider, however, should keep the safety of the child’s home environment in mind when making recommendations and may need to lobby for improved school- and community-run activity programs. For specific recommendations, see the Lifestyle Guidelines.

Behavior Modifications

The process for making dietary, physical activity, and sedentary behavior changes is often refered to as behavior modifications.  Behavioral changes for children and their families can encourage more healthy eating patterns, leading to less overeating and increased recognition of satiety; decreased sedentary behaviors, which may affect the child’s dietary intake or physical activity; and greater use of physical activities in a child’s normal activities.  For specific recommendations, see the Behavior Guidelines.


References

1. Barlow SE; Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: summary report. Pediatrics. 2007;120(suppl):S168.

2. Kleinman RE. Pediatric Nutrition Handbook. Elk Grove Village, IL.: American Academy of Pediatrics. 2004:571.

3. Kleinman RE. Pediatric Nutrition Handbook. Elk Grove Village, IL.:American Academy of Pediatrics. 2004:573.

4. Spear BA, Barlow SE, Ervin C, Ludwig DS, Saelens BE, Schetzina KE, Taveras EM. Recommendations for reatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(S4):S255.t

 

Toolkit Base: 

Motivational Interviewing

By: Stephen Pont, MD, MPH, FAAP
Assistant Professor of Pediatrics
Medical Director, Texas Center for the Prevention & Treatment of Childhood Obesity
Medical Director, Austin ISD Student Health Services
UT Southwestern, Austin - Department of Pediatrics / UT Austin - Department of Advertising
Dell Children's Medical Center of Central Texas
SJPont@seton.org  
On Twitter: @DrStephenPont

No more shoulda’, coulda’, woulda’ ….

Motivational interviewing (MI) is a technique used to produce positive behavior change through allowing individuals (a.k.a. patients) to convince themselves that they should change, that they can change, and that they will change. No more shoulda’, coulda’, woulda’, but, instead, through MI, individuals will decide that they should (importance), could (confidence), and will (commitment) make a change.

Some older models of doctor-patient communication have included confrontation (you must lose weight), education (obesity is harmful), and authority (you should listen to me because I’m your doctor). Motivational interviewing uses a different model. Instead of confrontation, education, and authority, MI relies on collaboration (walk alongside or partner with the patient), evocation (the clinician elicits the patient's arguments for change), and autonomy (the patient decides what and if to change).

Toolkit Base: 

Brief Background

Motivational interviewing was developed by William Miller and Stephen Rollnick for use in addictive behavior counseling and has been used effectively since the early 1990s. Miller and Rollnick describe MI as “a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with nondirective counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal." (1
 
In recent years, the field of MI has expanded rapidly as more applications are recognized. The excitement continues as elements of MI are now being distilled into “brief components,” which may lend themselves to be incorporated more easily and successfully into the busy clinic day. Many clinicians now use brief components of MI to enhance patient counseling and to increase the likelihood that their patients will adhere to treatment plans and behavioral modifications requiring changes in behavior. Hundreds of published reports, including many randomized trials, discuss and document MI’s success.

Motivational interviewing assumes that people usually are not ready to change. They may have thought about changing, but they feel two ways about it: the yes…, but. “Yes, I’ve thought about exercising more, but…” Motivational interviewing helps people convince themselves that they can and should make a change. The individual makes the argument for change. Motivational interviewing puts the control into the hand of the “client,” either the patient (if sufficiently mature) or the parent/child for younger children. With the practitioner’s careful and thoughtful direction, the individual can develop a plan and enhance his or her motivation; thus, the likelihood for actually following through with the plan increases. The treatment of obesity is a relatively new area for the use of MI, but it is a powerful tool with a lot of potential and should definitely be added to our arsenal. In the nonauthoritative spirit of MI, may I invite you to read on and decide for yourself?

Toolkit Base: 

The Basics

You likely already use many MI principles and techniques without realizing it. Motivational interviewing strives to help direct individuals to use their own energy and insight to discover the best solutions for themselves. Motivational interviewing uses good counseling skills, with genuineness, empathy, and an unconditionally positive regard. A clinician using MI expresses empathy, develops discrepancy, reduces resistance, and supports an individual’s self-esteem. Upon encountering a stumbling block resulting in resistance to change, the clinician adjusts the course, acknowledging without judgment that there may be strong reasons why a person may not want to change.

The spirit of MI can be summarized by four principles.

So what are they?

Four Principles: REDS

Roll with Resistance
Express Empathy
Develop Discrepancy
Support Self-Efficacy

So what do these mean?

Roll with Resistance

Resistance occurs when the individual argues against a change. If the clinician begins by making an argument for change, then the natural response from the patient will be to argue why he or she should not change. In MI, this is a red flag indicating the need to change directions and take a different approach. When the individual argues against change, he or she is likely to begin to convince him/herself to maintain the status quo. Instead, the goal for the clinician is to lead that individual in describing the reasons to make changes. The individual, not the practitioner, should make the arguments for change. Ultimately, the power remains with the individual. Too much resistance could also indicate that this may not be the right time for this particular change and that a different topic may need to be chosen. For example, if a patient is adamant about not discussing the removal of the TV from the bedroom, then the clinician may need to shift the discussion and ask instead what the patients thinks about reducing the amount of sugary beverages or spending more time playing outside.

Express Empathy

This is a core MI principle that sets the correct, supportive environment for a productive and positive encounter. Empathy cannot be insincere; it is acceptance and understanding, but does not necessarily require approval. Reflective listening (see below) can help convey empathy during a visit. 

Develop Discrepancy

A goal of MI is for the individual to make the argument for change. The clinician facilitates the process through an intentional conversation leading the individual to recognize the discrepancy between where he or she is now in life (i.e., with current behaviors) and where he or she wants to be. Small discrepancies between current behavior and future goals build together, eventually forming the motivation and momentum for change. Creating a decisional balance (see below) for which pros and cons of behaviors are listed can help develop this discrepancy.

Support Self-Efficacy

Not only must the individual be interested in making a change, but also he or she must be confident about success. Examples of when an individual has succeeded in the past can help build confidence for future changes. Even if a previous attempt at change was only successful for a brief time, it can be seen as a success. Patients can draw from what helped them make changes and then try to trouble-shoot and work through whatever happened, resulting in the return to baseline.  A confidence ruler (see below) is one mechanism to gauge self-efficacy. The clinician may also increase the individual’s self-efficacy by expressing confidence in the individual’s ability to make the change. Even better is when the individual describes all of the reasons why he or she will succeed.

Four Basic Methods (to establish rapport, work through resistance, and express empathy):  OARS

Open-ended Questions
Affirmations
Reflective Listening
Summaries

A little more detail please?

Open-ended Questions

Medical questioning with the goal of a correct and efficient diagnosis requires thoughtful questions that often seek yes/no answers. Motivational interviewing has a different goal, that of the patient self-realizing the need, ability, desire, and commitment to make a change. To reach this goal, clinicians must carefully select their questions and style of questioning. Yes or no answers decrease patients’ active participation. Motivational interviewing allows the patient to work actively during the conversation, slowly becoming self-aware of the need for change. Open-ended questions allow the patient to set the direction of the conversation, compared to yes/no questions, which allow the patient to become passive and wait to respond to the clinician’s questions. Initially, this shift in questioning style may feel awkward as the pace of the conversation may seem slower than a typical series of medical, symptom-based questions. And sometimes a moment of silence will be enough to encourage a helpful answer from the patient, moving the conversation forward.

Affirmations

Providing the patient with regular affirmations helps to set the correct environment ― open, understanding, and nonjudgmental ― for the MI session. Affirmations also help to support and build a patient's self-efficacy. Even simple responses can promote or erode the supportive environment. A patient may say that he has purchased some diet soda. One response could be, “Yes, but are you going to drink it?” A more affirmative response would be: “That’s great, now you will have the diet soda available if you get the craving for a soda!” Everything we say can contribute positively to an environment conducive for change.

Reflective Listening

Reflective listening is a key tool for helping a patient resolve ambivalence about a particular area for change. Becoming skilled in reflective listening will take some time and practice, neither of which will be fully covered through merely reading this section. There are many types of reflections; we will cover only the most basic ones. Simple reflections involve restating what the patient has just told you with a simple interpretation. It is a statement and not a question. The reflection should end with the tone of your voice remaining the same, and not going up at the end – which makes statements sound much more like questions. Say the phrase to yourself:  “Being teased about your weight upsets you.” If the tone of your voice goes up at the end, the statement becomes a question. While the goal of reflective listening is to encourage a response from the patient, statements should not be phrased as questions, because they could be answered with a simple yes or no and thus slow the pace of the conversation. Maintaining an even tone produces a statement and allows the patient to elaborate.

Summaries

Summaries are very much as they sound. A summary gives you an opportunity to make sure that you understood what the patient has told you and it gives the patient an opportunity to correct Summaries are very much as they sound. A summary gives you an opportunity to make sure that you understood what the patient has told you and it gives the patient an opportunity to correct you if you have misunderstood something. “Let me make sure that I understand. You are very concerned about your daughter’s health, particularly that she eats a lot of fried food and no vegetables, but whenever you ask her to eat anything healthy, she refuses and a fight ensues.”you if you have misunderstood something. “Let me make sure that I understand. You are very concerned about your daughter’s health, particularly that she eats a lot of fried food and no vegetables, but whenever you ask her to eat anything healthy, she refuses and a fight ensues.”

Toolkit Base: 

Decisional Balance

This tool can be used to help patients explore their ambivalence regarding a change. The patient is asked to list the good and the not-so-good things regarding a given behavior. The patient then lists the good and the not-so-good things about changing the behavior. Using the adjective “not so good” is an important subtlety. In the spirit of MI, we discuss the good and the not-so-good, rather than the good and the bad. Describing things as bad or as negative can lead to blame or shame regarding an activity, and these are two feelings that can be counterproductive to the MI session. After the good and the not-so-good have been listed, the clinician can summarize the not-so-good things about the status quo and then summarize the good things about making the change. This summary ends on a positive note, supporting a change, and can lead to more conversation, as the patient contemplates his or her interest, confidence, and commitment to making a change.

Confidence Ruler

The confidence ruler is another MI tool. It is best used after the patient has expressed interest in making a change in a specific area, perhaps through a decisional balance exercise followed by the clinician's summary. The clinician then asks the patient to rate on a scale of 1-10 how important making the change is to the patient, with 1 being "not at all" and 10 being "very important." Whatever the patient response is, the clinician should commend the patient for his or her answer and then ask why the patient did not choose a lower number. This then results in the patient describing all of the positive reasons for choosing the particular number. Next, the clinician may ask what it would take to rate the change higher on the importance scale. The questions can then be repeated, using confidence as the metric. Some patients may prefer to place their finger on a visual ruler, marking their position. 

Not at all     1   2   3   4   5   6   7   8   9   10     Very Important

Toolkit Base: 

Change Talk

Changing the Conversation
Change Talk Online Training Tool

This is what we seek. When the patient begins to use this language, it signals that we are moving toward behavior change. Change talk can be remembered by the acronym DARN-C.

D = Desire
These statements express that a patient would like to or desires to make a change.

A = Ability
These statements describe the patient’s confidence or ability to make a change.

R = Reasons
These statements describe why the patient should change.

N = Needs
These statements speak to the patient’s need to make a change.

C = Commitment
These are actual statements of commitment (e.g., I will change) or proximal statements (e.g., I may change). The stronger the statement of commitment, the greater the likelihood that the patient will change his or her behavior. Thus, the goal of MI is to skillfully lead the patient toward strong statements of commitment, through recognizing and helping the patient to elaborate, verbalize, and develop his or her desire, ability, reason, and need for change. 

Toolkit Base: 

Addendum: Assessing Readiness to Change

The "stages of change," developed by Prochaska and DiClemente, provide a framework to conceptualize the process for how people change by categorizing the stages through which people progress when contemplating a behavior change. Because the stages of change are sometimes mentioned with MI, a brief description is provided here. Motivational interviewing can facilitate and/or support change during any of the stages; however, many feel that it is most helpful for those in the precontemplation and contemplation phases, where ambivalence plays the greatest role. The stages of change are generally a cyclical process; however, one could quickly progress from one stage to the next or fall backwards. Furthermore, a person may progress back and forth through the cycle multiple times before the change becomes permanent, and different behaviors are likely to manifest at different positions in the stages of change cycle.

The Six Stages of Change:

Precontemplation

The individual is not thinking about changing a behavior.

“What would you think about exercising more?”

“I haven’t really thought about it.”

Contemplation

The individual is considering a change, but has not decided. Some add the time component of contemplating a change during the next six months.

“Have you considered exercising more?”

“Yes…, but…”

Preparation

The individual has decided to change and is taking some steps toward making the change happen. Some add the time component of contemplating a change during the next month. A key in this stage can be to encourage the patient to commit to making a change by setting a date for the change to begin.

Action

The individual has begun the new activity (or stopped the old one).

Maintenance

The individual has maintained the behavior for a period of time (some say at six months). After six months of maintaining a change an individual will be less likely to regress than during the action phase.

Relapse and Recycle

The individual has ceased the new activity, has returned to an earlier stage, and may or may not desire to resume the change. This is a normal stage in the process of making a change permanent and is to be expected.

Motivational interviewing is a rich, powerful mechanism to encourage behavior change. This has been a very brief introduction. Please consider further reading and taking an introductory training course. A large amount of free information and information about vetted MI courses can be found at http://www.motivationalinterviewing.org/

Further reading:

               online toolkit_MI        online toolkit_MI in healthcare
 


References:
1.    Mid-Atlantic Addiction Technology Transfer Center. Motivational Interviewing: Resources for Researchers, Clinicians, and Trainers. Available at: http://www.motivationalinterviewing.org/

Additional Resources: 

Martino S., Ball SA, Gallon SL, et al. Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficien Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University; 2006. Available at: http://www.motivationalinterviewing.org/

Miller WR, Rollnick S. Motivational Interviewing: Preparing People

Toolkit Base: 

Perspectives for the Future

As this toolkit is incorporated into individual clinics to evaluate and treat pediatric obesity, clinicians should realize that for some children, the onset of obesity occurred years earlier. This section gives an overview of the possible factors that may have contributed to patients’ obesity in their early years. Also, some suggestions are offered to help prevent obesity in the early years, a critical step in the battle against childhood obesity.

Evidence suggests that some of the contributing factors may have started in utero (1,2). Several obstetrical researchers have demonstrated that the abnormal hyperglycemia in pregnant mothers with pregestational diabetes or gestational diabetes (GDM) will contribute to a fetal hyperglycemic state that appears to have long-lasting postnatal effects, including obesity, hypertension, and at times hyperglycemia in the later months of the affected fetus (1,2). Many of these youngsters manifest themselves as babies who are large for gestational age (LGA) at birth. Some of these babies may also have difficulties with neonatal hypoglycemia; many will also have increased risk for obesity and other features of the metabolic syndrome as they mature into adolescents and young adults (1). Catalano and his group have demonstrated that some of the high-risk babies born to mothers with gestational diabetes can manifest many of the features of LGA babies, including rounded facial appearance, increased waist size, increased size, and fullness of their extremities, but are of appropriate weight for gestational age (AGA). These babies exhibit a larger visceral adipose tissue component of their body composition (3). Many in the obstetrical field are making every effort to help pregnant mothers realize a more normal metabolic milieu, thereby minimizing the deleterious effects on their unborn children (4).

We also know that babies who are small for gestational age (SGA) will often have a period of rapid weight gain or so-called “catch-up growth” in the first few months of life and will have a high incidence of obesity in later life. Unfortunately, no consensus exists on the management of these SGA infants.(5, 6, 7, 8). The prudent suggestion at this time would be to follow the American Academy of Pediatrics (AAP) nutritional guidelines―not allowing an overabundance of calories in these infants and not starting complementary feedings, with their attendant caloric content, too early.

Of the many efforts to improve the outcome of the battle against obesity in children, one major weapon is breastfeeding. Several reports have demonstrated that childhood obesity is seen less often in infants who are breastfed for at least six months (9).

Special attention should be given to all toddlers' dietary intake to ensure a well-balanced and reasonable caloric intake following the American Academy of Pediatrics Committee on Nutrition's most recent guidelines. In the summer of 2008, the AAP Committee on Nutrition made new recommendations on the fat content of milk consumed by toddlers aged between 12 and 24 months and for those older than 24 months. Among the guidelines are the recommendations that children aged between 12 and 24 months consume 2% milk and that children older than 24 months consume fat-free milk (10).

Furthermore, there is a concern that toddlers are not getting enough exercise. These youngsters should be given the opportunity to have active free play that emphasizes the use of large muscle groups. The day care industry needs to be directed to provide ample opportunity for kids to be active, with a goal of one hour of physical activity a day.

It is critical to realize that obesity will follow a life cycle. Infants of obese/GDM mothers have a high chance of becoming obese youngsters who in turn become obese teenagers. Unfortunately, girls who are obese teenagers may become obese/GDM mothers, thereby closing the loop of the obesity life cycle (11). Health care providers are obligated to try to intervene at all possible points of the cycle to prevent obesity in their pediatric patients. Prevention seems to be more effective than treatment.

In closing, the pediatric health care provider should have a higher level of vigilance for this special group of at-risk infants in early life. "Red flags" should be raised when you encounter any infants who are SGA, LGA, or “obese AGA.” Additionally, if the infants' mothers are obese, have gained an excessive amount of weight during their pregnancy or have a history of diabetes mellitus or gestational diabetes, a prudent approach for these at-risk infants and their families would include the following measures:

1. Breastfeed exclusively for at least six months and preferably for 12 months.

2. Delay introduction of solids or complementary foods, with or without breastfeeding, for at least the first six months.

3. Encourage the intake of fruits and vegetables by infants older than 6 months, toddlers, and young children. In other words, encourage fruits and vegetables for EVERYBODY!

4. Let children determine the amount of food they eat, but let the parents ensure that the youngsters have a healthy variety of foods to eat. Psychologists call this the authoritative approach―it is very effective and is associated with the least amount of obesity in the children studied.

5. Monitor maximum portions. Children's caloric needs, as well as appropriate portion sizes, vary with age. Included are recommendations from the U.S. Department of Agriculture Center for Nutrition Policy and Promotion regarding recommended calorie intake and serving sizes.

6. Encourage patients’ families to set up safe and comfortable areas in their homes so that infants who are already crawling have the opportunity to crawl to their hearts' delight. Likewise, give toddlers and early preschoolers the opportunity to play and be active.

 


References

1. Boney CM, Verma A, Tucker R, Vohr BR. et al. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics. 2005;115(3):e290-e296.

2. Catalano PM, Ehrenberg H. The short- and long-term complications of maternal obesity on the mother and her offspring. Br J Obstet Gynaecol. 2006;113:1126-1133.

3. Catalano PM, Thomas A, Huston-Presley L, Amini SB. Phenotype of infants of mothers with gestational diabetes. Diabetes Care. 2007;30(suppl 2):S156-S160.

4. Conway DL. Obstetric management in gestational diabetes. Diabetes Care. 2007;30(suppl 2): S175-S179.

5. Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ. 2005;331(7522):929-932. 

6. Ong KK, Ahmed ML, Emmett PM, Preece MA, Dunger DB. Association between postnatal catch up growth and obesity in childhood: prospective cohort study. BMJ. 2000;320(7244):1244-1247.

7. Ong KK. Catch up growth in small for gestational age babies: good or bad. Curr Opin Endocrinol Diabetes Obes. 2007;14(1):30-34.

8. Stettler N, Zemel BS, Kumanyika S, Stallings VA. Infant weight gain and childhood over status in a multicenter, cohort study. Pediatrics. 2002;109(2):194-199.

9. Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol. 2005;162(5):397-403.

10. Daniels S, Greer FR; Committee on Nutrition.  Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122(1):198-208. 

11. Kral JG. Preventing and treating obesity in girls and young women to curb the epidemic. Obes Res. 2004;12:1539-1546.

Toolkit Base: