Psychology Journal Club: Pediatric Obesity 2017

I think we're gonna move on to our next section, which is, um, we've called Journal Club. So we have 3 presenters during this and I'll introduce each one as they come up. The first one is She'thel Reddy, who is a PhD psychologist for the Strong for Life Clinic. She's actually been with us since the beginning. She really is the leader in the clinical programming and the psychology area as well as leading our research efforts in the clinic. So she's all, thank you very much, and we're really interested to hear your, the subject that you chose. Great. So, um, we're gonna actually be shifting the focus a little bit. I think the earlier talks have really been about, um, public policy and sort of these broad, um, psychosocial determinants of obesity in this article, um. The reason I chose it is because kind of gets into the nitty gritty of um more of talking about parenting styles, um different things that are happening in the home environment that may be um contributing to or promoting um obesity in our very young kids um and. The other reason I thought it was kind of timely is number one, this is really a study that is not focused on addressing childhood obesity in an obesity clinic. This is sort of an integrated approach in a pediatric general pediatric office, and the second reason I thought it was really appropriate is the most recent issue of the American Psychologist, which is the publication of the American Psychological Association. Um, their main focus in this issue was the integration of pediatric psychology and behavioral health in the, um, the general pediatric setting, so really bringing mental health into, um, the, the medical setting. So, so for those reasons I thought this might be of interest, um, but this article, um, was from the Journal of Developmental and Behavioral Pediatrics and I was looking at social-emotional problems identified in the 1st 1 to 3 years. Um, let me see if I can advance the. There we go, um, looking at social emotional problems identified in the 1st 1 to 3 years of a child's life and whether or not that actually predicts, um, obesity at age 5. And their question was whether or not a general uh brief parenting intervention, not focused specifically on obesity per se would moderate this relationship. So just to give you a little bit of background why they decided to look at this, um, so this is just a nice graphic I think Christine Woods um. Uh, talk earlier this morning actually had a very similar graphic, but we're really going to be focusing on not the broader picture but just mostly parenting styles and family characteristics. Hey Sheel, to advance your slides, you can just use the arrow keys on the keyboard. That's probably easiest, OK. See. That doesn't, for some reason, that doesn't seem to work. There we go. OK, it's just a little bit delayed thanks. So one of the reasons they, they were looking at this is they noticed that some of the risk factors um for obesity are similar to the same characteristics that go into the social and emotional development of children. These are things like emotion regulation, temperament, inhibitory control, and reward sensitivity. Um, and so one of the rationales was if there are general parenting interventions that are addressing some of these things, would they actually impact obesity as well? See, it looks like the there we go, um, so there have been some other um programs that have looked at improving, um, parent-child communication in adolescence, improving social development in younger children, and what all of these studies have generally found is that, um, there is a decrease in BMI. So what these general interventions have found is that in addition to targeting the behaviors of interest, they've actually found that there is a reduction in obesity, BMI, greater initiation of breastfeeding. So there is some evidence that some of these interventions might actually impact obesity. So they designed this study in such a way that they identified families who were whose children were considered not at risk for social and emotional problems, families whose children were at risk, but declined to actually participate in the study intervention, and families whose children were identified at risk and did decide to participate in the intervention. They had two hypotheses for the The families that declined to participate in the intervention but were also deemed at risk. What they anticipated finding was that these families would actually demonstrate obesity promoting feeding styles, and their child would have an obese BMI by the age of 5, while those who were not at risk would have lower levels of both. And they anticipated that. Families that had children who were at risk but decided to participate in the intervention would have similar levels of obesity promoting feeding styles and um obese BMI's as the um the the group that was not at risk. So these are some of the variables that they were interested in obviously social emotional development, um, looking at the parenting intervention, looking at the risk groups, and some of these dependent variables that they assessed were child feeding practices, uh, maternal child feeding practice feeding styles, and the child's weight status. And they anticipated some confounds which they controlled for as well. You can see them here, so gender, having siblings, insurance status, birth weight, and for the mother, age, race, country of origin, her educational attainment, marital status, employment status, depressive symptoms, and BMI. So the way that they defined their risk groups was through the use of a questionnaire, the ages and stages questionnaire, the social emotional subscale, and this measure actually looked at things like self-regulation, compliance, communication, adaptive behaviors, autonomy, affect, and interpersonal interactions. And depending on which um Which risk group the family fell into, there were 3 levels of the behavioral intervention that were offered. Um, the least risk, um, they would offer collaborative monitoring of behavior, so this is when the, the, um, family would come for well checks. They may get, um, some education from the behavioral health specialist, but there was nothing above and beyond that, um. The greater risk, there would be an on-site intervention. It could be a home visit or an office visit, but it would be focused on their behavior as well. And then if for families that had more severe risks or other concerns, um there were outside referrals for long term care. So looking a little bit in more depth with these dependent variables, some of the child feeding practices that they focused on were specific foods consumption frequencies, so how often children were eating certain types of foods or drinking certain types of beverages, how often they were eating out at restaurants, and how often they sat down for family meals. 3 validated measures of feeding. And those were the child feeding questionnaire, parenting strategies for eating and activity scale, um, and the comprehensive feeding practices questionnaire, and some of the behaviors they focused on were things like restriction, um, pressuring children to eat, um, setting limits on what a child could eat, monitoring, uh, reinforcing, using food as a reward, using food for emotion regulation, um, parental role modeling of healthy habits. Um, involvement and keeping a generally healthy home food environment. So this is retrospective data that was collected from a community health center that was providing pediatric primary care, um. All the mothers were mothers of 5-year-old children who had had at least one social-emotional screening during the child's 1st 3 years of life, and they included um participants that were both Spanish and English speaking. So you can see here, um, this is just a, a graphic of um sort of the, the sample size that they ended up with. Excuse me, Um, they ended up doing follow-up telephone surveys, uh, for 336, uh, families. So this is a graphic of their results. You can see here, um, this is the the rate of child obesity at age 5 among the three risk groups. So on the left there you have the group that was not deemed at risk, and then you have the group in the middle was the group that actually participated and was identified to be at risk, and on the right there you have the group that was at risk and declined to participate. Some of the things that they noticed um in the groups that were at risk and declined to participate, um, those groups, they observed decreased limit setting, less restriction, um, there was more pressure to eat, um, there was a lack of sensitivity or non-responsiveness to feeding cues. It's more permissive parenting. And mothers were more likely to report depressive symptoms as well. Um, one of the limitations that they noted in this study was the generalizability of the sample. This was a low income, um, pediatric primary care center in the Bronx area of New York. Um, some people argue actually that that, that's not necessarily a limitation since this is a group that's disproportionately affected by childhood obesity, um, but the authors did want to point out that that may be, um. One of the limitations to generalizing this to a larger group, there may be some selection bias. Um, there was really no identified reason they did not collect data on why some families declined to participate, um. They suggest that things like chaos in the home, poverty-related factors may actually have contributed to not participating, but we just don't know. I think one of the strengths actually is that they actually did look at maternal depressive symptoms during that 1st 3 years of life. As I said, we don't know why they refused to participate, and probably the biggest limitation is that they actually didn't look at which specific parts of the intervention. Um, may have impacted the families the most. Um, they generally did not talk about feeding, uh, feeding practices with all of these families unless the family was struggling with that in particular. Um, so some families may have received information about, um, uh, positive feeding practices, but we just don't know what impact that had. And it was self-report. Um, but I think the takeaways are that they were able to find a link between social-emotional problems during the 1st 3 years of life and a connection with obesity at age 5. And even better was that participate families that decided to participate in this generalized intervention actually saw some benefit in their child's weight status. There's also some support that these kind of interventions can actually improve maternal child relationships, um, which suggests that we need to be focusing on more than just, um, strictly nutrition and activity, but we really need to be looking at the bigger, um, family system of, you know, the relationships between the mother and child, um, parents and their children, what kind of messages they're sending to their children about eating, um, and healthy habits. Um, and I think it kind of supports this idea of better integration within the medical model of behavioral health specialists, whether that's psychologists or otherwise, but, um, specialists who can identify some of these may be more general characteristics that may, um, if we can intervene, may actually promote some um adoption of healthy practices within the household. All right. I think that was the end of it. So, if anyone has any questions, I'm happy to take those. It's fantastic and actually a really nice lead-in after Chris's, right, that we're still talking about some of those other, other determinants of health and the, and the bigger picture. Um, and I think that there's really been a lot of research now focusing on the 1st 1000 days of life, right, is, is sort of a key point in whether or not we're getting to families with multiple issues at that age range. How does the, I think the maternal depression piece is really interesting, because again, it takes the pediatricians. Dealing with adult patients, sort of any thought about that sort of interaction and how best to handle that. Do you mean, um, sort of how to address it in the room? Yeah, we have these, right? So if I'm there and I'm seeing the kid in these, you know, for his 9 month well child check, and I'm concerned about mom's mood, that adds a whole another level. Talk about an uncomfortable conversation, right? I, I think, I think going back to even to Chris's talk about how do you address these things in a sensitive fashion, um, I feel like what we've generally found is that um. The sooner we can identify those issues, I think parents are happy to talk about them. Anything that improves that maternal child relationship, I imagine that they would welcome, and we know that maternal depression can impact their bonding with their child. It can impact the the interaction and the quality of that interaction with their child. Um, so I think there are sensitive ways to do that. I mean, we screen, um, in addition to screening for depression in children, we also do a depression screener for, um, the the primary caregiver in our, in the clinic, which is usually the mom. Um, and so it really, um, It hasn't been as touchy a subject as we thought. I think there's some sensitivity that has to go into it and addressing it in front of the child, um, and sometimes we'll send them out and have that conversation separately, but. I, I think parents are actually relieved to have someone to Uh, talk with, talk about it with, and if it's going to help, uh, change something about the quality of their interaction with their child, I, I think they're pretty open to that, at least that's what we found. So we keep that, you know, it sounds to me like as we've gone through all these, a lot of these topics today, we're adding yet something else for the pediatrician to do in the office, right? They're not busy enough, right? So because, you know, you have, I don't know, uh, John, Chris, how many, how, how long do you have for a well-patient visit typically at this age group? Both in your in your office. Yeah, so we have, um, yeah, a, a typical checkup is 15 to 20 minutes, um, you know, and that's really, it's, it's really pushing it, especially like with an adolescent, that's really hard. And that's why I think it's important to figure out strategies and to spend time like how are you gonna ask this? How are you gonna have, you know, what, what is your staff gonna ask, what will the parents ask, what can they do in a situation like ours, making use of technology in our portal and. And those kinds of things are important too. Yeah, uh, you know, and then some of this, you know, as you talk about, you know, Stephanie, as you talk about the 1st 1000 days, um, Do you push that back even further if you're worried about maternal depression or maternal family factors? Is, is there a role for the OB provider? In any of this Well, I sure think so, but, um, I don't know, I don't know how many people, so I think that relationship, everybody, I think on the outside world thinks PS and OB are so connected, but we're really not, and I think that is something we could also work on as a medical community is sort of facilitating the care between the peds, um, the OBs and, and the pediatricians because we do have, we're either part of the same patient. If we have the kids and the mom's their patient, we're all still working together. I don't know, Dory or John or Chris, have you done any work with the OBs? Yeah, so we have, um, we're doing a pilot project right now taking our 5210 message and adapting it to the adult population, and we've also adapted it to the prenatal population, and we're pilot, we're going to be piloting about 5 OB practices this spring. And uh really looking at how do these messages resonate, uh, the role that the OB provider can do and starting to think about healthy eating, active living for the mom, and then that transition from the OB office to the family, uh, practice or pediatric office, how does that occur? So we're really excited about the work of the OBs are thrilled. Um, it doesn't seem to be a heavy lift for them. They, they just need some standardized tools and resources and then the connections, um, so we're excited about that. Yeah, that sounds great. We, um, we've been trying to work with, with the obese some too, and we're, it's more in the practice and trying to work with the moms, and we've been encountering a little bit of difficulty just getting it rolling, but, um, I think everybody agrees that there's an important need for that connection. John, do you do? Any connection with the obese? We, we, I mean, we start, we have definitely started to work with the obese, and the obese are very enthusiastic about working with us. We have a centering, centering group, um, and so we have been invited to go in and talk about breastfeeding, for example, um, uh, ahead of time in the centering groups. And I think actually the groups, the centering groups have been great having, uh, some peer support for our parents. We also have the same social worker for both our OB practice and our PES practice. So oftentimes, our social worker will let us know about a mother who's depressed ahead of time. Um, so there's been a fair amount of coordination in that area. And that really helps. Yeah, that's great. And what you also talked a little bit about parenting styles, which I know, you know, you can see those charts, authoritative, authoritarian, and all of that. What, um, any suggestions for good ways to really do a quick assessment for parenting styles? I think, um, and I can only speak to this just clinically sort of what we do, but I think one of the quickest ways to do that is probably to assess. Kind of a general assessment of what a kid's day is like. Um, you'll find out a lot just by asking what's a typical day like, whether there are boundaries in place for bedtimes, um, rules in place for homework, um, you can get a general sense of a parenting style based on whether or not parents are highly involved, maybe too involved, dictating too much, uh, maybe there are no rules in the house, maybe kids are going to bed at 1 or 2 a.m. Um, it's a pretty good indication that possibly there are fewer food rules. Uh, our rules around eating and mealtime as well, um, so that's a lot of times that's how we will, um, begin that conversation. It's just a general question about what, what's the typical day like, um, for your child, and you can, you can gain a lot of information just, just through that question alone, um, and I will say too, I think, um. I think pediatricians are slammed. I think this is a lot to really ask um for them to do, and I think that's why there's been a push to actually incorporate uh mental health within the practice. Um, I think the practices that have done that, at least from the research I'm reading, find it very valuable to have someone on the team who, um, you know, a psychologist say who. Has an open schedule and if you see a child who has possible ADHD or some issues at school or maybe there are some concerns about weight and um feeding eating practices at home to be able to ask the family to see the psychologist while they're in the office um really increases the likelihood that they're going to get some useful information at that visit instead of then referring them out to another center where they have to make another appointment and we don't know if they're likely to go to that. I, I think it's really interesting you bring that up, Sheel. I, you know, I just had a discussion with a, a psychologist colleague of mine. I think, you know, as pediatricians, we've been, we've had a hard time figuring out how to co-locate, but we have to figure that out. It's really, you know, and getting, getting our behavioral. Um, folks to do that, some of that early counseling is important around sleep and behavior, and so we're not dealing with oppositional defiant and crises later. It makes a difference, and we really have to figure that out. I, and I, anyway, it's gonna be an interesting, it's definitely the future. Yeah, I really think it is moving just towards having a patient centered home for, for medical care, but doing it with the pediatric population. Alan, Alan Brown asked, asked a question here and Alan's part of our faculty. I think we're trying to, we're trying to get Alan in here. OK, but I'm going to go ahead and read your question for you, Alan. Remarkable that intervention led to 15% incidence of obesity at 5 years old, a decrease, but still an unacceptable number. The question is how significant declining prevention was. Another question which comes first, the child's behavior or the parent-child interaction? Hm. I don't, I don't know that they reported the significance in the article. I actually don't, I don't think they did. Um, the one thing that stood out was that the, the participants that the, the families that were at risk and participated had the lowest consumption of juice of any group, including the ones that were not at risk. So it seems like some of this information really stuck. Um, particularly, I think, um, the messaging about sugary drinks, um, but they did not report the significance, and we don't know that. Um, I don't know if that's a chicken or egg question either, the parenting, um, styles or the, uh, relationship, um. It's, it's, it's probably intertwined, I would say. Yeah. Uh, there, there's also another question here from, uh, Matthew Smiley. Uh, as you point out, one of the biggest barriers here is time, limited time at the well-child checkup. There was a study that looked at the concept of well-baby group care in the 1st 2 years as an alternative model and strategy for providing care to at-risk families. The study showed a decreased prevalence in obesity at age 2 years in the group care. Has anyone worked in a setting that incorporated this model? So I guess I'll ask our primary care pediatricians. Oh, there you are, Alan. Good to see you. Uh yes, we do have a group. Care model. Um, we really are just getting it off, off the ground, um, but we've definitely seen increased satisfaction. Uh, we've seen, uh, improved, uh, rates of coming, coming on time to clinic. Um, so we'll have to see whether that translates into Better, lower rates of obesity and, uh, and lower rates of other parenting issues. Yeah, Victoria or Chris, have you, do you have any experience with that? We've never really had um success in doing that. I mean, I think it's always an interesting concept for us, um, but we've not been able to do that. We do our expectant parent meeting as a group, but that's the only one that we've been able to to pull off that way. We had the same experience too. It sounds like a really great idea, but we, we didn't. The dynamics of the group are so important, and, in our experience, there were some, um, some parents who sort of overtook the group, and it was hard. It, it just didn't work. So I think it's great that John, you're having some great uh experience. Maybe we should try it again. You know, there, there's some interesting, um, variations on it too, like you hear like. Um, like, I know some people have done not like a true group visit, but like almost like a stage kind of visit where there's like one common piece, yeah, you've heard of that too, Tory, it's there's 11 common piece, but then you break off and have an individual piece as well, so. That, that's how we do it. I mean, we have a central piece, but then we, they each go to their room and get their own exam, and they have a little time in case they want to ask any sensitive or personal questions. And it's worked really well and, and hopefully one of my residents will be presenting at PS this year. Oh good. You know, I, I guess as a, as a surgeon, it'd be hard for us to have, uh, you know, we can't put everyone maybe with the right inguinal hernia in one group or. But how do you, uh, are there HIPAA issues with that, or like, do you have them sign a waiver, or how does that work? We, we do have them sign a waiver, and we haven't had any problems. No one so far has complained or, or balked in any way, and I've been amazed at how open parents have been to, to share their stories with the, with, uh, each other, perhaps even more open sharing with each other than they would have been with me or, or my colleagues by themselves. But yes, we do have them sign a waiver. I think when they work, they work really well, but when they don't, you're really stuck. We, we struggle being in Atlanta and that nobody's close enough to come. At any particular time, so we have a hard time getting people to groups in, in any form or fashion, our bariatric support groups, etc. um. So I think, but it's a matter of maybe being a little more creative with the, we could look at being a little more creative with the clinic setting, like what you're doing, do you do some sort of education piece and then sort of break everybody off and but keep it much more contained, I think that's an interesting idea. We'll have to look at that as well. Think, OK. All right. Well, I think, thank you, thank you, Xizal, that was fantastic. We really appreciate that talk.