A Report on the Development of the Hawai‘i Pediatric Weight Management Toolkit

Introduction

The Hawai‘i Pediatric Weight Management Toolkit (HPWMT) was developed as an evidence-based resource for health care providers to assist in implementing national recommendations concerning the identification, evaluation and counseling, treatment, and monitoring of overweight/obese children and adolescents. In November 2007, the HPWMT was presented to the medical community in a four hour continuing medical education session. Since 2007, some 350 healthcare professionals throughout the state have been trained in its use. The HPWMT offers a methodology enabling health care professionals to actively intervene with their patients and families and address the Hawai‘i pediatric obesity epidemic one patient and family at a time.

Background

Childhood obesity constitutes one of the most pressing public health issues today as evidenced by First Lady Michelle Obama's national campaign to fight childhood obesity, Let's Move. Obesity in children is a risk factor for chronic diseases, including Type 2 diabetes, cardiovascular disease, hypertension, osteoporosis and some cancers.^1–2 There are also psychosocial consequences for overweight children; it may contribute to a delay in academic and social functioning as well as poor self-esteem and depression.^3–4 The latest NHANES survey by the Centers for Disease Control and Prevention, from 2007 to 2008, reported 10 percent of infants and toddlers and 18 percent of adolescents and teenagers were obese.⁵

Although Hawai‘i is known to be one of the healthier states in the country, it is not immune to the American childhood obesity epidemic. A population based study of children entering kindergarten in Hawai‘i from 2002 to 2003 showed that 28.5% were either overweight or obese.⁶ A study of mostly low-income children attending a rural health center on O‘ahu⁷ found that 26% of children 2 to 19 years were obese and 16.5% were overweight. Certain ethnic populations and communities in Hawai‘i have double the national rates of obesity. According to Chai et al,⁸ in a 2003 study, the percentage of overweight 6 to 11 year old children of Hawaiian ancestry was 26.5% compared to 21% of children of non-Hawaiian ancestry.

Research studies suggest that interventions to prevent obesity should begin with younger children who are just developing food and activity preferences and habits.⁹ Evidence based anticipatory guidance from pediatricians and family physicians is a logical first step that should be offered to families for prevention and if necessary identification, evaluation, and initial treatment of childhood obesity. Physical activity and nutritional choices are two essential areas that are known to affect weight, and thus child health.¹⁰ In a study by Perrin et al¹¹ in 2008, the pediatrician's confidence and comfort level were increased when tools for obesity related counseling were available for their use. A study of the prevention and treatment of overweight in children and adolescents, concluded that the family physician should focus on early identification of the at-risk and overweight child and adolescents and include education for the patient and families illustrating the health problems associated with being overweight.¹²

The HPWMT was developed based on the premise that to consistently identify overweight children and initiate counseling, protocols and appropriate materials need to be developed and routinely incorporated into primary care pediatric offices.

Development Process

The co-author of the HPWMT drafted a patient educational pamphlet for families of children that were identified as being overweight. The families and patients appeared to value the material and the author began tracking the response of the evaluated children. Over a 1.5 – 2-year time period “successes” as described by parents and as evidenced by improved weight status was noted. The educational pamphlet and tracking information was presented to the Kapiolani Medical Center Obesity Task Force, then a work group was convened that applied for and received a grant from The Hawai‘i Medical Service Association Foundation to develop the pamphlet into a “toolkit” for primary care providers. The goal of the HPWMT was to be a resource for primary care pediatricians to enable a uniform method of identification, evaluation, and intervention for overweight children and adolescents when no other health care resources (eg, dieticians, care coordinators, pediatric sub-specialists, or pediatric obesity multi-disciplinary clinics) were available.

The Toolkit is available as a 3-ringed binder organized in five sections.

1. Clinician Forms were designed to assist the clinician in eliciting readiness to change, relevant family medical history, eating, and physical activity history; and documentation of physical findings, assessment, and plans.

2. Seven patient education Healthy Eating Tip Sheets recommend portion sizes and a desired proportion of each food group during a meal. Specific food choices are presented based on an adaptation of the National Heart Lung and Blood Institute's We Can! campaign. The adaptation utilized the University of Hawai‘i College of Tropical Agriculture and Human Resources' Hawai‘i Foods Website¹³ and added foods commonly eaten in Hawai‘i.

3. Seven patient education Behavioral Intervention Tip Sheets offer details on specific strategies that physicians can recommend to parents and their families. All of the strategies, with the exception of “Rice Reality” are evidence-based. Rice Reality was included because of the known high consumption of rice in Hawai‘i (personal communication USA Rice Federation) as well as its higher glycemic index and the current concern over the consumption of higher glycemic index foods and obesity.¹⁴

4. Monitoring tools.

5. Supporting material including Body Mass Index % curves by age and sex, the Kapiolani Medical Center for Women & Children's Pediatric Body Mass Index Guide, and overviews of motivational interviewing.

Focus Groups

With the goal of producing a toolkit that was useful for primary care health care providers and their patients in Hawai‘i, focus groups of community based pediatricians and parents of overweight children were conducted. Focus group participants were recruited by convenience sampling. Two focus groups of community-based pediatricians were held in May 2007 in Honolulu. A total of 27 primary care pediatricians who were members of the Hawai‘i Chapter of the American Academy of Pediatrics participated. The physicians were given a color copy of the draft “Hawai‘i Pediatric Obesity Toolkit” (the original name of the manual). Using a pre-written script a facilitator (the dietitian co-author) reviewed each page of the Toolkit with the participants. They were asked about their opinion on the concept, content, layout, and design of the toolkit. The participants were provided dinner and given a nominal monetary amount.

The physicians agreed that a standardized approach to identification, evaluation and intervention would aid their practices and the HPWMT would be a resource they would use. They had concerns about using the word “obesity” in the title of the toolkit as they were worried about offending patients and their families. They were not sure how best to “label” the overweight child when engaged in dialogue with their patients and families. The behavioral intervention tip sheet “Beverage Battle” includes information about sugar-free diet drinks. There were concerns expressed about the safety of artificial sweeteners. The “Go, Slow, Whoa” food choices list was thought to be too restrictive and not practical enough for their families to follow.

Four focus groups of parents were held in July 2007. A total of 32 participants, primarily mothers, were recruited based on convenience sampling from local Women Infant and Children (WIC) programs and pediatrician offices. All participating parents believed they had at least one overweight child in their family. Groups were held at various locations throughout O‘ahu including Downtown Honolulu, the Ala Moana Area, Waipahu, and Wahiawa. Participants were given a redrafted color copy of the “Hawai‘i Pediatric Obesity Toolkit” that incorporated changes based on the feedback received from the previous physician focus groups. The same facilitator, using a pre-written script reviewed each page of the Toolkit with the participants. Parents were queried on terminology, asked to look at each form and handout and asked if there was anything that needed to be added, deleted, or changed, and their overall impression of the toolkit. Participants were given snacks and a nominal monetary amount for their participation.

The parents were enthusiastic about having the medical community actively address the pediatric overweight problem. One parent said, “Finally someone is doing something about this.” They liked the content and presentation of the HPWMT and wanted to begin using it with their own children. They had concerns about the term “obesity” in the title and preferred “weight management” or “healthy lifestyle” instead. They could not offer a specific term for the overweight child that they would like to hear their physician use. The parents also had concerns about recommending artificial flavored drinks. Many parents wanted to receive specific daily caloric intake recommendations. They recommended early and frequent follow-up with the physician to monitor and reinforce behavioral changes.

Following the focus group meetings, the title was changed from the Hawai‘i Pediatric Obesity Toolkit to The Hawai‘i Pediatric Weight Management Toolkit. A section was added that summarized the FDA's acceptable daily intake of the various artificial sweeteners. The “Go, Slow, Whoa” food choices list was modified and expanded to make the “Go” and “Slow” choices more palatable. Although parents asked for caloric recommendations, the HPWMT process is not based on calorie counting, and hearing from the physicians that they were not comfortable in calculating caloric goals for overweight children, it was decided not to include any discussion or educational pieces on calorie counting.

Dissemination

The HPWMT was released on November 8, 2007 in a four-hour continuing medical education session in Honolulu. Subsequent trainings held in 2008 and 2009 were two hours in length and were held on O‘ahu, Kaua‘i, Maui and the Big Island. At the beginning of each session the participants received a HPWMT copy. Approximately 350 healthcare professionals have participated in HPWMT training.

In 2008, information was added to the original Toolkit that included additional behavioral intervention strategies (the role of breakfast and sleep and recommendations for pedometer use). Motivational interviewing has shown some successes in childhood obesity intervention.¹⁷ Assessing readiness to change is an integral part of motivational interviewing, so readiness to change screening tools were added to the clinician forms. Feedback from physicians and parents was obtained prior to inclusion of these new forms in the Toolkit in a similar but smaller structured format conducted by the same facilitator as the original focus groups. These additional sections were provided to the latter half of the trainings sessions as the “Hawai‘i Pediatric Weight Management Toolkit 2008.”

Although the HPWMT was designed with the primary health care solo provider in mind, it has found additional use in the following settings:

1. Castle Medical Center's Wellness and Lifestyle Medicine Center developed a community education project in Waimanalo based on the HPWMT.

2. The HPWMT has been incorporated into Kaiser Permanente Hawai‘i's smartset electronic medical record giving all of their providers access to this resource.

3. The HPWMT is used in the Kapiolani Medical Center for Women and Children's inpatient evaluation of the overweight pediatric patient.

4. In October of 2008, L & L Hawaiian Barbecue introduced the HAAPening Plate. This plate lunch based on the HPWMT's “Pass Your Plate, Please!” offers a healthy choice of barbeque chicken or salmon, ½ cup of brown rice, salad, and fruit. Details on the HAAPening Plate can be found at http://hawaiiaap.org/pdfs/HAAPening_Plate.pdf

The Toolkit is in the process of being evaluated at the Waianae Coast Comprehensive Health Center and the Kaiser Permanente Nanaikeolu Clinic by the Hawai‘i Initiative for Childhood Obesity Research and Education (HICORE) funded by the Kaiser Permanente Hawai‘i Safety Net Grant. This three year grant will examine the acceptability of the HPWMT for health care providers as well as patients.

Discussion

In December 2007, shortly after the release of the HPWMT, the American Academy of Pediatrics published the Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity. The expert committee recommends that clinicians actively address the pediatric obesity epidemic and advise patients and their families to adopt and maintain the following evidence supported specific eating and physical activity behaviors: (1) limiting consumption of sugarsweetened beverages, (2) encouraging consumption of diets high in fruits and vegetables, (3) limiting television and other screen time, (4) eating breakfast daily, (5) limiting eating out at restaurants, (6) encouraging family meals, (7) limiting portion size, (8) eating a diet rich in calcium, (9) eating a diet high in fiber, (10) eating a diet with balanced macronutrients, (11) encouraging exclusive breastfeeding to 6 months of age, (12) promoting moderate to vigorous physical activity for at least 60 minutes each day, and (13) limiting consumption of energy-dense foods.¹⁸

The HPWMT addresses many of these evidence supported strategies and offers specific guidance for families that can help the clinician implement the 2007 expert committee national recommendations. An understanding of the background of the HPWMT will hopefully stimulate and encourage clinicians to review their own strategies for systematically engaging with their patients in prevention and with their overweight patients in identification, evaluation, and intervention.

There are some limitations of the HPWMT. The HPWMT was not subjected to a patient literacy evaluation so may not be effective for lower-literacy patients. The HPWMT is only available in English so will not be as useful to clinicians who service patients who are primarily non-English speaking. Recent literature has demonstrated the usefulness of interactive multimedia as a means to improve patient knowledge and behavior.¹⁹ The development of HPWMT multi-media material to augment the written behavioral intervention tip sheets was stymied due to lack of funding. The effectiveness of childhood weight management intervention is dependent on the clinicians' ability to modify patient behavior. The HPWMT only briefly introduces the concept of motivational interviewing. Formal training in motivational interviewing as specifically applied to the HPWMT material would enhance its effectiveness.

The HPWMT is a locally developed resource that can assist physicians and other pediatric health care providers routinely identify, evaluate and manage patients with childhood obesity and help physicians guide the children and families of Hawai‘i toward healthier choices, healthier weights, and the avoidance of adult chronic diseases.